All right. Good morning. I'm John Lowe. I've got Jay Shore and John Torres. So thank you for joining us this Tuesday morning, bright and early. We were doing a little bit of a wager as to the headcount and we're just amazed that 20 of you plus now have joined us this morning to hear about apps and innovations to support the practice of psychiatry, current and future development. So thank you for coming. Just some disclosures. Jay is the chief medical officer of Access Care Services, which provides telehealth services, technologies and does receive royalties from American Psychiatric Press and Springer. And John and I have nothing to disclose. I think I do have, I used to have royalties from American Psychiatric Press, but I don't think anybody buys my concise guide in computers and technology, which was published in 2002 anymore. So I don't know why they still list it, but anyway. Jay. Good morning. Thanks for joining us. As John said, I'm Jay Shore and I'm going to talk a little bit about sort of where we are, how we got here and where I see the future of telehealth video conferencing going. And then my colleagues here will be talking about apps and informatics too, and then we'll have a discussion. So what I want to do is just give you my brief in five minutes version of human history. This is the Temple of Asclipolis in the Peloponnese of Greece. And it's arguably, it's not arguably, it's one of the first learning centers, medical school, as we began to consolidate at least Western medicine. And over the last 2000 years, again in Western medicine, we've seen the increasing urbanization, centralization, industrialization of healthcare. And this is Fitzsimmons where I work, University of Colorado, like many of us in these behemoth medical centers sprawling across the Western plains. And so I'm going to say a lot of profound statements that are obvious, right? But society, healthcare parallels the cultures it finds itself in. And so I do a lot of work with indigenous populations, and arguably they are some of the most patient-centered medical systems, right? With the healers and providers living together, knowing each other's context very well. Even though we're in this digital and technology age, I would argue that where we are in medicine and the tensions we're all feeling is because we remain at the peak and pinnacle of industrial age medicine. And we really saw it come to fruition in the 20th century. If you look at our hospital systems, right, they're really organized by production models. We group patients in wards for efficiency by disease processes, move them through the system, quality management, which is very helpful in terms of looking at the system's ability to effectively treat patients. That whole movement came out of the Toyota total quality improvement system. In the 80s, it was then adapted by managed care. And so there's these several convergent trends. So that's certainly one of them. I think another trend that is affecting all of our lives and healthcare is best illustrated by the parable of the game of chess. And so the story of the invention of the game of chess goes that the inventor invented chess, and that was before PlayStation and on-demand streaming movies. And so really the ruler was really excited when everyone was playing chess, wanted to reward the inventor, brought the inventor in and said, how can I reward you? And the inventor said, look, I'm not a greedy person. If you'll just take one grain of rice and double it at every board on the chest, I'll be fine. And so the ruler agreed. And of course the kingdom was bankrupt because he didn't really understand the power of the exponent. And this is where we're living our lives right now. This is Moore's law, not Roger Moore from James Bond, the second best James Bond. But this was an engineer in 1971 who hypothesized that we would double the processing power of the microchip every two years. And this exponential curve has held. And it's hard for us to really get our minds around conceptually, again, this exponential doubling. But I would argue that we've all felt it in our lives over the last 25 years is the computer processing power has doubled and doubled and doubled. So there's a great book that came out, I believe, in 2016 that sort of captures this inflection point in human history by Thomas Friedman. It's called Thank You for Being Late. And he points out that we sort of turned this corner in the early 2000s, 2006, where the processing power of computers really began to allow us to make revolutionary changes in our technology and what it was doing. So that's the year the iPhone came out. Facebook was started, Airbnb, Uber, right? And it was because of all these systems. And we continue to see it, right? You know, and it's sort of insidious. We sort of take it for granted now. But I remember, you know, Siri came out in like 2012 on your iPhone. And it was really almost like a party favor. You'd say something and Siri would say something totally different and didn't understand you. If you haven't noticed now, the voice recognition is pretty good right now. And that's because the algorithms, the processing power continues. So Thomas Friedman liked it till, you know, I'm sure we're all big fans of Brandi Carlile and her song The Eye. And the main chorus of The Eye, I won't sing it for you because it'll kick me off stage. But it's, you can dance in the hurricane, but only if you're standing in the eye. And that's where I think we are in technology in our personal lives, right? The change continues to pile up and it can be pretty disruptive. But there is a sweet spot, right, in our personal lives and professionally where we can sort of sit with technology. But if you get to the edge of it, things begin to swirl, become disorganized and unmanageable. So I think that's a really apt metaphor for where we find ourselves. I think the other trend, so we've got this industrialization, we've got the microchip. I think also in the last 20 years, we're seeing sort of this tension between what we call digital immigrants and digital natives. And this comes out of the education literature in the 2000s. And people may have heard this. It's a pretty basic concept, right? I'm a digital immigrant. I really, I mean, I grew up with Pong. I had a little Atari. But I wasn't using computers in my professional and personal life until the 90s. And I was sort of having to learn the language of the digital land as I went. As opposed to my children, if you see the picture of the child up using multiple devices, that was also my daughters because I was really bad about managing screen time, right? So I just throw a bunch of devices at them. And by the time they were six or seven, they could play on the iPhone, watch TV, use a Kindle and a computer all sort of simultaneously. And we're seeing now the results of that, that imaging studies are demonstrating that actually when you're exposed to technology that young, the brain is wired differently. Is it better or worse? I don't think we know yet really. I think the digital immigrants are like, oh, these kids can't concentrate and pay attention and they're distracted easily like we all are. And that may be true, but there's probably some benefits on that side around speed of processing and how they process information. And so what is happening now too, at some point there will be no more digital immigrants in this country, right? And as we see the younger populations age into healthcare, they are really also the consumer demand and driving of this use of technology. So let me shift gears and I'll come back to those trends and talk briefly about the history of video conferencing and telemedicine. So this is a little collage that I put together. And the concept of treating patients as a distance in Western medicine is not new. You can see, actually I did this before COVID, you can see the doctor with the plague mask because back in the days when the plague would come to town, they would send out white smoke signals. So it was really like, you can think of it as very slow asynchronous email, sort of a parallel to that. You can see the lithograph in the middle, there is this great paper. This is the York Asylum from the 1800s, where the researchers went back and studied the letters between providers and the patient's families. And they were going back and sharing information and getting collaterals and managing patients through these letters that would take months to arrive. But again, it was certainly part of management, this distance management. Obviously the radio and then the telephone was really revolutionary as a tool in managing patients. And then video conferencing, which I've spent the bulk of my career in, you can see these black and white photos. This is 1959, University of Nebraska did one of the first pilots from Omaha to Lincoln. They did Grand Rounds, which is sort of what we're doing now, right? And also group and individual psychotherapy. And if you go back and read those papers, besides the technology, the type of questions that we still ask, what is the nature of the relationship over the medium? How does it impact the patient? Does it affect outcomes? Those same types of experiences. Hey, we can see patients from a distance, but we need to be conscientious about what this video system is doing to that relationship. And so now we find ourselves, right, where video conferencing, now video conferencing is free, right? Most of your devices come with it. It's not really free, right? Because if you're not paying for it, you are what's being harvested, right? Soylent green is made out of people, just like Facebook. So it's an evidence-based way of practicing. And, you know, the field of telepsych, like this is the Garner Hype Cycle. Oh, it's hard to see because I got a blurry slide, I guess, but you can see, right, this is about what happens when you get a new technology. You have the innovation trigger. You've got very high expectations. You have the peak of inflated expectations. Then you get the trough of disillusionment when people realize this new technology is not going to solve everything. And then you work your way to the plateau of enlightenment where you actually figure out where and how it's going to work. So telepsychiatry, what I find very interesting, really started to take off in the 90s when the technology began to get cheaper and cheaper. One of our mentors started videoconferencing in Australia in the early 90s, and his first unit was $500,000 a side to set up videoconferencing, right? So as the cost came down, we began to employ it in psychiatry. And the first decade was like, let's just repeat what we're doing in person and see if we can do it over a video. Can you do a consult? Can you do med management? Wow, yes, you can. Oh, you can do group therapy. So we kept doing that. And then we entered this era where we began saying, okay, let's blend it with other technologies and begin to think about how we can change the models and how we deliver care. And that, I think, has been a really exciting phase for telepsychiatry and videoconferencing. And as we continue this trajectory, right, there are more and more technologies that are going to be blended and added in, and we'll hear about some of those this morning. The other big concept, right, is this concept, and we were talking about this in the tech sphere before COVID, what we called hybrid care. And the concept of hybrid care is that we hold relationships with patients through multiple mediums. So if John's my patient, I see him in person over video, over a cell phone, patient portal, telephone, right? And each of those things have their strengths and weaknesses and boundaries of communication. And so hybrid care is about sort of understanding that space. And then obviously COVID hit, and we all actually entered, I won't even say it was a hybrid world, because there was no in-person. We're all trying to sort of manage across these multiple technologies. But as we emerge, we are going to be in a hybrid world. And we always thought we would, but COVID like did a decade of implementation for us, for better or worse. As we also entered into the pre-pandemic, right, we have all these trends in healthcare, workforce issues, value-based payment reform, healthcare consolidation, burnout, disparities, all these factors were sort of churning. And then, so I would say before COVID, right, we had really the hybrid relationship beginning to make its appearance on stage. We had a lot of anticipated practice transformation in mental health, again, with these reforms and workforce pressures, unclear where it was going, and care redesign. And these things sort of feed into each other. And then, boom, right, if we were living in the eye of the hurricane, we then get hit with the tele-mental health tsunami, right? And in one month, March 2020, things just changed for everyone. We all experienced this. And I see it as two major things. We all turned to video conferencing to provide clinical care because the apocalypse was impending and we needed to stay off the streets, right? And secondly, and this was really important, we all had to virtualize our business operations. These are two really separate things, virtualizing the clinical care, but also virtualizing how we are interacting behind the scenes and getting together. And it wasn't like, you know, prior to COVID, when I do an implementation of telehealth for an organization, it could take six months to two years. There was a lot of training. There was a lot of getting patients and providers used to it. There was sort of careful strategy. And again, in some of the systems I was involved in, I'm sure everyone here and the double Johns here too, right? We did this in 24 hours. And so there was, certainly there's been a lot of sort of lessons learned the hard way from that. And it's been very interesting. We can see this as some APA surveys. This was in June right after the pandemic bottom line here as well. Surprise, surprise. Psychiatrists are now doing video conferencing, except for those patients who don't have access to it. And they're seeing them via the phone when they can. This is a follow-up from the fall and sort of going last year at that point, about 81% of psychiatrists were seeing 75 to 100% of their patients via telehealth. Many in the patient's home. This should be right of surprise to no one in this audience. I think another sort of big change in uncertainty looming out there is there were, and the way I think about administrative administration and regulation in the sphere of telehealth is there are four sort of major areas. And I think you could slice or dice that pie, however you want. But I look at state licensure, federal regulations around controlled substances, billing and reimbursement, and HIPAA and privacy. And you can see all of those areas have become much more permissive due to federal regulations due to the COVID emergency. And every day people ask me, and we were talking about it here, what's going to happen? We don't know, right? The emergency is set to expire in July. It's going to be renewed probably to October. I personally predict it will go through the end of the calendar year, but this is all gambling. I've given you the odds and my predictions here if you guys want to go bet. I think state licensure will go back to what it was. Just my own prediction, pretty good odds. We'll be back to the system. The COVID exemptions will go away. I also think the federal prescription, controlled substances, you can see my odds. I think that's reverting. I think billing and reimbursement will, some of those additional codes and the phone visits will stay, but there'll be more boundaries put on it. And I think HIPAA compliance will revert, at least initially. So I think it's been very permissive for telehealth, which has helped us. But again, I'm a little more pessimistic about the speed. And also, right, this requires congressional action to make these stick. And right now this is probably not the number one priority of our political system. So obviously we've all been dealing with some of these COVID challenges. One is the regulatory environment. Second is the stress and burnout of Zoom fatigue, but it's really the burnout too of the pandemic and being virtual and quarantined and today we're masking, tomorrow we're not, sort of this back and forth. And I think this will certainly continue for another year. We've been talking about, even before COVID, our research methodologies, where it takes from your inception of a really interesting research idea or just studying in real time, before you actually get a publication that you're sharing with your peers, we're talking a three to five year timeline for a quick turnaround. There is no way we're going to be able to keep pace with the exponential curve with that. And we really have not had that discussion as a field of how we look at examining and getting real time data to make those changes. And then last but not least, the issue of the digital divide, right? In some ways we're so lucky that COVID hit when it did. If it didn't hit like 15 years ago when we had video conferencing, but you had to do cameras, people would be lining up in their COVID masks at clinics to try and use like video conferencing equipment. So I think video conferencing has been a savior, but as the Leonard Cohen song says, there's a crack in everything and that's where the light gets in, right? We have seen that these disparities around access to digital healthcare and video conferencing have widened for many populations. So what do you need to access technology and participate in digital healthcare? Obviously adequate broadband access. You need a up-to-date technology platform. You need to have some tech literacy and comfort with the specific program, software device that you have to use to access healthcare. You need real tech support, not a ticket that generates a response in four to five days, but you need real time. And you need the coverage of the cost. You need your healthcare provider, your plan, or you need cash on the barrel that will pay for that service. And so again, there are huge gaps in our country about who has access to this new world of digital healthcare. So if you remember that we had this inner swirl before COVID, practice transformation, hybrid relations, care design, and telehealth. And now we have COVID, these healthcare system trends. We've got continued acceleration of the change. And again, this disparities and equities that I'm talking about. So these are sort of where we're going here. Those are sort of the critical issues. Where, what does it mean? What are these hybrid relations? How do we as individual providers select the right technology at the right time for the patient right in front of us? And it may vary with the patient depending on where we are in their care episode. How do we redesign care and have more efficient models for resourcing and aging workforce and working with other professionals? How do we keep pace with the practice transformation? it's sort of the middle caribou theory in technology, right? If you're the caribou at the head of the pack, you're probably gonna crash through the ice first and drown, and the wolves always get the caribou in the, at the back, so we wanna, how do we sort of be the middle caribou for most of us with the technology? Some people like to be the lead caribou, I'll let those two. Talked about the methodologies for research, and again, the digital disparities and equities. So I'm gonna stop, because I think in our conversation, we'll sort of shift to, that's where I see we are, and I think in the discussion, we can talk about, so what are the opportunities for change in practice? But I think we all need to, one of the key themes, right, nowadays, is tactical flexibility. You may remember the epic scene in The Princess Bride, where the Dread Pirate Roberts was able to defeat the giant because he had only been fighting large groups of men, and so he couldn't do good at the one-on-one fight, so I think the field of psychiatry needs to keep that tactical flexibility as we go here into the future. I'll turn it over to you, and look forward to talking a little later. So first, thank you all for getting up so early on a Tuesday, this is a hard one to get to. So I'm gonna pick up where Jayshore left off, but I think it's exciting to have a panel like this, I've certainly learned a lot from these two folks as a resident moving forward and watching technology change. I think for anyone out there who's junior, it's still a wonderful time to get into technology, it's always changing, there's more to learn, so I think I would connect with these two afterwards if you can, but if we think of telehealth, clearly whether you like it or not, you've probably had to use it, right? By a show of hands, has anyone avoided telehealth and done all in person for the last two years? No one. So we've all been using telehealth in one form or another, but I think if we look at what telehealth can do, and by telehealth here we'll talk about synchronous telehealth, video visits via Zoom, via a platform that your hospital, your clinic, your practice may have, what you can imagine is, ooh, let me get rid of that, is you are able to see people anywhere in the world, it's terrific, you can see people in India, you can see people in Argentina, you can see people in Boston, but you're still only one person, you can still only see people, and we'll talk in the next slide how quickly you can see people, it's an interesting issue, but so synchronous telehealth is useful, but it distributes clinicians in a better way, and that will increase access to care, but it's gonna plateau because you have to eat, you have to sleep, you can't always be on a video visit seeing people constantly, so we like to increase an access to care of synchronous telehealth, but it doesn't truly solve the large issue of access, and this was a WHO report saying even in 2021 that they said it's a disappointing picture of worldwide failure to provide mental health to people, so again, we've done better with telehealth, but we really haven't solved the problem per se. I think we also have to wonder again, as we're talking about telehealth, it's certainly something in the news, it's a story evolving out, but there was a company, or there is a company called Cerebral, this was the headline from May 7th, so what, about two weeks ago, saying Cerebral under federal investigation for possible violations of controlled substances law, so clearly it's under investigation, we don't know what will happen, but the concern here was, were there kind of then telehealth providers that were having visits so quickly and so many visits and prescribing substances like Adderall that they were potentially creating risk, and again, we don't have access to what the Department of Justice is looking at, we don't know how this will end up, but I think we have to realize we do want to increase access to care, we don't want to increase access in a way that there's perhaps quality concerns either, so it can go both ways with it. I think where it becomes interesting, we really want to transform access to care, we have to think about asynchronous telehealth, and the idea is, is there a way, right, that you could be in the center, and you could actually be working with multiple people at once, and asynchronous telehealth is not an overly new concept, but you can imagine this can actually help scale you in what you're doing, and if we think about how would we actually do this, right, people would need a device to access telehealth, all those patients you want to see, they would have to have the digital literacy to be connecting to you, they'd have to perhaps be able to do video visits when you need it, we don't want to give up on seeing people, but they'd also have to be able to connect and do asynchronous telehealth, so if you say, what type of device would meet all of those stages, and how would we radically increase access to care, it quickly becomes smartphones, for better or worse, because especially for number one, what device that people have access to, increasingly, it's smartphones, if you're looking to reach more minoritized populations, populations with less resources, there's good data to more likely have a smartphone of internet connection than a computer that will let you reach them, and of course, if you have a smartphone, we'll talk about the interesting world of apps and what you can do through technology that may help people, so I hope we can at least, we can talk in discussion, but it's hard to ignore smartphones, and a lot of my patients are connecting to me actually on a smartphone, even for the video visits I'm doing, they may be in their car, parked, we stopped a patient who was trying to drive on the freeway, that was a no-no, you cannot be doing a video visit while driving, but a lot of my patients will be parked in the car, and they'll be using their smartphone to connect to synchronous telehealth visits, but again, if they're using their phone, there's a lot more that we could potentially be doing, and if we're gonna start using smartphones, I think the question then should be, what can a smartphone do and how? This was a story, the headline is not mine, it's from New York Magazine, it's free to download, it says, the lunacy of text-based therapy and other technology solutions for a nation in trauma, so I think it's a hilarious one to read, if you're on the airplane going back, it's pretty fun, but the point being, smartphones open up a lot of new possibilities that we couldn't do before, and this was a quote from it, it says, yet the pandemic has been a potent reminder of exactly what tech can and cannot replace, nobody thinks a Zoom happy hour is a satisfying alternative to anything, does anyone here disagree with that? So again, and it may be, again, this is not a research paper, this is the opinion of a reporter who wrote it, but we're gonna see a lot more interest in different types of using phones in different modalities, and again, let's say, even if you say, John, I never wanna use text-based therapy, that's ridiculous, why do I even have to care about it? And has anyone been to Reno, Nevada? It's actually pretty fun, but Reno, Nevada, during the height of COVID, you can see they passed a resolution, it was approval of agreement with Talkspace to provide remote counseling services for approximately 200,000 people in Reno for 1.3 million, so the city of Reno used its COVID relief money to not fund local psychiatrists and therapists on the ground and made a contract for Talkspace because they said, this looks interesting, it could potentially increase access to care, and I think my challenge to all of you would be, as issues come up wherever you live, whatever politicians you interact with, your health systems, there's gonna be pitches coming up and you need to be able to say why this could be a good thing or a bad thing, again, so I'm not saying you need to use it, maybe text messaging therapy does work and we should, but we'll return to what happened in Reno, so you can see this was actually in 2019, I think they started it, so we'll look at the 2021 update later in the talk of was Reno happy after 1.3 million, were they not happy after 1.3 million, so again, even if you don't love this stuff, you need to be aware of it. So I think if we're thinking about using smartphones and kind of embracing asynchronous telehealth, I wanna put it into three models we're gonna talk about and what are three different ways you can begin to deploy it the first one will be self-help based, can you give all your patients resources, can you say, here's a mindfulness app, here's a breathing app, here's a CBT app, I think we'll talk about, there's a lot of them, the second way you could go, well, maybe I should have a guide, someone to kind of help people use the app, I can't support them, but I'm gonna have one of my office staff, I'm gonna have a coach help people use it, the third model could be, you're gonna integrate it into your care, you're actually going to be using that app and telling people what to do outside of session, so that's more a hybrid model and I think each of the models has potential, we'll quickly look at some of the data, some of the challenges on each of them, so I think one of hybrid use perhaps is the easiest for us to consider, you're saying to a patient, I just saw you for a synchronous visit, we are together, why don't you use this app outside of session to track your mood, to do CBT skills, to do X, Y or Z and Kaiser Permanente, clearly more West Coast healthcare provider has certainly embraced this, this was a paper from New England Journal of Medicine catalyst in January 2021, but even before COVID, they were actually having prescribing apps after sessions to patients and they're an interesting use case because they're both insurer and a provider, so it's a little bit sometimes easier for them to do things, but Kaiser Permanente said they were prescribing tens of thousands of apps, they have a small library of apps and we'll talk about building a library, but this has been done before, at a relatively large scale, using this hybrid model of apps, it doesn't create access to care, if you're not a Kaiser member, you don't have a visit with a Kaiser doctor or therapist or psychiatrist, you're not going to be increasing access to care radically, I think what we don't know is what does it mean that we have patients perhaps doing more things out of session, does it increase quality of care? We hope so, does it increase outcomes? We know it's feasible, we know a huge healthcare system can do it, but I think we're still learning a little bit about what are the outcomes in it, there's many things we know we love to do in healthcare that don't sometimes make a difference, but again, maybe this one will, I'm going to give an example from our clinic in Beth Israel, this is our clinical director, Michael Goldstein, and we'll come back to this example if we call a digital clinic at my hospital, Beth Israel Deaconess Medical Center, we're not very original in naming things, so we thought digital clinic was a great name to cover a lot of different technologies, but you can see that, so Michael or I would be seeing a patient and after the visit we would work with them and say, hey, we want you to access these tips and learn them and read them, or we want you to do something on the app, and it's been an interesting model to practice in, and I'll keep building on this, so you can imagine Michael and I are seeing people referred from primary care of depression, anxiety, and we're doing, again, a synchronous visit, we're billing as a normal visit, but we're having to do a little bit extra outside of it, so this is, again, that hybrid model of care, and I think one thing we have to acknowledge is starting to use apps or new tools in care takes a little bit of training, because no one really covers this in medical school, in residency, one of the projects I'm part of is SMI Advisor, we have a ton of free educational videos and resources on the website, it's a project funded by SAMHSA, there's no catch, there's no got you, there's no secret things, but if you want to get a ton of CME videos on demand or different resources, I would go to it, we have ones about integrating apps into care, looking at how you can work with different populations, how can you work with patients with psychosis around this technology, so I think it's a nice free resource, and I'm biased because I put a lot of resources up there, so I think hybrid model three can work, but again, it takes a little bit of training, we're learning more about it. Hybrid model number two of having a coach is becoming increasingly popular, and this may be something that if you ask your patients, have they tried a mental health app, have they found one, increasingly there's a coach, and you go, why do we need a coach, the whole point of having an app is that it's scalable, people can be using it around the world, there's good data, this was actually on the left from 2019, this is from 2021, but if you hand an average patient a smartphone app, even one that is, we'll say better, the decay curve, the drop off is going to be fantastic, you're gonna lose 95% of people in 10 days, they're just not gonna be using it. The Veterans Administration puts out a very good library of free apps, you don't have to be a veteran to access VA apps, you can refer your patients to them, this was a study they did on an app they made called COVID Coach that helps with stress around COVID, I know no one who would not benefit from stress reduction around COVID, but you can see in the paper they say, people used it briefly for about a week or two, but then about 95% of people were probably not using it, so again, we're not seeing long-term sustained engagement, and that's where this idea of coaching has come in as one potential solution, and I think task sharing makes sense, we certainly know, especially other countries have become very adept at using task sharing, but you don't need to be, perhaps, a board-certified psychiatrist, therapist, social worker, nurse practitioner, peer, to help someone engage with an app, and this is a quote from actually a report for the government of Australia, kind of thinking about what would their national digital mental health framework be, and they were saying, we'd like to establish clear digital mental health training, development, and certification pathways for non-professional practitioners that include peer support workers, care navigators, and lived experience workforce to equip them to write skills and knowledge to use digital tools and platforms effectively, so could we have a kind of new member on the healthcare team that helps support and implement and roll out these technologies? There are a lot of different companies, again, offering coaching right now, when your patients may be signing up for this, because again, if there's no coach, engagement is usually very low. This is one of my favorite headlines, it's from 2018, but its basis launches consumer mental counseling app with almost $4 million, it's impressive, and it says, the app offers 45-minute counseling sessions with trained but unlicensed mental health specialists for $35, so as soon as this headline came out, I think the public laughed. They said, why would you pay $35 to talk to someone? It's not, they're actually bold that it's not a professional person you're talking to, and again, we don't want to have, start charging money for things that are free, of talking to a friend, or making connections. So again, I think we see a potential for coaches, but we don't want to, again, start charging people money for things that hopefully should not cost. We've done a review, it's down here, of looking at different coaches, and I think one issue is, who are these coaches? We often don't know. They're often, they may receive five hours of training, 10 hours of training, maybe it's terrific training, is it the same coach every time? So again, I think this kind of new mental health professional is evolving, but currently it's evolving in a very chaotic way, there's no regulation, there's no oversight, there's not many standards, but I think it's something we can't ignore. Going back to kind of thinking, is there a way to standardize that coaching, if we're gonna be having people use these asynchronous apps, and we need that engagement to be high, perhaps what we could do is, again, at least think of, what are some basic competencies we want people to have? So this also goes back to SMI Advisor, but we have a project called Digital Navigators. And the idea is a digital navigator could be a peer, it could be a volunteer, it could be an experienced clinician, but they would be able to help you sort through the mess that is the iTunes and Android store, help you select what could be a useful tool, they'd be able to help you and the patient with technology set up and troubleshooting, resetting your Android password, clearing memory to download an app, and they'd be able to do app data preview and summary, helping drive engagement, make sure things are working. So it's not a clinical role per se, but later in the summer, we'll have a online training that will be available, and we'll keep basically testing it and hopefully building a registry of different digital navigators. How do they be deployed? We'll learn. How do they be certified? We'll learn. But I think there is some need for some standardization in what these coaches could be, because right now, the marketplace is pretty wild for how they operate. So if we go back again to the digital clinic we have, if you see in this headline or here, we have the synchronous visit that Michael and I are doing with patient. We have the app asynchronous, but we also have a digital navigator we're using. So the digital navigator means that Michael and I can focus on seeing the patient, then we'll say, digital navigator, can you help Ms. Jones track her mood on the app this week and help her find a mindfulness app? Because that's not a good use of our clinical session, to be downloading an app, helping her find one, and then what the digital navigator can do is bring that data back to us in the session. Most apps do not dump data neatly back into your medical record. A digital navigator can say, hey, Mr. Jones used the app, here was his average PHQ-9 score, and he reported this. So again, in some ways, a digital navigator could be a useful glue for making this work well. I think if we look at self-help apps, so again, we've looked at kind of hybrid, you're directly integrating it, there's a coaching model, and then of course, there certainly is the most scalable model, right, of everyone downloads an app, everyone has mental health in the palm of their hand. This is terrific, right? We've solved the problem, we can all go home or go in a riverboat. And I'll say from my role as editor-in-chief of JMIR Mental Health, which is a technology journal, we publish generally smaller pilot studies that are exciting on digital mental health. I am the web editor for drama psychiatry, so clearly drama psychiatry looks at certain larger papers that come through, and I'm one of the field editors for NPJ Digital Medicine. So I see a lot of the research coming through on digital mental health. And a lot of it's very exciting. It's a field that is going to get better, but a lot of it is very early, if we're gonna be really honest with ourselves. And I think we just have to say, the question is like, do apps actually work, right? The fundamental question, if we're gonna tell someone, use a self-help app, do you have confidence to say that it will work? And this was a meta-analysis that we put out in January of this year. And what we showed was, there's a lot of research on apps, and that's terrific. We want more research. A lot of the research are uncontrolled pilot studies done by companies that may have a bias. And that's the first step in research. You wanna say, hey, people could use it when there was no control group, it was okay. But if you look at kind of what has the biggest effect size in research, the apps have a pretty strong effect size when you look at an inactive control group. You say this group got the app, and they got CBT on the app, and this group got nothing. And I think the real question is, is that valid to say nothing? And I think the answer, what I'll show you in a couple cases is no. This is a brand new paper that came out in March of this year. It was actually a study by Novartis. And Novartis actually did a study on an app for schizophrenia. And it's called PAIR-04. But I'll read two quotes from the paper. So it says, this is a 12-week, multi-center, randomized, sham-controlled, radar-blinded, parallel control group, proof of concept study of 112 participants of moderate to acute exacerbation of psychosis. So they were given a mental health app that offered different types of psychosocial support, information, resources, something that would be useful. But what was interesting is it said, similar to PAIR-04, the therapeutic one, the sham app delivered three daily notifications, prompting the participant to open the sham app, then displayed a prescription timer, a digital clock for the remaining duration of the app availability. So if you were randomized to the sham group, you would open the app and it said, you have 10 days left in the study. You have five days left in the study. The study is over. If you were in the control group, you got this app with all these features. And this is actually rare. We don't have a lot of studies, right, that have any type of control. And you could say, John, a clock versus a whole therapy app. Come on, it needs to be better. This is not fair. But what's interesting is the results of the study, they said, well, people that got the full therapy app, they got better. The clock group did nearly the same on all metrics. Their PAM score, for those who do psychosis research, it went down. And again, that's not a bad thing, where it just says, what is going on in these apps? This is exciting. What is the active ingredient? And this is not the first time in the history that we've had control groups. We don't have many control groups. This was a study where a group in Bath, UK compared Tetris to a well-known mindfulness app. And they said using Tetris seemed to be just as good and was free. And again, this one on BMC psychology by Chris Noon, he actually got Talkspace to agree to do sham mindfulness. Whoever's narrating the mindfulness actually kind of didn't talk about mindfulness. They talked about something non-therapeutic. So they took out the active ingredient. And what happened was both groups of students were like, wow, we feel better. So again, it's not that apps don't work. People are getting better. But we're going, what is the active ingredient? What is working here? And how can we scale that up? And if it is something basic, then we need to understand what it is. But again, we want to really ask for high-quality evidence and research. It's not enough that someone comes to you and says, well, one group sat in a room that was dark, and they got snakes thrown at them, and they felt depressed. Another group got an app, and they felt better. That's not the type of research we want. We need to have these high-quality studies. So we may be saying, what's happening in these self-help apps? Why are they not working? Is it because of low engagement? And we saw that one solution is the coaching model. One solution is the hybrid model. Is there an active ingredient that's missing? Or is there an active ingredient that comes through these apps? Is it something else? But this may be one of the most hardest questions. And there's interesting papers coming out looking at why do people engage with health apps? And again, usually these papers are well done, and they have terrific citations. But they'll say, well, let's talk about the care team role. Does it fit into the patient journey? Is it interactive design? Is it educational support? It's complex. It's multifactorial. But I think one thing that has always intrigued our team was we thought back to Winnicott and object relations theory in some way. So could it be for some patients, and clearly not all, but is there something that if you're using a smartphone that you're part of a study, you feel a connection to a treatment team? You feel a connection to a medical center? If your therapist or psychiatrist says I want you to use this app to check in your mood every day, do you feel that you have a stronger alliance with your clinician? Again, if so, that's a terrific thing. We always want to increase the alliance, right? I think we need to say, well, that's the baseline of how effective apps are, and let's do the real work to make these apps even more effective. So again, we like the high-quality research, but we want to make sure that we're not reinventing the wheel, or if we have a 21st century teddy bear. So it would be a fascinating app, right? Just a teddy bear app and see how people react to it. Always new idea. But again, as we're learning what apps work and don't work, you have a hard decision because you're going to have patients coming out and saying, what should I use? Does it work? So with the American Psychiatric Association, we've built a app evaluation model. The idea of the app evaluation model says, we should first look at the risk of these apps, then the benefit, ease of use like tolerability, and then what are you going to do with it? So again, this is basic clinical decision-making. Some people say, well, why do you have to look at the risk of an app? At the worst case, it's not going to be effective. But I think what we've learned, and this is a report from May 2nd from the Mozilla Foundation. It says, when it comes to protecting people's privacy and security, mental health, and prayer, so we're not alone, and prayer apps are worse than any other product category Mozilla researchers have reviewed in the past six years. So if you want a sobering read, type in Mozilla Foundation Mental Health Apps. It'll actually give you a review of apps that you made under name, and tell you what some of the privacy flaws are. It's a little bit concerning that, well, why prayer apps? I don't know. It's a whole different story, but let's keep this secular. So we'll jump on. Our team at Beth Israel has taken the APA app evaluation framework into a database that we call MindApps.org. You can access this today, it should be live, and you can get on your smartphone, you can share it with patients. The idea of MindApps.org is we have filters on the left. So you can actually go into privacy and say, show me of the 600 apps you guys have rated, show me the ones that have a privacy policy. You want that. Show me the ones that keep data on my device. Maybe you want that, maybe you don't. Show me the ones that do CBT. Maybe you want that or not. But the point is, with MindApps.org, we're not going to tell you what the best app is. We're not going to tell you what the worst app is. We're going to say, here's a way to search apps beyond stars. Here's a way to search it beyond what comes first in the iTunes store or the Android store. And again, it's an interesting thing to share with your patients. You can see here I put on a filter of totally free because my patients get really upset when I recommend an app that's freemium. And after a week, it's like, you should start paying money and you have to stop using it. So if you put in a filter that says totally free, has privacy policy, can delete data, can opt out, see what comes up. It's always fun to explore what's on that database. So again, if we look at the three models, I think hybrid care is interesting to use apps. Kaiser Permanente is making it working. We're learning more about guides and coaches, what could be there. Self-help apps, they can make people better, right? It's not that those studies were making people sick. But again, we're kind of curious what's happening, what is the active ingredient for it. And quickly looking at what may come next with smartphones. We've been focusing a lot on kind of what the app can offer your patient in a therapeutic sense. Clearly, apps run on smartphones. Smartphones can also take in a large amount of data, right? So your phone probably knows exactly where you are right now because it has GPS on. It probably knows what time you woke up at because the accelerometer or the alarm started vibrating and the phone picked it up. So already, you may have how many steps you took or what time you woke up, which could be useful information for behavioral health. And of course, this brings up certainly many ethical issues about what would happen with that data. But we also can't ignore that that data exists. It's being collected. So you could say, if we're trying to offer more personalized care, if we're going to need to use these devices, it would be nice to be informed about what behaviors our patients are happening. So that's what we've done in our digital clinic. Because of perhaps the interesting app marketplace, we built our own app. We're very transparent. We share all of the code of it on something called GitHub. So you can take our app, you can download it, it's open source. But we basically said, well, we can make a mindfulness module as well as anyone else. So it's not overly hard. We can certainly put up CBT exercises. But with permission, with patients, we say, in certain cases or research studies, we say, can we also get information from the back of the phone, from digital phenotyping, from sensors? So in some cases, I may say a patient, is it okay to get accelerometer so I can kind of learn about how much time, or your screen state, how much time you have on the screen? So the patient may see the front of the app that's doing all the therapeutic exercises. With permission and consent and numerous privacy protections in place, we could be getting interesting information, right, about how many steps someone took, their home time, about metrics that would kind of help us guide and inform care. So in doing this, we can generate lots of interesting data. We've built a whole data portal to share data back with patients. And it's actually become a very fun way to practice, because we don't want to go over every graph all the time. But you can imagine, patients like learning about themselves. Many of my patients will say, like, I took a Harry Potter quiz What character am I? I guess it's useful. But it's more interesting to say, well, what does my step count look like? How does my step count correlate to my mood? So even getting my patients to do these, I call them kind of small experiments. It's tremendous. It makes it exciting. We don't spend a lot of time kind of talking about, well, how was your sleep? And again, the smartphone data isn't always right. We always say, hey, it's a phone. You may have left it at home. But let's talk about what it could mean and what that data could do and how it tells us how we're making progress towards your goals. And I think used in that frame, the sensor data becomes very exciting to work with. So we go back to our friends at Reno who started with that. So it said, Reno Mayor hopes transition patients back to local therapists as Talkspace contract ends. What seemed to have happened is no one in Reno actually really, less than 0.01% of people actually ever engaged with the service, even though it was free. And there's no data on, did that mean they just signed up? Did they actually have a session? What did they do? So it's an interesting one to figure out. And again, I don't have all the data. I just have the headlines as well. Maybe it worked very well for some people. But again, Reno has ended its interesting experiment with this company. So going back to digital clinic, I think you can see now how we have, of course, therapists. We're doing synchronous telehealth. We have digital navigators. We're using the app for digital phenotyping. We're customizing it to people. And I think if you put all of those together, so it's a little bit of model one, two, and three, it certainly could be perhaps a way to increase access to care. So our lab's website is digitalpsych.org. Again, we're not very original at naming things. But you can find more information there. So thank you. Thank you. So we're going to take questions at the end. So I'll try to make my stuff quicker, because obviously, it's hard to come after John. So anyway, this is sort of, many of the things I'm talking about here are pretty obvious, right, social media and mental health. I think obviously, to me, the way I see it is that social media made technology more accessible, easy to use, and engaging with, you know, people that are your friends. And so you get to share pictures, stories, et cetera. And I think that has helped the sort of adoption of technology, the comfort of technology and engagement that I think why in the pandemic with apps or telemedicine, you know, there's a sort of frame shift of adoption. And I think that, you know, this is where patients and providers actually became more comfortable with the idea that does everything have to be in person? And part of it is just because social media are just a way to tell stories, right? In a way, it's kind of great that you can tell one story to many people at the same time, because they're your friends. And so they get a copy of the feed. It's kind of like a digital broadcasting platform for your friends. So, you know, and sometimes things happen. This is one that I found where you could say it's creepy or good, right, but the facial recognition algorithm in the photos of Facebook had these two people go, wait a minute, they're the same person, but they're actually not. And so they actually thought that they were twins that were separated at birth. And so then that created an interesting story. So this is sort of the Facebook equivalent of, you know, using 23andMe and discovering relatives you didn't know that were there. So anyway, but the point is, the technology is great. It enables this newfound information or sense of who am I and how do I connect to the people that I love or people that share common interests. And of course, while on Facebook, people do many things, right? We have news agencies that publish feeds as, you know, my wife gets most of her news actually on Facebook and she'll like click on the link, watch her, even while she's exercising, you know, she's getting the local Channel 5 feed on this news article and telling me about it. I actually rely on her for lots of things because I really suck at Facebook, to be honest. I don't, I'm beginning to use Instagram a bit more, but I have reasons for that. Part of it is I just feel like I don't have time to, you know, sift through all these pictures, but she'll tell me, she goes, hey, John, did you know that former resident of yours at UCLA just had a baby girl? You know, I'm like, no, thanks. That's good, that's good for me to know. But anyway, so the point is, you know, and Facebook wants this, you know that, and I say Facebook only because that's pretty much, let's just admit it, that is the major social media platform now. No one's really competing, but right on the plane, people are checking their Facebook feeds, et cetera, you know, everywhere, right? Or probably some of you in the back here who are not paying attention, which is totally fine, are probably checking your social media feed like, oh God, what's up next? Oh, I'm gonna hook it up with my friends, you know, because this talk is so boring. I thought Dr. Loewy could be more interesting, but Jesus. I already know this stuff. Anyway, but the point is everything's connected together, and it's pretty amazing. But also it has power, right? There's this person that shared on the story directly that his, and you know, it's assuming some of the friends were there, that he was suicidal and planned to overdose because he was tired of his chronic drug use. And of course, now Facebook has built in, you know, these AI to read these chats and stuff like that because if there's a danger, then it can try to alert the authorities to where you are to do a welfare check. But in this case, one of his friends happened to be on and therefore contacted local authorities to take him to the hospital so he was able to get treatment, right, in acute psychiatric hospitalization. And therefore he says, my friend saved my life, right? He got into rehab and things got better. So isn't it, it's just amazing, right? You're alone. So think about here in the pandemic, right? Hey, I can't go to the market. I can't go, you know, to restaurants. I don't visit my friends because before we had the vaccine, how could you stay connected? And so social media became, I think, really a way to kind of unwrap us with using the technology to kind of stay connected. I discovered for me that because, you know, as a CL psychiatrist, our hospital policies, we still had to go in. So I enjoyed, if you will, although with some risk, right, that engagement still, because while I was a skeleton crew of residents, no staff, just residents and a few other attendings, you still saw people, I still had that engagement. And of course I had the other anxiety, right? What if I bring COVID home? And therefore I had to follow a sort of strict, you know, almost, John, you got to shower outside. You know, we almost practically put an outside shower. Fortunately, there's one right in the house. I get too straight, but I didn't even say hi to everyone. I just went straight to the shower, scoured all that kind of stuff. But the point was that, you know, I think, you know, whether it's Facebook chats or groups or even text threads or people using Zoom, we all use the technology to stay engaged and together. Otherwise, you know, and although that obviously wasn't enough because there's still this sort of mental health crisis from this pandemic. So you can see here, you could still get access to services in a way. You could get peer support by going to an anxiety and stress disorders groups. And many of these groups are totally not moderated. It's just people providing a little helping hand or, you know, comforting words, kind of like John talked about, like, what is the app really doing? What's the magic in it? If just a clock could get people to be feeling better. And so I think, again, many people turn to social media and these groups to get a sense of like feeling not alone. Same thing goes with families of schizophrenia. So while NAMI, you know, creates these great groups for families to get together, but, you know, and every organization is very different. How quickly can you pivot, right? You heard, for example, you know, I'm very lucky that at a major university, University of California, Irvine, we literally flipped the switch in two days and went from mostly a hundred percent of in-person visits to virtual, right? Because we already had the technology, but I noticed a significant lag that the county mental health clinics were literally like three, like almost one or two months behind us. And therefore I saw a huge uptick of patients in the emergency department because they couldn't access their meds. They couldn't get refills and things of this nature. And so, and basically this is what social media has done, right? It's helped us bring the world a bit closer together. So I think that, you know, we collectively, both patients and providers are more comfortable with technology, sort of embraced it. But as you're hearing here, there's different elements that we have to figure out what makes sense to, for the, what we're trying to achieve. So other social media includes, this is actually from the World Health Organization. It's trying to educate on depression. So people go to social media like YouTube for understanding their symptoms, what they might have. In fact, I actually have a patient that said it was, you know, he was struggling with focus and concentration. And he said that YouTube gave him hope to actually get help for what he thinks was attention deficit disorder. And mind you, this is very interesting. This is the patient I treated 15 years ago at UCLA. I forget now, because I don't have the medical records. I think there were paperback then, what I was treating him for. But then because he had that connection to me, he found me using Google search engine and realized I was now at UC Irvine to engage with care because he trusted my judgment, trusted, you know, that engagement with me, that I was gonna give him the straight scoop, you know, not just, you know, give him a pill if that's what he wanted. But anyway, but the point was that this is all because he, you know, did some research, but the YouTube videos he found really informed him and made him decide to get care. And of course, YouTube is also used for professional purposes. This is one of my colleagues, Dr. Gabrielle Cora, who has a professional YouTube profile. Now, I'm not saying that, you know, everybody here has to leave. The take home is start your own YouTube channel. I think it kind of depends, right? What's the goal of it, right? Is it to get more brand awareness of your clinic? But I think in her case, it's more that she's a media person, an expert, professional coach, things of that nature, and really shows up on lots of TV shows. So it's more in that space versus I think trying to attract more patients. And Twitter even, right? Twitter is probably not used for community supports, more about people expressing opinions, stuff like that. But, you know, there's actually people that talk about depression in Twitter. And, you know, but it's also used for professional purposes. The medical educators also use Twitter to communicate. I think, let's see here, it's every Thursday night at nine o'clock Eastern. And so they just have a Twitter chat about topics. You know, so it's totally, it's synchronous, but not visual. It's just tweets between people that are interested in this topic, so. And I think about Facebook, right? You know, I learned a while back, I think they probably moved on to some other platform, but they won't share with me. Residents at the APA meeting, I always wondered how the heck did they figure out where this reception was, or what thing was cool to go to? Well, one of them said, oh, come on, John, come and get with it, man. I thought you were the technology guy. We use Facebook and we share all the resources there. And to me, I'm thinking, oh, I never thought of that. But it just tells you how, even when you think about, you know, the APA meetings app, which I think is quite good, far cry from many years ago. So I think there's definite improvements that our organization has done to try to help us stay engaged. But, you know, I think that one of the challenges is that, like you've heard a bit here, is there's places, there's information everywhere. There's, everything's not perfectly integrated. And so it's hard sometimes to, you can imagine, right? One of the challenges we face is that as Jay was mentioning, the digital natives versus the digital immigrants. I'm actually a digital immigrant too, even though I'm fairly tech savvy, I still love, you know, the crisp, wet, from the lawn newspaper. I can't read the newspaper on my phone just because it just doesn't engage me enough. I don't think I can find serendipitously from the headlines. Even though I can get the PDF version, it's just not the same. My brain cannot engage and find information. And so I think that, you know, one of the challenges we have, and this is where I think, as John Torres was mentioning, having digital navigators to help people outside of the clinician, get people to use apps or to turn on their video, things of that nature is really important. But I think this also gets back to user interface. Can we make it easier, right? Because there's too many buttons, you know, to learn. And, you know, although you would argue, like for example, for those of you using Epic, for example, as an electronic health record, it's a very powerful system. And so it mandates, you know, that you get at least a half to sometimes a full day of training to use this. You don't make mistakes, but can we get it to the point where, you know, the technology is, if you will, you know, idiot proof? I don't know. We'll see. But Facebook has this young psychiatrist network. So people now, so this is like where psychiatrists are getting their own kind of help. They kind of give each other advice. And so, you know, I've heard one of my former residents say that she belongs to a, you know, women professionals Facebook group. And, you know, she can chat with OBs who, you know, get curbside consults, not necessarily somebody in their hospital, but somebody across the country. And so we're seeing this sort of trend where we're getting more comfortable, both as patients and providers, with this sort of integration and connection everywhere. It's sort of challenging though, to figure out which one's going to work. I thought this was interesting too, right? I talked to another psychiatrist at a meeting about the physician support line. So those who are getting burnout, being on the front line due to the pandemic can actually get, you know, support with psychiatrists to do assessments, provide online treatment as well. So, but this is all great, but let's not, I just want to think, kind of John talked a little about this and so did Jay, but there's some areas of concern when it comes to social media use, right? Well, of course we have to worry about HIPAA, right? As providers, we have to make sure that we don't post something like stupid patient tricks or the extent of the injury or describe it in much detail. Because obviously when you say, oh my God, I couldn't believe in the ER, I saw somebody with a forklift tying through their leg. I'm sure that's not a very common injury and I'm sure somebody will figure out who that is. Because these things, obviously, because of HIPAA, we have to be careful what we say. And so this is a constant thing where, although we're doing better job in training with medical students and residents, like, you know, maybe you shouldn't post that, that'd be good. But then used to be as training directors, I'm a, I think a third time training director now, there was this sort of sentiment that, well, you couldn't be on Facebook with your trainees because of the sort of relationship in a sense that you're kind of an employer and they're an employee. That's how some people thought about it. But then I thought about it as, well, you know, in a way I'm also kind of a paternal figure and so if I'm not connected to them, how do I know what's going on? And when they do something that's inaccurate, how can I educate them? And so there's a sort of tension and no one's figured out perfectly how to handle that. Although I think nowadays that barrier and discomfort is less. I noticed that my daughter, for example, doesn't share cell phone numbers with people that she meets on campus at Chapman University. She actually gets their Instagram handle, puts that in and that's how she kind of communicates with them. And so I was like, wow, mind blown because I never thought about that. And the other thing too, right, is social media is great, but it kind of creates a sense of familiarity, but there can be boundary issues, right? This whole idea of can your patients see and be connected to you on social media, that could create problems where the accepted social, physical and psychological boundaries that separate physicians and patients is lost, right? On one hand, it's good to have digital navigators, other tools, but where are we in terms of being able to say to our patients, I'm at a conference, you really, you gotta call the person covering for me because I can't address your issue in a timely manner. And of course, if you don't know how to use social media, you just gotta be careful, right? This is the Columbia psychiatry chair, Dr. Lieberman, who unfortunately, I think was not intentionally trying to make a bad racist comment, but because his tweet was, you know, controversial, he was stripped of basically his chair position and is now, I think, I don't even know if he's still on the faculty, but the point is, you know, in social media, once you screw up, you're a host, basically. So what can you do to manage your privacy and reputation? Well, of course, you should get alerts, I hope many of you are doing this, right? You should have in Google or Yahoo alerts when people are searching for you, they won't tell you who they are or where they're from, but at least you get some sense that, whoa, somebody is like stalking me, right? And you know, the other thing we have to keep in mind is there's another social aspect, there's physician ratings, and I've, okay, no problem, wow, this is great, I never thought anybody would want to take a picture of my slides, this is awesome, I was just kidding, I was feeling kind of sad because I noticed I was taking pictures of J's and John's, and I was thinking, yeah, my stuff is pretty boring, all right, cool, but you know, physician ratings, this is affecting us, in fact, just last week, I got a notice from health grades that I got a new physician rating, so I went and I saw like, oh, anyway, we'll go here, this is RateMDs, so I didn't have any ratings here, but what's the problem with physician ratings? Well, anybody can rate you, and even you could, although this is ethical issue, right? By the way, I just did this for educational purposes, so that's my bias, but I thought, well, I'll give myself five stars because no one else was giving me one, and so that's the problem, right? We all know that only patients who are really unhappy with you are going to complain and kind of give you poor ratings on social media, but you know, so this is where the problem with, they say, oh, no, don't worry about it, Dr. Lowe, if you really are concerned about it, just pay us, you know, like a thousand, and we'll bury the poor review somewhere in that site. So, here's another one, vital, so you can see I got a 4.5, but anyway, that's not scary. What's scary is they're actually not just Google as a search engine, they're actually companies that do specific searching on you, the individual, so these are what they call people search engines, like PQ, True People Search, PIPL, Spokeo, et cetera, I'm not getting into them, but I'm going to show you a couple, and if nothing scares you from all the stuff that you've seen today, you definitely need to check this out, and part of it is you've got to accept, I think, in a way that, well, there's information just out there, but everything we do, whether it's social media, apps, all this data is being collected about us, and so somebody knows who we are and what we're about. So, for example, PIPL, this is an older picture, and this is a bit older, obviously, because I was 50 at the time, although I think I still look young and charming, but it does say that I'm at UCLA, so that was inaccurate, because I was at Riverside then, and it has inaccurate information that I'm an owner at Moriso Corporation, which I have no idea what the heck that is, and I got an EMBA from China Europe International Business School, like, oh, cool, I could add another title, but the reality is, actually, so one could argue, oh, this is horrible, they don't know who I am, really, but actually, I look at it as, oh, good, there are other people out there that have John Lowe's names, therefore that's throwing off the scent as to who I am, but it can be frightening, because they have accurate information, they pull different databases, stuff like that, so this one Spokio, actually, I can tell you, although I guess I am being recorded, so I have to be careful what I say, but I'll just say one of these is actually accurate in terms of it listed who my relatives are and where I've lived in the past, and so that's kind of frightening, and then let's not forget image search. Image searching software has gotten much more powerful, and you can see here, looking on John Lowe, of these dozen images, only three are accurate, although I want to point out this one guy here, actually, is also John Lowe, was actually a med student at Brown who went into geriatric medicine, and I've noticed lately that he's been going under the moniker of Johnny Lowe intentionally, because I think search engines get the two of us confused, although I think I'm a bit more handsome than him, but anyway, but the point is he has a company that actually sells insurance, and I'm positive that he's got tired of being mistaken for when people are searching for me. The other way I look at it is I was actually hoping he would go into psychiatry, because then I would have a true doppelganger where I could pawn off all my other search engine hits, but oh well, didn't happen, and then there's another one, cluster maps, this one was pretty frightening, and I blocked it because this information is actually accurate, my current address, and it has my former address that I think I don't have to worry about, but this is kind of creepy, like it had my rent value at the time, like whoa, what kind of data does this site have on me? Anyway, I wanted to end because I wanted to give some time for us to talk, this is my contact information, you're welcome to, you know, email me, Twitter chat with me, find me on LinkedIn and on Instagram, if you wish, but I'm going to sit down and really want to give us 15 minutes to kind of engage and field questions from all of you, thank you. Thank you all for this very informative and exciting presentation, my name is Koda Aduban, I used to be in Boston, now I'm in Birmingham, Alabama, and you know we don't read there, we eat clay, and we don't know where the computer is, but anyway, we got scared in our group by the malpractice attorneys, who told us do not share your email address with the patients, ever, and be extremely careful how far you get involved in this telegame, and don't be reachable 24-7, and make clear you have clear boundaries, and if you can, go back to in-office care. They didn't specify what the details of the risk were, but they said it's a headache, and I just wondered if you could comment on that. Well, I think my sense is that, you know, first of all, patients will find your email no matter what, it's not that hard, especially if you're in a university setting, it's just easy, because it's just there, they just go to directory dot whatever, and then, you know, you're pretty much stuck, but I think that the key is, I think your documentation, right, you need to say, and document, and show, or whether it's creating a policy that says, look, you know, I'm not available 24-7, but it says, you understand, if you contact me via email, there are risks. First of all, you can contact me by email, but I can't contact you in the same way, unless I use secure messaging, and many major systems have a way to designate that, but, you know, same thing with phone numbers. I mean, come on, I have spam phone numbers calling me, a real estate agency sending me text messages saying they want to buy my house, because they know it's worth a lot. Good God. But, you know, with patients, actually, this happened to me, I thought I had copied the patient's phone number to an app that was supposed to be secured and masked by number, but somehow my number went through, and so my patient got, you know, got my phone number, and I'm thinking, great, this is not good, but, and so she has schizophrenia, and slight developmental delay, and so she would call me periodically, and then I would have to talk to her, and I would constantly talk to her, and say, you know, if you call all the time, I don't, you know, I'm a busy doctor, and not to say you're not important to me as a patient, but, you know, I just can't answer all the time, and so if it's really, and I don't know when it's a crisis, and I'm not available always, and so you have to have those conversations, and I think you have to document it, so I think those, unfortunately, are kind of back to old school ways, but that's what you have to do in order to set boundaries and expectations, and yes, there's malpractice risk, but you know, I also think that a patient having, I think nowadays, there are actually some psychiatrists are very comfortable giving their cell phone number out, or their Google phone number out, just because who has a landline anymore, right? I mean, no one's, some people actually don't even have home phone lines, so this is the way you have to contact them. Anyone want to comment on that? All right, next. You mentioned AI on Facebook as potentially intervening on patients, and their suicidal ideations are concerning speech patterns, and also mentioned some of the back channel data that you're able to collect in some of the apps that are under development. I know in geriatrics, they're working on sort of using some of that back channel data for fall risk and outreach to their patients' providers. Is there anything in that avenue regarding concerning patterns of cell phone use, internet histories, to create alerts for providers regarding their patients? I don't know the answer, but there's a geriatric psychiatrist called Ipsit Vahia at McLean, who's done a lot of work on exactly technology and older adults, so I would almost, he would be the world expert, Ipsit Vahia, and he's not at the meeting, unfortunately. Hi, thank you for the great discussion. So just looking at kind of how social media has played out nationally, the flood of misinformation, you know, fearful messaging, how that kind of stuff gets pushed by the algorithms. Are our efforts to improve digital health literacy and reach our patients, are they drowned out or even negated by this phenomenon? I don't think so. I think that, again, it comes down to the relationship, right? And this is where, you know, I have patients now, right, that I've actually had a scene in person before all this technology was great, but now the technology's enabled it so that they can see me digital by video conference, so that way they don't have to travel long distances. So for those of you who are familiar with geography, when I was at UCLA, so the patients lived on the west side of Los Angeles, but to go to see me at Riverside was literally like a almost two-hour drive, and some of them actually did, but now that I'm in Irvine, which is not as far, but you know, LA traffic really bites, you know, video technology has been great for them to come see me. And so I think that, you know, if you have a connection with the patient, you can sort of explain how there's misinformation out there. It's no different than if they say, oh, I was on a forum that said, you know, the antidepressant you recommended to me was really bad. I'm like, well, let me see that. As long as you continue to engage with them, then you're able to, I think, address those issues that are raised by this sort of falser information. But it comes down to ultimately rapport, connection, you know, alliance. If you have that, then I think, you know, you as the provider still have, you know, that domain. In the digital literacy work, when we reach people with psychosis or bipolar, they're very receptive. And again, as people, they learn how to use these devices quickly. They've never been formally trained. I think the biggest barrier we've run into is not the training per se, but no one can figure out where in the healthcare system would that build? Or who is the digital navigator at digital literacy training? Is that part of the clinic's responsibility? Is that the hospital's responsibility? Is that the county responsibility? So it almost is like a hot potato. Everyone knows we want to do it. We can bring more people onto digital platforms. So it does really generate a whole new base of users. But I think no one really wants to, the economics of it, I think, are the biggest barrier. I'm not sure if there's an answerable question here. But one of my concerns, especially when you're working with, you know, younger people, teenagers who are digital natives and are online, communicating with their friends all the time, is like the concern for bullying, concerns about maybe self-esteem. When you, you know, looking at Facebook and all your friends, they're just posting the best picture of themselves. And I feel like that can really feed into, you know, low self-esteem or problems like that. I don't know if you can speak to that. Well, I think it comes out, I agree. I mean, this is that challenge, right? And let's not forget, there's also, it's kind of old, but there was that kind of, these internet trolls, right? The 4chan, you know, the cutting for Bieber phenomenon, right? Where they tweet, oh, stop Justin Bieber from smoking marijuana, show the cuts on your arms to keep them, you know, as a Facebook, or sorry, Twitter campaign. And so I think there's not much you could do to stop it technology-wise, even though, you know, there's a lot of companies out there trying to be in this space, like Net Nanny, stuff like that, monitoring and stopping. I mean, the bottom line is, even if you have like protections on your phone that say decrease or don't allow the app to be used from this time to this time or this location, you know, teens are clever. They learn quickly how to figure ways around it. So then it comes back to, I think, instead of a protective mode, one really needs to be more in the sort of education mode, right? Like, how do you then engage them and say, look, okay, I understand you found this or that, but, you know, let's talk about it. What was driving you? How did that affect you? And really comes down to, I guess, back to, I still, the answer is just your engagement, because otherwise you just can't prevent them from doing those things. I think there's also, I mean, so that's at the individual level, but I think in this country, there's a huge set of policies above it, right? We know there's an epidemic right now of depression in our youth and social media is certainly one of the complex factors driving that. And so until, if you compare sort of the controls around social media and data and, you know, these are machines sort of designed to suck you in very purposefully. And so I think we, even beyond sort of the profession of psychiatry, really need to look at, you know, reasonable sort of policy, like in Europe and consumer protection. So I do think there's things that we can do beyond the patient if we have the political will, which we may or may not, right? But there's some significant problems we have that will only be solved at a very high policy level in my mind. Good point. Yeah. Thanks for a great talk. The question I have is about thinking about people spending so much time on their phones in various ways and becoming more socially isolated and whether or not we have any sense of, you know, comparing the efficacy of some of these app-based interventions versus motivational interviewing, or just trying to get people to engage in the world, take a yoga class, make more friends, engage in sort of in-person types of activities, and just that general area. It reminds, oh sorry, I was going to say, it reminds me there was a, I think it was a Toyota, I can't remember the commercial, but there was a commercial about how there was a young person that said, look at me, I'm really social, I'm got all these friends on Facebook, blah, blah, blah, and then the commercial was, or maybe it was Subaru, but anyway, it was a car manufacturer where you see the parents going out with people in a car, going like mountain bike riding, stuff like that. So that's kind of getting to what you're talking about, and I think that, I don't have the answers, but I noticed this trend, like my daughter, you know, I guess I could say this publicly, I'm not going to shame her enough to make a change, but she doesn't have her driver's license, huh? You're not here, but this is being recorded, but anyway, but you know, she doesn't have her driver's license, and so, you know, she doesn't want to go anywhere, exactly, and so it makes me worried, but you know, I guess, I don't know the answer. Well, I do think even before COVID, there is this argument, like, particularly like patients who may have social anxiety and social phobia videoconferencing, right, into the home. So on one hand, you may be able to engage that patient, right, in the home, because it feels safer, and it's a way to deal with their anxiety, and then the counter argument is, well, you're enabling it, right, because you're not doing the behavioral activation component of the treatment. So I do think at the provider-patient level, you do have to assess that with each case, and it's really hard, right? I mean, before the pandemic, you could say, all right, I'll, let's do the first couple sessions over video in your house, but now I'm going to make you come into the office, because that's part of your treatment, right? It gets harder during the pandemic if they can't leave the house because of the apocalypse, but now that the apocalypse is ending, I think at the individual level, you're making that assessment of the patient, see how they're using technology, and seeing where it could be causing more isolation, and then working with the patient to sort of negotiate solutions about what's healthy and unhealthy use, just like anything. Don't forget, I think there's also like kind of wilderness camps where they actually put your phone away and make, you know, you can still send your kid to that. Thanks for a great talk. Exciting space. The algorithms are getting better for voice recognition, facial emotion recognition, how you touch your phone like insole. Is somebody working on tying that all together in a way that clinicians can use? I think it, again, if the sensor data is accurate and precise, you could do wonderful things. A lot of these interesting kind of smartphone sensor data sets looking at accelerometer, location, light exposure, they've never been replicated, and I think we've learned right from other research of looking at EEG studies, looking at brain imaging studies. We don't want to just say because we got the first digital biomarker at work. Do you want to say, well, prove it to me in three different settings that this digital biomarker works, and then pair it with an intervention? But what we see is a lot of times people say, I found a correlation, it's great, I'm going to pair it with X, and they try it in a new population, and clearly there's algorithmic bias. So I don't think it has worked today perfectly. I wonder even by next year's annual meeting if we'll have some better use cases of it. All right. Hey, thank you guys. That was an awesome talk. I worked at state government level, so use of social media for good. We do a lot of, we put out a lot of state department type announcements, so resources, call line, things like that, be healthy, do wellness, all that from a state government level. We also put out job postings, so we do things like that on Twitter. You know, we have jobs available in our state facilities and things like that. Other idea I'd bring up is, gee, I'd like to see you guys cover podcasts. I'd like to call out Dr. Torres. Your podcast is awesome. Thank you. And, you know, I mean, speak of telehealth going up, like my podcast consumption went from this to like thousands, just thousands of podcasts. There's a lot of great professional information on there, and also stuff we've, as colleagues, you know, I get colleagues like support, listen to Brene Brown or something out there and all that, and for patient purposes also. So I think podcasts are really awesome also. Thank you. Thank you. Thank you. Okay. Suggestions about, for those of you who didn't do telemedicine for years before the epidemic, like Jay, I mean, Jay and I have been doing it for 15 years, 10 years, 12 years. How to find and track the regulations as they get pulled without getting in trouble with your state board of medical examiner. I'm on the board. We're trying to warn people, but the board here. That's a good question. And at the end of the day, even if you work for the organization, the legal onus is on you. If you really, really want to be uptight, you periodically go to the website for your specific state board and see how those are changing. That's really the only way to stay current. There are bigger resources, like there's a couple good, like C-TEL, the center for telemedicine law will do like the 50 state summary of all the different things, but they only update that like once a year. So, and quite honestly, if you have a good institution, they're sending out updates to you too. So is it fsmb.org? Yeah, actually connected health. That's the website that I follow closely. They update constantly. Okay. And they do the 50 state and they have a map and you click and they say what's the most recent regulations. But if for some reason they're wrong. Yeah. No one's gonna, right. Right. But how come they can't just create like a, I don't know, like a Twitter feed that says they broadcast it out because if I have to go over the website and find it, I just want to have it. Every time there's a change, you can just update. Yeah, it would be nice. Well, and also what people don't realize, a lot of people, I don't know if everyone knows this, but all those regulations about across state license, uh, practices, uh, are going to revert back if they haven't already in your state and state trumps federal when it comes to things like that. So if your state, like Mississippi said, you cannot see people in the state of Mississippi unless you have a state license. And they did that eight months ago. And you're in upping up in Michigan and you've been seeing people down there, you're, you are actually, uh, breaking the medical practice act for the state of Mississippi. And they can actually turn you into the Michigan board saying this person is, is, has been investigated. And then that will, that will start to start to start up. And I'm not trying to scare people, but just, just make sure you pay attention to this stuff because it's going to get, it has the potential to really kind of sneak up on people and bite them in the rear. And the government hasn't helped because they keep extent that, you know, all of a sudden they accidentally extended for another 150 days. And so anyway, I just, I just want to put that, uh, bug in your ear. All right. Thanks, Pat. Well, I guess we're at the, uh, nine 30 hour. Thank you for coming to this early in the morning. Appreciate it.

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