American Psychological Association (APA)



Title: Using Apps in Clinical Practice: Practical AspectsDate: 02/12/2020[Sonja] Good afternoon and welcome to the webinar using apps and clinical practicepractical aspects, All participants are muted throughout the webinar please usethe questions tab to submit any questions questions will be answeredthroughout the webinar and now we will have an introduction of our speakers byDr. Marlene Maheu. [Dr. Marlene Maheu] Hello everybody. I would like to thank you the APA forco-hosting this event with the Coalition for technology and behavioralscience (CTiBS). And also in collaboration with the APA divisions 18,19, 29, 31, 32, 37, 42, 46, 53, and 56. My name is Dr. Marlene Maheu and I have beenfocused on technology since 1994 at the APA is was where I started. I am theexecutive director of the Coalition for Technology behavioral science as well asthe executive director of the tellaBehavioral Health Institute. My gueststoday are Greg Reger who is the deputy associate chief of staff for mentalhealth at the VA Puget Sound health care system and a professor at the Universityof Washington School of Medicine. His research is focused on the developmentand evaluation of innovative technologies to support service memberand veteran psychological health. Also Julie Kinn is with us she's a clinicaland research psychologist specializing in the use of health technology toimprove patient outcomes. She's worked in the Department of Defense for over 10years and now leads the defense health agency the DHA connected health brancheducation and training program. The coalition technology behavioral sciencecan be found at and I want to also thank Dr. Jack Si who organized theAPA divisions that the president of division 18.What we'll talk about is telehealth competencies because our topic todayabout apps is focused on addressing some of the competencies and helping youunderstand how to use apps clinically from the perspective of developing yourown competencies. So first I'm just going to step back a little bit and talk abouthow competencies are developed and how they fit into the lineup of what goes onbefore we start developing professional services. So what we have at the top are laws thatare generally and put into place by our legislators and out of that ourregulatory boards decide how that is to be interpreted for our professions. Andwe have ethical standards that are developed by the professionalassociations and sometimes adopted by regulatory board sometimes not dependson the state of the province or the country. Out of ethical standardsguidelines are developed and at the APA guidelines have been developed forseveral years now to look at telehealth not necessarily apps but telehealthgenerally. And some there are some overlap with apps out of that not notout of guidelines but further breaking down what everybody has to do withregard to all of the the categories above are competencies. And if you willthe way I like to think about it is those are sort of a building blocks theamino acids of what we should be doing so it amounts to knowledge, to attitudes,and skills that then can be measured. So out of competencies should come trainingon training should come professional services, because as most of you know weshould be doing so we should be delivering services that are based onnot only evidence but also our knowledge and our interpretation of that evidencewith regard to the person in front of us the family in front of us or the groupin front of us. So what CTiBS did was to organize a group to look atdeveloping competencies because nobody had done that in the technology relatedworld and we came up with an interprofessionalframework for telebehavioral health competencies that looked at the idea ofcompetencies from the perspective of all the behavioral disciplines that we couldfind and we had representatives of six different disciplines as part of thatteam. So we worked in four and a half years and came up with seven generaldomains, five sub domains, 49 objectives that should be addressed by apractitioner that wants to go into this kind of work and out of that 146practices or competencies. We broke it down into novice, proficient in authorityand that's why it took is that one it was because we came up with a draft of it,we send it out for comments to lots of different associations and groups andindividuals, we got the comments back took us a year to integrate, what wereally received a lot of comments it was quite heartening, to see theinterest in the work that we had done integrated all of that again and we sentit out again for comment and then integrated those comments. So there's a longprocess but we came out with these seven competency domains of which M health andapps is one of them. So today we'll be talking about the objectives related toM health and apps and here I've got them on a slide for you. So we've identifiedfour of them and I'll read them for your convenience, but they generally focus on what we need to do asa clinician. Okay so that is to assess client or patient use of mobile healthtechnologies. Are they appropriate for is the app appropriate for what we want todo? Somehow I lost that slide here it is. Okay then the connectivity is appappropriate is the person of probably does the person have the fingerdexterity do they have access to the app and then select thetechnology with a specific purpose and documents and monitors that. We'll talkabout that here today. And then practices with an evidence-based technologyapproach and that means looking at not onlythe data in research what we learn in groups like like this one today but alsofiltering it through our own minds and our own experience and then applying itto the person and talking with them about it so having a collaborative approachwith them and doing that. And of course attending to all legal regulatory andethical issues and if needed given that we're have a firm footing and the legalregulatory and ethical issues come up with new approaches if we - if there isno database to support us yet. So with that will start with our firstdiscussion question here today for Greg and Julie. And that would be why wouldapps be a relevant technology topic for psychologists across the APA?[Dr. Julie Kinn] So I'm Dr. Julie Kinn,you can tell which one I am NOT just because I'm female because there's nofire behind me Greg is the one with the fireplace. I so let's take a moment justto think about how you woke up this morning. So what woke you was it for kidsan alarm clock your dog spouse or most of you I'm guessing it was probably yourmobile device. These days most of our clients, patients, or beneficiaries arewaking up with an alarm on our cell phone and so that means the very firstthing you're touching in the morning is your cell phone and probably the lastthing at night too. And although that can be a little scary that's not always agreat thing it also gives us an opportunity. We can leverage the factthat our patients our beneficiaries are carrying mobile devices with themwherever they go. It's the kind of thing where ourbeneficiaries would rather turn around and go home to get their mobile deviceif they forget it and be a few minutes late to work. What we're seeing is thatour patients are already using their devices to help with health althoughthey might not think of it that way. So for example consider the last time yougot with a new kind of symptom. Something youhadn't seen before or someone in your family. You probably didn't goimmediately to the emergency room you probably played Dr. Google at first andlooked up similar images and symptoms online you probably looked at websitesthat you trust if it was an ongoing condition maybe you even downloaded anapp to help you come up with ways to track your symptoms. All of these areexamples of ways that our beneficiaries are currently using health they'rewearing wearables they're tracking data such as weight lifting, diet, step, allof this is common these days. And again I know there's arguments for and againsthow much we are using technology but because it's so pervasive let's leverageit for patient engagement especially since there are some phenomenalevidence-based apps websites podcasts other kinds of health technology outthere. So for all these reasons technology and mobile health technologylike the use of mobile apps is totally relevant for psychologists across APAfor a huge variety of health conditions.[Greg] Yeah and I think I would just add to that you know as a psychologist the VA manyof us and it's obviously not just in VA but psychologists in many differentsettings are working to address issues of access to to mental health resources.Many many many of our client populations are living in parts of America or Canadaor wherever you might be where there's limited number of mental healthproviders to provide psychoeducation, resources, interventions, and M healthopens up some opportunities to really expand resources in those ways. So youknow it's a regularly occurring conversation for me and and otherleaders in VA thinking about how do we get resources to ourclients who are living in remote areas, rural areas, places where there are a fewproviders so M health has some promise there if we can address the manychallenges to getting good resources into their hands.[Julie] And I'll just chime in real quick. So Greg,you use the word m-health. And just to make sure everyone's on the same page, Mhealth stands for mobile health and that just means accessing health care usingmobile devices like cell phones. And also I know we only have an hour today andit's a huge topic one that Greg and I have devoted a decade of our lives to here. Weboth of us in the DoD and the VA have tons of educational content availablefor free for all of you. So after today's webinar I hope you'll follow up with usand the links at the very end of the presentation to see some of our otherresources. [Marlene] I also want to add some questions that are coming in or commentsare coming in so please feel free to type things in if we can include yourcomments than we will. But I can't promise that we'll answer every questionwe already had many questions before the event and we are very limited in ourtime. But nonetheless let me just make make a comment that suddenly did writein that it's not just for psychologists or somebody wrote that she's a mentalhealth nurse practitioner and she using that apps a lot to strengthen the therapycomponent of the visits that that she's having with patients. So good perspectivethank you.In the CTiBS behavioral health competency frameworks, clinical domainand identified objective is thinking about how to incorporate M health orapps into client treatment planning. So how do you think about treatmentplanning with apps? [Julie] Well I'll start with this one. If theycan go on to the next slide.Thank you. So bottom line here in bold the technology is not the treatment. Theway we like to recommend treatment planning with the use of healthtechnology is the same way we always do treatment planning. Sofor example let's say we have a patient who has post-traumatic stress disorderPTSD. My first thought wouldn't be okay how do I get technology into their hands.My first thought is what's the right treatment approach for this patient.Let's say the treatment team decides for this patientprolonged exposure is going to be the appropriate treatment of choice and thepatient buys into this treatment, then I would explain prolonged exposuretreatment and additionally give the option for technology to assist. Now forthose of you who do prolonged exposure treatment you know it's a fantastictreatment for PTSD but it does have a lot of homework assignments, trackingrecordings, etc and fortunately there is an app the PE coach app which I thinkGreg is going to talk about mark made by the VA with help from the DoD. The PEcoach app would be an appropriate app to recommend to help assist with all ofthat. So the treatment planning isn't necessarily focused on the app thetreatment is still the treatment no matter what it's still prolongedexposure. The technology is just another modality to help provide thisevidence-based treatment. In addition to considering you know what's the generaltreatment approach and where can technology fit in, I would also can lookat these patient considerations. The top one and the most important one ispatient interest. Some of your patients are already going to be using technologyand for them it makes great sense. Some of your patients are not at allinterested in using technology or maybe they use it just for fun and they don'twant to involve their healthcare with their technology. So that patientinterest is a really important important part of the engagement we don't want tobe pushing our patients into unfamiliar or uncomfortable terrain simply becauseit exists. That's said for your patients who already are using technology itgives us an opening. So for example if I have a patient who loves podcasts andthey're there for pain management I would recommend an evidence-basedpodcast such as the "living beyond pain" podcast to help them. Since that'salready technology modality with whichcomfortable and familiar. For a patient like that it probably makes more sensethan reading a chapter about pain management. You know when I was ingraduate school we had a shelf full of good books that we would alwaysrecommend and that's what my supervisor used so that's what I used but I lookingback I realized a lot of my patients probably weren't as into reading as wewere. And so there's other opportunities now to still get that information across.I'd also look at contraindications, Marlene and you mentioned this a bit ago,you know if somebody is recently recovering from a traumatic brain injuryof course we wouldn't want to be pushing help technology for them. Although fortheir caregivers very likely also if someone has a technology delusion thencertainly technology doesn't make sense. And if someone is prone to compulsivebehavior I'd want to be very careful in terms of how we're using it in thelimits we're putting up or the limits we're setting out to make sure thatthey're not using it too much or too little.And finally ability and logistics fortunately cell phones mobile devicesmobile computers are so much less expensive than they used to be butunfortunately there's still not universal as well as the logisticcomponent I know in my hospital there's not Wi-Fi yet and I'm guessing that'sthe same for many of you in your clinical settings. So sometimes there arejust logistic considerations that make it more difficult we can't just assumethat everybody has the same access to this technology. And Greg did you want toadd anything here? [Greg] Yeah I mean I think I just underscore kind of some of what yousaid by just highlighting you know treatment planning is always acollaborative process with our patients and that's an individual collaborativeprocess with that person that involves cultural factors, their goals, theirinterests, their preferences, and certainly that you know the literaturein mental health has done a nice job and recent years of highlighting the role ofpreference and outcomes and so all of these thingsinterplay with the things that we like about technology or given apps that wemay have preference for. It's really woven into the process of thiscollaborative treatment planning process. [Marlene] So we've had a few other comments comein that I want to address. One is a request for us to share specific appsthat we recommend. And we chatted about this beforehand because in the list ofquestions that were originally submitted, it must have been 80 percent of themwe're requesting a specific app for this or that or this or that. We don't havetime to get in a lot of that but also there are liability concerns for usrecommending a different one over another and so just for the sake of practicalityand reality here we will be teaching you how to find the ones that are best forthe person in front of you. Because we're not in a position to do that. That's partof what we're supposed to be doing as professionals. So we'll be getting intothat in more detail, Greg will address it. We also had another question come inthat asked how a podcast reaches evidence-based status. So I think thatmight be bouncing off of you and Julie about a particular one for pain. [Julie] Yeahthank you for the question. Because I'm alwaysexcited to talk about podcasts. So just like a book about evidence-basedtreatment written by experts can help deliver that evidence-based treatmentsame with a podcast. So for example in the defense health agency connectedhealth branch where I work we started a military health podcast program. We haveseveral podcasts that are made by experts in the military health system. Soa couple of them in particular I'd like to highlight: one is the "living beyondpain" podcast in which we interviewed the pain experts in the DoD and VA aboutnine specific topics that relate to pain management, including cognition, emotionmovement, how to explain pain flare-ups to kids. Another podcast that isevidence-based that we produce is "a better night's sleep" podcast. It's wonthe People's Choice podcast award for best health podcast in 2019.And in it we interview the health, I'm sorry, sleep experts across theDepartment of Defense about listener questions. So the podcasts are based onthe evidence. And in addition we are now running a trial at Madigan Army MedicalCenter, Joint Base lewis-mcchord where I'm located, to see if the inclusion of "abetter night's sleep" as part of a short-term CBT-I (cognitive behavioraltherapy for insomnia) group will help promote patient outcomes. So it's justlike a book that features written documents by evidence or by experts. Samething with a podcast it's just an audio medium instead of a written one but itcan be so engaging to our beneficiaries because for those of us who listen topodcasts you know you get to know the host. Plus you can access it in differentways you can listen on your commute and although many of us love to read some of ourbeneficiaries would rather listen to content instead. [Marlene] And I'd imagine there toJulie that it's just like when we were encouraged to give books to our clientswe were supposed to read them first. So I would imagine that with podcast it wouldbe helpful to listen to them and see if these people really are referencingevidence do you think that they sound like they know what they're talkingabout they're not just making it up. [Julie] Absolutely just like you wouldn't justpick a book off the shelf. You got to kick the tires yourself and vet it to makesure it's appropriate. [Marlene] Yeah we have another question that came in that Ithink is great and it gives me an opening to talk about one thing that Iactually added a reference for. And it's that the comment is now lots of treatlots of treatment apps are coming out but research consistently shows activeand active ingredient in change human relationships.How do outcomes vary with changes and how much in the support is added to thetechnology? And there was a publication that I became aware of just last week isby Wiesel and a number of other researchers and I added as the lastbecause the last reference on our four slides of references here today and whatthey found was after checking many many many different studies there was ameta-analysis is that a standalone app is not sufficient for behavior change ina number of categories they looked at and it was quite a few depression andanxiety and a lot of different ones. So it just was published at one it was a2019 publication so it was just put out I encourage you to take a look at it ifyou interested in that. Okay so we move on to the next slide. [Julie] I'll briefly touchon this technology is phenomenal for many many reasons just want to make surethat our viewers here are aware that there is evidence based technologyavailable to help with all of these areas. Such as self-care for example theVA DoD have produced apps that help teach diaphragmatic breathing that helpteach coping skills assessment there's a great study by Bush et al. Greg, youmight be on that study too that showed that a self assessment on computerversus written versus mobile apps all give equivalent result. Psychoeducationtracking just sleep wearables, mood with mood tracker apps with homework as Italked about with prolonged exposure coach and of course maintenance oftreatment gain. And just to double-down and what Marlene said none of these areinstead of treatment apps are another fantastic addition to treatment. [Marlene] Okay soanother question that we formulated for you is clients will sometimes tell usthey have found an app that they find useful or we hear about an app that wehaven't used. How can psychologists and otherprofessionals effectively evaluate and select apps for use in practice?[Greg] Yeah so I love this question and I think it dovetails nicely Marlene with yourquestion earlier from viewers about what happened to you or what you know anygiven problem X in other words it's the most common question we get. Which iswhat app should I use for problem X? Right and so kind of thinking about howdo we select apps how do we evaluate apps merits several minutes and I wantto unpack this in a little more detail here. You know one approach and that'sprobably the most common is we hear about an app and we look it up in theapp store. We'll take a look and see how many stars does it have what are thereviews of like and you know that's a reasonable starting point but you canimagine but that basically tells you that the users liked it and you know ifthey had significant problems with it that will often come to light. You know abunch of people are saying an app is crashing you can see that the reviews.But there's some critical information as psychologists or other disciplinesthat's missing from the reviews of users. Right like it effective is it based onsound psychological principles you know what is the privacy associated with thisapp. Because those things are missing we need some alternatives. Now one approachthat's proliferated, and we can go the next slide for Marlene, is uh you knowexpertise right subject matter expert reviews. And so there's there's a numberof these these aren't the only ones out there but cyber guide is a niceaggregator of reviews of mental health apps. A year or two ago division 56,46,2, and 1put together a mental health mobile app reviews database. is another one. And then there's others. Right we can review theseexpert reviews of mental health apps. Again is another reasonable startingpoint for those of us trying to identify a potentially useful app. There areshortcomings with this approach as well. That is important to think about so onthe one hand probably reasonable approach foridentifying apps as a starting point but let's think about these sources in termsof a static review over time. It's a monumental effort to keep reviews ofapps up-to-date over time. If you think about the thousands of mental healthapps that are out there to adequately keep an up-to-date review of the currentevidence of apps, I mean Marlene decided a brand newmeta-analysis writing the evidence is ever-evolving and just as importantlythe apps are ever-evolving. The updates to apps are ever evolvingyou know bugs are being fixed new contents being added new apps are comingout. And so it's a really monumental effort to keep these up to date let'slook at an example of cyber guide it's just one example.Cyber guides funded by one mind. This is a nonprofit organization in brain healthit operates out of University of California Irvine and their goal is toprovide objective information that's accurate, the anxiety and the socialanxiety and depression Association of America is partnered with them for somemental health app reviews. So you know this is a group that we look to to dosome nice work and they do. But when you look at their criteria for app reviewsthey have it one of their many scores is for whether or not the software updateshave been conducted recently. It's a reasonable proxy right foris there support for the app is it updated frequently these are support forthe app and so the best score is given for an app that's been updated in thelast six months and if there's been an update to the apps in the last year youget the second best score right now. However to kind of make the point abouthow hard this is I want to thank my research coordinator Cheyenne Porter, outof the 171 mental health apps listed there she went through and put down thedate of the review in cyber guide. And the average age of the review was 668days so that's almost two years ago only 19% of the reviews had happened in thelast year, only 6% reviews occurred in the last six months.So I think I want to lift up cyber guide for their great work not take shots atthem. I simply want to highlight incredible challenges with maintainingup-to-date app reviews over time. And cyber guide acknowledges this themselves intheir you know disclaimer where they say you know you we strive foraccuracy but you shouldn't rely on the information contained in this website. Sowe need a different model we need an alternative model they can build on someof these other approaches and thankfully there's some very practical useful appevaluation frameworks that any clinician can use. Simple, these frameworks that youcan work through as a clinician to think through whether or not and an app may beuseful. And the one that I want to highlight here is this APA. And herewe're talking American Psychiatric Association at the evaluation model. And Iwant to give a shout out to John Taurus and his colleagues who've just donephenomenal work and research of apps and they helped develop this model. And thesteps here you can see really involved gathering background information on theapps, looking at the risk and the privacy and security of the app, considering theevidence, step four is looking at the ease of use of the app and then thefifth step is the interoperability of the app. So it's a simple five-stepframework that that any clinician can work through. And Marlene I'll give it toyou there. [Marlene] Okay before we get to our next question we have a poll we have twopolls. And Sonja could you help us with polls please?[Sonja] Sure one moment. Okay the poll is now up. And you can go ahead and vote. [Marlene] Questionis how many different unique clinical apps have you used in your practice? Andplease select one of the four options we've given you. 59% of the people havebeen using one to five. About 1/3 have not used any, let's see wehave at 7 percent of the people that have used 6 to 10 and about 2percent 11 to 15. So most people are either using none or 1 to 5. So justgetting started so it's great good to know. So our next poll.Ok so 17% looking at the App Store reviews. Those by the way can be skewedbecause people can be hired to go answer or just go give star ratings, so those area little bit questionable. Coming from clients client recommendation so likeyou said Sonja 51 percent colleague recommendation and then 11% visit at thebehavioral a prove your website like you were talking about Greg and then 10percent have got formal training. Do you want to comment on these resultsGreg given what we were talking about? [Greg] Yeah no I mean I love it in fact I meanwe often hear about an app from you know clients or colleagues. I mean if you wantthose together the vast majority of app recommendations. And so having an idea inyour head of framework for considering whether or not that's not you want toconsider using for clients... [Marlene] So then let's get to this nextquestion of can you walk could you walk through a brief example forus as a demonstration. Greg of using the app evaluation framework.[Greg] Or and I'll just build off that poll to kind of build the example here. So youyou know I just walked through this APA app evaluation framework. So let's gothrough an example here. So let's imagine that you're a therapist who recently wastrained to treat PTSD with an evidence-based psychotherapy called PE.And Julie references either 8 to 15 psychotherapy sessions the treat PTSDyou go to a three-day workshop you learn the skills and during the workshop theysay by the way there's just app that you can consider using help you out make thetreatment more convenient built by the VA and the DoD so take a look. So youleave the workshop and you're thinking well maybe this would be useful. And soyou want to check it out and given that this really the context of the patientmatters let's consider a hypothetical 42 year old woman who comes to you fortreatment of PTSD she owns an Android smartphone she's comfortable using it inher day to day life, she uses it for her calendar and texts with people. Shecan solve a few apps but hasn't ever used it for health or mental healthpurpose. And you're considering a discussion with her about whether or notto incorporate this into her PTSD treatment. So let's walk through this appevaluation model as an example as it relates to PE coach 2. So the first stepof course was that background information to give us some contextabout the app. So as we walk through these questions and Marlene here you cango to the next slide note that there's more questions foreach step then I'm going to review here for our time purposes. You can go to thewebsite on the earlier slide for the model to see them all there. But I'lljust illustrate a few things here. So you know in gathering the background we wantto know who's the developer, in this case the Department of Veterans Affairs andwe read the description of the app we see specifically it was designed by theNational Center for PTSD. Which you know informs our confidence about the contentwe ask what's the cost of the app and what is the business model. How does theapp support its own development. Here it's free to users because its developed by thefederal government and supported by them. Is it a medical app, is it claimed to bemedical. Well PE coach 2 is categorized as a health and fitness appand it is stated to be designed for use during therapy for PTSD in combinationwith a health professional. We look at the platforms it's developed for and wesee that it's available for iOS or Apple devices and Android. Then we look at howrecently was updated and we see for Android it was updated in April of 2018.Which is listed as the first release but we know that that PE coach 2 followedabout five years of PE coach. So with that background now we turn to step 2the risk in the privacy as it relates to an app. And so here we want to consideryou know is there a privacy policy and if so you know what data are collectedour personal data de-identified who are the data shared with. And if that's ouris that we're not sure we look at the app and we can't tell we probably canstop right there. The APA has designed this there's a hierarchical set ofquestions. In other words if you can't answer an earlier questionsatisfactorily you can just stop right. We don't know what data is beingcollected or there's no privacy policy we probably don't need to worry aboutother things because we're probably not going to recommend it to a client. So inthis case for PE coach 2, we see there is a privacy policy. It's clear itstates that no identifiable data is transmitted to VA and we see that thedata is on their device and the patient's responsibility to ensure thesecurity of that data after the apps installed. So we think about how we'lltalk with our patient about that. Third steps evidence you know here we'rethinking about is there evidence for potential benefits. Now there's a questionearlier I think alluding to there's very few apps thathave evidence on mental health outcomes. I mean there's thousands of mentalhealth apps very very few have evidence for an impact of the app on outcomes. Andso we we've got a look at this and think you know what kind of evidence are welooking for. And usually what we'll do is certainly we can look at our academicsearch engines to see if there is evidence we can also install the app andlook at it and say is it consistent with our our own expertise of psychologicalprinciples. And you know does it do what it says it's designed to do. Is itsensible as if it is it's based on evidence principles. And so for PE coachwe look in psycinfo and we find five relevant articles. Most of them are onusability case series. There's no randomized trials of PE coach on PTSDoutcomes. So we install the app and look at it some more and see it aligns wellwith PE coach. It does indeed have features of support the in session andthe homework and it looks like it fits well with what you learned in your PEworkshop. So we go on to step four ease of use. So here we're talking aboutusability you know it easy to access can a client that we are thinking aboutusing it with navigate through the app, does the app need an active internetconnection in order to be functional and if so is that available in your clinicalsetting, other culturally relevant factors to consider. These kinds ofissues if an app sits well within you know your psychological thinking of whatit should do but patient can't navigate through it we're going to be dead in thewater right. It's got to be a usable functional app otherwise it just is notreally worth proceeding. Then the last step here is interoperability. And herewe're talking about the age of digital technologies you know there is interestin whether or not these things can transmit dataand and talk to one another. You know are there opportunities for the app to linkwith other devices, Fitbit or other devices. Can we link to the electronicmedical record will it transmit data to our cliniciansthe provider can you get access to the information if the app is used by yourpatient. And of course all that sits within the questions of privacy andsecurity and how that transmission happens. So you look in PE coach andyou can see the data is not being transmitted. You're going to be lookingat this screen with your patient side by side, you do see there's an option in thesettings for socialization to email data off the app to you and so you do seethat. And so you take all of those steps and then you can think about our 42 yearold client that we're about to do PE with and think about whether or not PEcoach 2 is a good fit from your perspective as you go into the processof shared decision-making with the client.And I'll pause there Marlene. [Marlene] Yes we have some comments. Greg, um first some peoplehad some comments on the platform. They wanted to know why why there was not anoption for the professional themselves have reviewed the app by downloading itand using it themselves. And we had other options in there but the APA platformonly allowed us to have five. Okay five options to pick from so we pickedfive. But Gregg do you want to comment on that do you think that's a reasonableapproach is for some of the downloaded to tried themselves see how it works? [Greg] Yeahabsolutely if I didn't mention that it was in my notes. Certainly we want toinstall the app and look at it and examine it ourselves and that's thatprimarily how we're going to find out issues of usability, what the privacypolicy says. Yeah we've certainly got to take the time to look at it ourselves.[Julie] Yeah and one thing I learned with a book just like really even if you hear on NPRthis is a great book you're not going to recommend it to your patient unlessyou've actually read it yourself. Same thing with a mobile app. [Marlene] One of these tolook for is that on the bottom of the app it says on your phone there shouldbe about five no more than five options there as part of the architecturebecause people will hit more than one so little things like that can really getin the way and bog people down. You know if their their fingers are too big theyhit two things at once it's very annoying so the last little featureslike that you may want to think about. There's another comment that came inthat said I'm confused PE coach has 2.2 stars, PE coach 2 has 2.2stars, users aren't liking it. Does that not need to be taken into account aswell as other evaluation steps?[Greg] I would so I would certainly be interested in what users think of theapp. I mean my my starting point for any technology is our users are never wrong.If we have built something that our users don't like then our users aren'twrong. We are, as it relates to PE coach 2.0 I haven't reviewed theusability data the VA certainly embeds top quality usabilitystudies and our user reviews are going to be important. So there are thingsabout PE coach 2.0 that I don't like. And so you know there may be that when welook at usability studies for any app it's time to do an update right. So no Ithink that the things you want to consider is a psychologist we want toconsider the data appropriately right. How many user reviews are there, how manyyou know what number of data sources are going into those star ratings, and thenstar ratings don't include key parts of information that are available in thisframework. But yeah, usability and reviews online are one piece of information thatcertainly we need to consider. [Marlene] I would I would add caveat to that just because of some ofthe things that I've seen. That they can be if they're skewed in any wayartificially it would be they would be rated as too good. Because people can paypeople to go rate them good but people rarely pay other people to go ratetheir own app as bad. So I think user reviews can be taken into account ifit's reflecting something negative. Also within the review that could be a fairamount of information about what they don't like and it may not be relevant towhat you're doing. So with sometimes it's useful to readthe reviews and actually see what's in there. [Greg] It's certainly not a scientificstudy right. I mean we're not now not getting a randomized sample ofindividuals to evaluate our app so it has extreme limitations. But I'm also notgoing to ignore it. [Marlene] Okay so I think we're ready forthe next next slide. How does a provider need to keep up to date with all the newapps?[Julie] Can I take this one Greg? Okay so you can't. Because there are so many apps outthere it would be a full-time job of a huge team, there's so many coming out allthe time but again I'll go back to that analog of books just like there's somany books coming out all the time doesn't mean we don't want to payattention to some that are very highly rated. I think for those of us who arereally into technology this is a fun pastime but for those of you who arejust getting started here I would hate for the overwhelming nature of theamount of apps out there to prevent you from getting started. So what mysuggestion is is to consider what are one or two of the main presenting issuesyou're seeing in your client population. Let's say it is PTSD then what I woulddo is on your own or with a committee of your co-workers, take some time to vetone or two really good solid evidence based apps along with one or two reallygood solid easy to read book chapters about PTSD, a couple websites that arevery easy to read and evidence based, maybe podcasts, other kinds of healthtechnology and make sure these are ones that fit with your treatment modalitieswith your perspective. Again evidence-based easy to use and I mayhandout a flyer so that when you have a patient come in who has PTSD and theymight be more interested in a podcast or a book or a website or mobile app you'vegot these resources available in the moment. You're not trying to decide ohwhat's the newest PTSD app out there. Instead you know this is reliableinformation if you have new people join your team you can help them get familiarwith them know what's happening with these apps, when they're good, whenthey're bad, if they need an update for example and then once a year go backthrough and see are these still the best or should I add a different app insteadand as well as you do this process over and over with other presentingconditions you'll soon have a nice reference library for whatever thepatient need is. [Greg] Yeah and I think I would just add that you know one one given howmany apps are out there one nice way to keep up to date with apps is keeping aneye on the developments of key developers. In other words given theimportance of who developed the app to some of the questions we addressed inthe framework earlier. It's nice to keep an eye on Samsa and APA and VA and DODbecause some of the highest quality stuff will likely come out of theseshops and that way you can be alert to some of the better stuff coming up. Andyou know it's evidence-based if you see a new app come out of the VA NationalCenter for PTSD you know already this is from a trusted source same with our appin the DoD coming out of the defense health agency. [Marlene] We have we're having morecomments come in particularly about privacy. So let's just talk about that alittle bit more I think people are concerned about the privacy issues. Iknow for a lot of the training that I've done the focus has been on actual how doyou implement it in session. And one of the things that we've encouraged peopleto do is to help the person get used to it right in the session. So open it putthe app help them put the app on their phone get it starteda lot of times there's a screen that opens up and asks them if they want toreport bugs or problems to the developer. We may want to encourage them to not dothat because frankly we don't know what that developers going to be doing withany of the information we're not there to to check every line of code that getsdeveloped and get sent on to the developer. So maybe best for them totoggle that kind of thing off. You know so for us to walk them through thatthere anything else Greg Julie you'd like to add about morespecific related to privacy?[Julie] You want to go first Greg? [Greg] Oh well yeah. Sure I'll go first okay you know I haveto say Marlene like I think this was really hardI think the privacy issues are very very concerning because if we don't know whothe app is developed by. We don't know who the apps developed byclearly there's no guarantee that the privacy policy if in order and to ourliking even accurately represents what is done with the data. I think this is anarea that's really going to emerge in the coming years because there's arecent study that again John tauros and his group did looking at how data wastransmitted off of apps and they don't often adhere to their own privacy policy.So there's some real concerns here which is why I'm really in my own mind I'mstarting to really emphasize the developer of the app and thetrustworthiness of that developer is the key starting criterion. Because of someof these issues.[Julie] I concur 100%. With the VA app you know exactly how any external data is beingused you can choose to send data to be aggregated to help the VA track metricsbut it's toggled off as a default. In the DoD apps it's not even an option thedata stays on the device it doesn't go anywhere. But beyond that we can'tpromise what's happening with other apps that's part of that important vettingprocess. And figuring out if it's a trusted source I'm glad to hear thisquestion I think it's essential. [Marlene] Yeah we have a segue to that somebody asked sowe need to have somebody sign an informed consent document so that theycan be sent to the information through email or that we could be sent theinformation through email it wasn't specific but anyway so the team so thatthe information could be sent to email one of you like to address that both ofyou? [Julie] I'll jump in to start I think there's two separate issues here. One isinformed consent in general to use health technology. At this point APAdoesn't have a specific recommendation about informed consent procedures withrelated to health technologies with relation to health technology. But what Ido recommend is an open discussion about health technology with patients and thenreferring to that in the patient record. So for example if I'm recommending PEcoach as part of prolonged exposure treatment I would make a note of that inthe patient record and also indicate the kind of discussion we had about it. IfI'm in private practice and I have the ability to add a section to my informedconsent about use of health technology or about social media usage for exampleI like to do that as well. But for many of us we can't actually adjust ourinformed consent procedure on the other hand is the issue of how to handle whena patient emails us. It's tricky as soon as somebody emails you something it ispart of HIPAA right. When the data is on the patient's device and they're theonly moment success it's not relevant to HIPAA, butas soon as it gets to it is. In the DoD we made a decision that we would notallow any data to be shared from our app it all lives on the device. In part toprevent this from happening we want to make sure it's extra safe we want all ofour apps to be able to use be used anonymously. And so it's awkward when apatient comes to session with an app like that the virtual Hope Box app. Theywould need to actually show the device to the provider to show what they'vedone. There's no data sharing there the VA graduation speak more to this Ibelieve has some apps that do have data sharinghowever it's using a secure server with two-factor authentication and a tokennetwork through my VA apps I believe. This is very deliberate very safe it'snot just hey here's my data and emailing it to you. Greg? [Greg] Correct I mean where this washeaded longer-term of course is is excited if the client of mine is usingan app and I can log into a secure web-based portal and see in real timethe homework that they're doing if they're symptom reports to reallyclinically relevant data. And we've got some opportunities to enhance care inways that are super promising. For you know at least be AI think there may beother healthcare systems that are further along with this but you knowthat's still in the future and there are personal health portals like you know Ithink the VA has added veterans can interface with in a secure manner. Andeventually these things will be linked so the apps talk to those places and theclinician can see them. In the interim you certainly want to use great andcareful appropriate caution in terms of privacy and you know in you know inaddition everything Julie said we got to consider your organizational policies onemailing with clients. And you know for example in Va I know that I cannot emailwith clients because there's no opportunity for them to use an encryptedmethod of sending their data to me. So even if an app has that capability I'mnot going to recommend it client email their mental health data mydirection. [Marlene] So we have three minutes left. Let me just help us most of it so theremaining, nobody could talk for a few hours about this but these arevery good questions so obviously we've taken them as we've gone along so we'renot going to be having a question answer period at the end. But email is notsecure so for most email. So just want people be clear about that and you need it to gothrough some processes having to do with informing your person about riskingbenefits of using email before you try to use any any unencrypted email. So letme let me move us to the next question and then we're going to have to end. What arethe practical ways to recommend an app to a client once you've identifiedone that you'd like to recommend?[Julie] Can you go to the next slide? So first discuss it, make surethey're actually interested, demonstrate it in an ideal world we would all have atablet with the apps that we want to recommend pre-loaded on it so thepatient can feel it can see the advantages of it without having to takethe time to download it on their own. And then prescribe it! Here's an example,prescription pad that we make in the DoD has VA apps on there as well if youdownload our PowerPoint presentation later and click on this link you can getaccess to this the other side of podcasts and websites. And follow up justlike you would with any other kind of homework assignment or other activity orother kind of prescription be very specific about how you'd like it to beused and then make sure that you're asking the patient about it. Greg? [Marlene]One moment before anybody scoots out the door, I'd like to encourage you to stickaround and fill out the the evaluation for this program is very important sothat we can keep programs coming your way yes. So Greg, you want to saysomething? [Greg] No nothing to add its fine. [Marlene] Okay, what about this last questions yes what Ithink I'll just move on toto the resources that we've got. The reading list for everybody, we've gotfour slides of reading, and some people did ask about the the one themeta-analysis that I commented on earlier and it is the last one on thelast slide here we saw because it's W. Okay so lets see if we have any other questions.Any apps and different languages? Let's take that question[Greg] That's a great question, that's not myarea of expertise and so I really can't answer but I think that goes back to theimportance of you know the cultural factors that interweave with theseclinical decision-making issues. Before working in a clinic that's primarily youknow Spanish speakers or other languages those are critical questions. [Julie] Absolutelyand most apps are able to be translated very easily.[Marlene] Ah! Nice to know. Well thank you very much to my guests and once again thank you tothe APA. ................
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