Thank you, though, for coming to our 8 a.m. session. I think what's unique about this session is everything we're going to talk about is going to be hands-on. It's something you can take back to your clinic, to your practice, to your group. The goal is we're going to teach you things, but again, these are tangible things to do. So we have no financial disclosures. Everything we're talking about is free and accessible. And we have a very esteemed panel of folks here. So I'm John Torres. I'm a psychiatrist at Beth Israel Deaconess Medical Center. Then we have three folks I'll present in order here. So we have Alana, Jane, and Bridget, who will be talking about different aspects of what a digital navigator is, how you evaluate apps, how you use digital data in care. Then we have Jonathan, who's a now almost child adolescent psychiatrist, who will be our discussant and wrap it up. So just an overview to broadly frame why we're here and what we're talking about. I think every one of us did in-person psychiatry and telehealth before COVID. Clearly we all got pushed to do synchronous telehealth with videos during COVID. And I think we've all heard little bits of this asynchronous telehealth world. In some ways, that's a very big word to just say apps, virtual reality, chatbots, what are all these different things that patients can do on their own, self-help programs. And I think at this point, all of us know that asynchronous telehealth does not work on its own. If you just give a patient an app, you give them a chatbot, some people do well, and that's good. But it does not really solve the mental health crisis. It does not really increase access to care. And I think what this talk is going to focus on is how do we put all these parts together? How do we take the best of in-person care? How do we take the best of telehealth? And how do we take the best of these new asynchronous technologies like apps and put them in a way that increase access to care? And to do that, there's three things we need to focus on. This is not an implementation science talk, but I think we don't want to focus just on the technology. If you look on the right one, we have the innovation, and we've heard lots about innovations at this meeting, different AI and chatbots and large language models. But it's really only as good as it works for our patients, if they can use it. It's only as good as we as the clinical community can use it, and then there has to be the outer setting, the context, right? It has to work in our clinic, it has to fit in our workflow. So it's not just having the technology, it's having it that all the patients can use it, all the clinicians can use it, and you have a clinical setting, you have a legal setting, you have a reimbursement setting to actually put it together. So what's interesting about this is whenever someone comes and says, oh, I have a new app, it's going to change care, I show them this figure. So this was a 2023 paper, not by our team, but they said, what are all the things you have to think about to go wrong in the innovation domain, in the individual domain of teaching, and in the regulatory domain? And the ones in red are the ones that are kind of most common, so regulatory challenges. So what this talk is going to talk about is we're going to focus on what does it take to make sure technology works for all of our patients, that we can teach digital literacy, so how can we look at those patient barriers? We're going to look at a way to think about all the innovation, how can you evaluate it, how can you make a smart choice and avoid the ones you don't want to see? Then how can you begin to kind of integrate it into the clinical setting? So we're going to touch some of the barriers, not all, but if anyone comes to you and says, I have an app, I fixed mental health, you can go, no, you've just begun. It's wonderful you've begun that journey, and we encourage that journey, but this is complex work, so I'll hand it over, and we'll get started on the nitty-gritty with Bridget. Hello, thank you, Dr. Torres. So my name's Bridget, I'm a clinical research coordinator in Dr. Torres's digital psychiatry lab back in Boston, and today I'm going to talk to you about one of the implementations of the digital navigator role and one way to integrate, potentially, digital tools into care. So it goes without saying that we live in a digital age. Technology is constantly evolving and has been increasingly brought into the healthcare fields. This is a graphic from, so also the pandemic especially increased, of course, this reliance on digital tools to deliver healthcare. This graphic here is showing that telehealth visits are 38 times more common after the pandemic, and in 2022, 80% of physicians reported using telehealth visits or some sort of virtual care, as opposed to the prior years, a trend that is just predicted to increase as time goes on. So of course you all know Maslow's Hierarchy of Needs. This is not, of course, based on real, actual science, but it's a graphic we like to use to show how digital technology has been, kind of become a fundamental aspect of life and something that can, what we deem, a social determinant of health. So of course, increased reliance on digital tools subsequently increases the risk for digital inclusion, and something called the digital divide has evolved from this increased reliance on digital tools. The digital divide, as defined by the National Digital Inclusion Alliance, is defined as the gap between those who have affordable access to access skills and support to effectively engage online and those who do not. Basically, as technology evolves, the divide prevents equal participation and opportunity in all parts of life, disproportionately affecting people of color, indigenous people, households of low income, people with disabilities, people in rural areas, and older adults. So essentially, in short, a divide exists between those who can adequately access and navigate technology, and the people in underserved populations, such as those with mental illness, are disproportionately excluded from the benefits that technology has to offer. So what are the two main culprits of this digital divide? Or the main culprits of this digital divide, because it has barriers at different levels. So the first portion being access, what we deem a first order divide. So access to technology, such as the physical device, a smartphone, a laptop, that's a barrier for so many people, and it's something that we probably, a lot of people take for granted. But then access even has a second level to it, which is internet access. If you have a device, if you don't have access to the internet, still you're not able to get that benefit. I'll talk a little bit more about that in more detail. But the second order divide that I'll talk about later on is actual use. So say that first barrier, that first order barrier is filled, and you have a device, you have the internet, do you have the digital skills or digital literacy, the autonomy, or the social support to even engage or effectively interact with these devices? So, talking a little bit more about access in detail, this is a graphic taken from 2023 data that shows 90% of adults in the U.S. do report owning a smartphone. However, while this number does sound pretty promising, it's actually much lower for people in underserved populations, with predicted 16-point decrease, especially for people with mental illness. To add on to the access portion, smartphone ownership, while it is much more common, more people access the internet on their smartphones than laptop devices. So this is kind of going to show that smartphones, because they are just more well integrated into society and more people have them, internet access through smartphones is something that we really need to focus on, because laptops is almost kind of a second device that just a lot of people don't have. So that being said, even if they have that first barrier filled of access, then there's also internet access. As I said earlier, people can't use their phone without it. This is a graph from 2020 data showing percentages of households without broadband internet access. The areas in dark show the houses with the lowest internet access, and unsurprisingly, these locations do overlap with people in low-income households, and we're all aware that people in poverty are more likely to have a mental illness. However, that being said, if I were to make a guess, I would say that as of very recently, internet access is much lower across the United States. If you're familiar with affordable connectivity program, it's basically a government program that provides low cost or free internet to low-income households around the U.S., and about 23 million houses in the U.S. rely on the affordable connectivity program to deliver their internet. As of April 2024, this program ran out of funding, which means 23 million households in the U.S. will lose access to internet, subsequently affecting their access to healthcare and schoolwork and all of the other things that we know internet is so important for. Now I'm going to talk a little bit more about actual use and digital literacy as a barrier to technology access for so many people. So this data, so essentially, even if someone has that device, has internet access, do they have the skills to use it? I have worked with many patients or individuals one-on-one who have the device in their phone, have theoretically all of the skills, but they don't know the first thing about how to turn on the phone, let alone send a text message, even find the Google app to search something that might help them. And this is from a paper that looked at the socio-technical factors affecting patient adoption of mobile health tools and showed that the biggest barriers to this are one, increasing age, and two, digital literacy skills. And that being said, individuals with serious mental illness have a much lower ability to overall access and interact with digital tools. This was a study done in the U.K. that showed us the proportions of patients who self-reported that specific symptoms act as a barrier to internet use. So people with serious mental illness, the results show that 43% of people with serious mental illness lacked the essential digital skills, such as connecting to Wi-Fi, that they required in order to actually interact with devices. So essentially, it's a problem on multiple levels, and people with mental illness are disproportionately affected by it. Now that you've been reminded of all of these disheartening statistics, we want to give you today some ideas of how we've integrated methods of digital inclusion in our work setting and hopefully give you some take-home ideas and examples of what you can do as a clinician. So mainly, we're going to be talking about the digital navigator. It's a term that's been thrown around a lot lately and maybe has different definitions of it, but we'll give you a few definitions. So basically, in efforts to increase digital health equity, the question of who is responsible for this often comes up. Is it a healthcare provider? Is it an extra role that a clinician has to take on? Is it a technology person? Is it a peer? Who is this? Well, we think, why limit it to one definition? Essentially, a digital navigator is a person who's a member of the care team whose role surrounds bridging the digital divide in different ways. Whether it be troubleshooting with a device, teaching digital literacy groups, helping a patient sign up for the Lifeline program, or the different implementations you'll hear about today, the digital navigator role was developed to be adaptable to the setting that you're working in. The thing is, to become a digital navigator, you do not need a formal degree. You have to go through, of course, a training, and you will be adequately trained, but it's, in a way, we're capitalizing on the almost innate technological knowledge of so many people, especially young people in our society, and it works as a great first role in healthcare, which of course is a barrier to so many people looking to enter the healthcare field. They get patient interaction. They're not delivering clinical care in any way, but we're leveraging their digital knowledge to help patients. So today, we'll be talking about the three different implementations, and more specifically, I will be talking about how to support anyone to use their smartphone towards recovery and digital combat, digital literacy. So I will be specifically talking to you about how to implement and deliver digital literacy, facilitating digital learning. We at Digital Psychiatry have developed an eight-week digital skills curriculum called DOORS. It stands for Digital Outreach for Obtaining Resources and Skills. It's an eight-week interactive course that we have developed based on what we deem are essential digital skills. Each session has a lesson associated with it, as you can see up here, and we meet one time per week for two hours, typically. The curriculum starts with very basic skills and advances throughout the course. These skills were originally derived from a UK framework that they called essential digital skills, and we've sort of narrowed it down to what we really think is important from working hands-on with patients. That being said, we do emphasize the flexibility of this digital literacy curriculum. You have to, of course, be aware of the digital literacy knowledge of the population you're working with. You don't want to start too fundamental if they have maybe the first four skills filled. So we always leave time at the end of each session for patients or clients to come up and talk to us and ask us, you know, their specific questions. We've helped people apply to jobs or find resumes online. It's not limited to these fundamental skills only. Each session has an associated handout with whatever the person learned that day so they can go home and practice these skills on their own device. And we've developed a separate curriculum for both a smartphone, both Android and iPhones, and also laptops. We've created a manual for aspiring DOORS instructors, and we do have our own digital navigator training. So now to give you a little bit more of an idea of what a DOORS session and digital literacy session might look like, we will go through a mock session. So essentially if I were to be running a DOORS session, we would start with a survey, which I'll touch on a little bit later. We would give an overview. So I would say today the skill of the week that we're going to work on is connecting to Wi-Fi. We would have a discussion, do some hands-on practice, and then have a practice activity. With the hands-on practice, we really emphasize one-on-one care. So we will stand up here and tell them what to do, provide pictures, and then we'll have probably four volunteers, and we'll walk around the room and make sure that we meet with each person one-on-one and watch them do it on their own. We don't take the device out of their phone and say, oh, do this, do this, do this, and overwhelm them more. We sit with them and make sure that they have done the full process that we're trying to learn. So if this were a DOORS session, I would open it up with, how can you use your smartphone towards mental health? Does anyone have an idea? You could shout it out. Calendar app. Yes, your calendar app. The calendar app is a great way that you can manage your doctor's appointments. You can keep track of your health in that way, and that's one way that digital technology can really leverage you being in charge and taking autonomy over your mental health. Of course, there's ways to contact your providers or something like that, but that's an example. So then the next thing we would do is the hands-on activity where we would talk them first, sorry, first have a discussion about what we're learning. So this is actually one of the most common questions we get that's very confusing to people. The difference between Wi-Fi and data and how to actually access the internet. So we often explain Wi-Fi like it's connected to a building. Sometimes you need a password to access it. It's not everywhere like when you're walking around the street, but it's available in common places like the library, maybe a coffee shop. But we really emphasize it's connected to a building whereas data is typically something you have to pay for on your own and it can have different plans or contracts and we would help them with how to how to find a reduced price contract. But yeah, you usually need data to make calls or text messages or things like that. So then we would explain the skill in more detail about how for example applies to iPhones for people in the crowd or people in our lesson who have iPhones. We would go through the same thing with Wi-Fi or sorry, excuse me, with Androids and then at this point we would basically walk around the room and make sure that everyone gets a chance to go through this process. So things to consider. Hopefully now you have a better idea about a DOORS session and what it may look like. Again, we really do leave time at the end for people to come up and talk to us if there's something not developed, not in the curriculum. And I really want to reiterate that it was developed with adaptability in mind whether for other clinicians or digital navigators or other settings to deliver this digital literacy training whether it be like the time time frame that changes or the content of the course, we can provide you with materials and you can adapt them to your work setting. And of course, there's different things to keep in mind when you're doing this like assessing the baseline digital literacy of the population you're working with, the cultural needs of your population, the technology access because we want to assess those barriers and what level people are on to kind of provide a more tailored care. So as I mentioned earlier, we do give surveys to patients and we have actually created our own digital literacy assessment because as we all probably know there's no universally accepted digital literacy scale. We conducted a review of some of the most common scales, the DHLS, the eHEALS, the spider scale based on the ADS framework and combined it with our knowledge of working hands-on one-on-one with patients to what we think is a very actionable survey. A survey that will inform you about the level of digital literacy knowledge or skills that your patient or client, whoever it is, where they are right now. We wanted each question to be actual actionable and inform the digital navigator or clinician or whoever's delivering the survey to be able to do actually do something with the information that they're getting. So now I'll take you a little bit through the questions. So the first question is just indicating whether or not they have a digital device. Of course, what kind of device if they do and if they don't, if they would want to qualify for a free device. And so as you can see, this is our way of addressing the first-order divide of access. The next questions ask more specifically about their skills and internet access and what they can do by themselves without help from anyone else, what they can do. And yeah. And then the questions are continued. I can, we specifically ask about health care in the last two questions, which is I can use my device to do the following activities related to my health care. But this is the first time that we actually even mention health care because digital skills in itself is what leads to digital access that leads people to to access digital mental health care. And then we do a lot of work with mental health apps. So we ask people, have they ever used a mental health or wellness app? Because we know the benefits that they may provide. And we're looking to get some more information on that. And then, of course, the last question is if they have a free response and anything that they would want to learn about. So just to reiterate, this scale was developed because people have different varying levels of digital literacy. And we want to integrate a measurement-based approach for digital navigators or clinicians to actually be do some, to quickly and adequately assess the needs of their patient and subsequently tailor their care. So that is what I have for you today. This is a QR code to our presentation website that has the resources such as that scale and the other things that my colleagues will talk about. Thank you. You can also submit questions using this QR code and we can address them after. Okay. Thank you, Bridget. My name is Jane and I am a clinical research coordinator in Dr. Torres's lab. I am going to be discussing an additional role the digital navigator plays in the health care setting in evaluating the current mental health app landscape with a tool developed by our team targeted for integrative care. This tool can be used by a digital navigator, a clinician or even a patient to be able to gain more knowledge about the tools available to them. So in our modern era, the landscape of mental health apps has witnessed exponential growth and attracted significant interest. During the pandemic, the demand for digital mental health care increased exponentially, promoting individuals to seek accessible tools anywhere they could find them. So, of course, they took to look to the App Store, of course, for care, for those with access to digital devices and have the digital literacy to navigate tools available to them. Smartphone-based care can help and be a great option for immediate help or be able to supplement current care they are already receiving. There are currently over 10,000 mental health related apps available to download on the Apple and Android Store. The demand for mental health apps has grown exponentially with the pandemic. Since COVID, searches for depression apps rose 156 percent, while searches for mindfulness apps rose 2,483 percent. So mental health apps present a crucial opportunity to expand access to mental health care, from mood tracking to medication tracking, psychoeducation, and direct connection to a clinician. These features can be helpful to integrate into daily life with these technologies right at our fingertips. They offer a more affordable solution in some cases for learning coping skills and implementing them into daily life through the use of notifications, for example. Outside of the clinical setting, where mental health care can be very scarce in the populations that Bridget discussed, these tools can help aid. However, there is always another side to things, so with over 10,000 mental health apps available to download, we're faced with an oversaturation market that lacks standardized evaluation metrics, while apps can make very grand claims of treatment without clinical evidence to back them up. And this, of course, can be very harmful to users. Some apps are ill-equipped to assist users in crisis situations with non-functional suicide helplines. Non-existent or inaccurate crisis helpline phone numbers were provided by mental health apps, downloaded more than 2 million times in apps that claim to target depression and suicide. Privacy is another significant concern with mental health apps. While some apps may not have malicious intent, or developers may not, you know, it may not be intentional, but their handling of data varies very widely, with some developers selling sensitive health information for profit while being very vague in their privacy policies for users. And we all know that we have clicked through the, I agree, I agree, to different privacy policies and truly not knowing what we are really agreeing to. This lack of standardization for transparency and evidence-based content poses a challenge for users to navigate the plethora of options available. Even a challenge for users poses a challenge for users to navigate the plethora of options available, excuse me, even the most popular apps may not be appropriate for all users, emphasizing the need for a formal evaluation framework. Additionally, with the proliferation of artificial intelligence, while it does hold a promise in the space of mental health care tools, without sufficient research and testing, users can be faced with insufficient guidance in times of need. For this example here, a patient was in crisis, they were using a mental health app chatbot, and it did not respond in a way that the patient felt like they were being listened to, and ended up making them feel even worse. And that is clearly not what we are trying to get out here. So, if I were to ask you, what is the absolute best treatment for depression, there may be some commonalities in your answers, but with every treatment for patients, there is, of course, nuance. So, when I asked ChatGPT what the absolute best treatment for depression is, we have this image here. There might be some fireworks involved and some candle lighting activities, but as we know, there is clearly not a standardized care. This is not a one-size-fits-all model in health care for any patient, just like for treatments like medications or types of therapies, we know this will not look the same across patients. And the same can be said for mental health apps. This, each person requires a very tailored approach to choosing the right app that meets their specific needs at this time, and we know this can be very flexible throughout the course of treatment. This underscores the importance of having a diverse range of options available for them. It is just the same as other types of care. They should be able to explore and try different things that resonate best with them. So, in order to tackle this issue, our team collaborated with the American Psychiatric Association to develop an app evaluation framework to help clinicians choose suitable apps for their patients and access apps their patients may already be using. I'm sure that for the clinicians out there that maybe a patient has come up to you asking about an app or they may already be using a mental health app that you don't really know what type of resources they're accessing in addition to your care. This framework consists of five key considerations. Accessibility, evidence for efficacy, privacy and safety, app usability, and data integration towards the therapeutic goal. These five key frame points encompass app costs, online features, data protection, and data sharing capabilities for a collaborative experience with the patient and provider. So, with this framework, we have developed the Mental Health Index and Navigation Database. This is really targeted towards making the framework an easy-to-navigate system to ease the process of evaluating these different app factors for clinicians, the digital navigator, and patients to be able to use. So, this is available on mindapps.org. Don't worry, I will give you a very in-depth tutorial on how to navigate the database. But it is constantly being updated and designed to make the APA framework easily actionable for public use. Using mind apps can leave clinicians and patients empowered to thoughtfully integrate apps into clinical practice. So, these app evaluation concepts were translated in over a hundred yes-or-no questions in order to ensure an objective metric to evaluate the apps. These questions are in line with the levels of the APA pyramid and are designed for you to pick which matter where and when and in what scenario. So, the questions, like I said, are aligned with the pyramid. They target origin and functionality, including detailed information about the privacy policy, excuse me, privacy and security, inputs and outputs, clinical foundation, engagement style, and data sharing capabilities. So, these questions, the over a hundred questions on the mind apps database, you are taking a look at what's an app rater on our side of things, the process of rating an app. So, on the left-hand side, we see the filters and then on the right-hand side, we see the output for patient navigation or the digital navigator to work right with the patient or what the clinician can see in order to filter out what app meets the criteria they are looking for. So, like I said, we deal with app evaluation, have many experience going through mental health apps. We add new apps all the time to the mind apps database because the mental health app landscape is growing exponentially. We download and test each app and go through it in detail to assess the functionality and features and we apply the APA framework through these yes or no questions. Another role that the digital navigator can use mind apps for is to facilitate database navigation and app matching through what Bridget was talking about with the DORS groups and as well as we hold a digital skills group on the inpatient unit in the hospital that we work with. So, we will open up the mind apps database and here is a look at it there. There will be a QR code, so don't worry. This is what the home page looks like and on the left here are the filters. There is cost, developer type, engagement, evidence and clinical foundations, features, functionalities, inputs, outputs, privacy, supported conditions, treatment approaches and uses. Oh my, okay. So, if you were to want to find a free app, for example, you can navigate to the cost tab and expand it and you are seeing lots of options, free to download, in-app purchases, payment, subscription or totally free. If you click on totally free and you will see in the search filters one filter is already applied and it will be up in that many other red box there and you will see the all filtered the totally free apps. So, this can be applied in many case scenarios, but our target is really to be able to quickly find a mental health app to integrate into your practice that fits your standards. Really clinical relevant features, well, they encompass all in the mind apps database. Possibly you would want to find something that meets HIPAA or has a feature to be able to send your data to a medical record or collaborate directly with your provider. So, there is also a light version to the database. We work a lot with patients and really try to integrate a lot of feedback and really make our resources the most accessible no matter what skill set you're coming from and make it a very easy process. So, if you switch to the light version, it will be pared down greatly and this can be a little bit easier if you're first starting out and maybe don't want to get into too much detail. So, these filters include the cost, privacy, features, treatment approaches, and supported conditions. So, you can make it really easy to collaborate with your patient. So, if you would like to scan the QR code to navigate to the mind apps database, I will go through a few case scenarios. So, it's not a quiz, but we can navigate it together if you are interested. So, suppose you have a client experiencing anxiety symptoms. They are interested in using an app to log their mood every day. In their spare time, they enjoy writing in a journal. They would prefer to have an app where they could connect with someone such as a therapist. The client feels very strongly about having an app that meets HIPAA. So, you can navigate to the database and the key words that we are looking for is the anxiety symptoms, a feature to be able to log their mood, a journaling feature that works for them, and a collaborative feature to work with their health care provider as well as HIPAA. So, if you are in the app, here are the specific filter categories that you could navigate to in order to find these. I can give a little bit of time if you would like to maybe have a little hand if you need any help or you can come around. But these supported conditions, we would find the stress and anxiety. Under features, we would find track mood and journaling. Under privacy meets HIPAA and under engagements, collaborative with provider. Great job, everyone. So now moving on, this is what you would find if you navigated it in the way that I described. There would be two apps that meet the criteria for your patient. And on the top you can see the filters that we have selected. The second use case scenario would be for your client who cannot afford to spend money on an app. Their doctor has told them that they need to exercise more, but they can't really think of anything specific they want to target. But they know that videos and the gamification feature can be engaging to them. If you want to scan the QR code yet again. The areas that we would focus on is cost and the targeted treatment approach or sorry, the targeted condition could be exercise. And if they can't think of anything, but they know that there are certain features that they like that help them engage, we would select those. So here there would be three apps that meet this criteria. And the filter categories go under cost, treatment approaches and engagements. Now we have a client's provider has started using dialectical behavioral therapy with them and has recommended them to practice these skills between sessions. But your client is confused on what DBT therapy really is and what it looks like and wants to learn more about it. Your client also lives in a rural town where good sources of Wi-Fi are not always available and data sources are unreliable. Yet again, if you would like to scan the QR code and navigate to the MindApp database, we can work on this one together. So the treatment approach that you would be trying to target is DBT. And if your patient is confused on what it looks like and wants to learn more, there is a feature for psychoeducation as well as good sources of Wi-Fi are not always available. We can find a feature that makes sure that they are able to access the app while they're phone is offline. So here is what the app's database would look like once you have navigated through the features, the functionalities and the treatment approaches. On the top under app library, we see the psychoeducation feature, the offline feature as well as DBT. And we see that four apps all meet those criteria. And something that we really stress is the flexibility and option to go between resources and really find what works for you. Sometimes reading the most popular apps and seeing what works for your friend or works for someone even with a similar condition for you may not be the app that is right for you. And yet another case scenario. A client is having trouble sleeping. They like the idea of receiving graphs of their sleep data. They're open to finding an app that can offer this. The client expressed concern about data privacy and they want to know that data will only stay on their device. So the targeted features that we will be navigating are sleep, graphs of data, because it can be very helpful to visualize the inputs that you have put in, like maybe today I felt really good. Yesterday I did not feel as great preparing for this presentation. They're open to finding an app that can offer this. The client expressed concern about data privacy. So we want to make sure that they can have an app that they feel secure using where data is only stored on their device. So after the proper navigation, we can see the filter categories are under the supported conditions, outputs and privacy. And under supported conditions, of course, sleep app. Under outputs, graphs of data. And under privacy, data that is only stored on the device that we can ensure is not going to be going over a server and then going into somewhere else that we do not know. So to summarize, since COVID, there is clearly this proliferation of mental health apps. There is a lot of people very interested in mental health apps and using them already. But maybe not know exactly what they are agreeing to when they download the app. There's a very confusing regulatory system surrounding data privacy, AI, and nonfunctional features for people in crisis situations. There is a lack of objective evaluations of mental health app landscape. But there is no one size fits all for care, especially for mental health apps. We collaborated with the APA app evaluation framework to form the MindApp database. And this can be used to navigate by a patient on their own, by a clinician, or by a digital navigator. We do this work a lot, and it's very important to us. So thank you all for listening. I'm going to turn it to my colleague Alana now to talk about the digital navigator role in integrative care models. Thank you. My name is Alana. I'm a clinical research assistant at Beth Israel, similar to Jane and Bridget. And you all have just heard about the first two iterations of the digital navigator. And I'm now going to introduce to you the third way that we apply the digital navigator role and how a digital navigator can be used to increase patient engagement and benefit from technology for both patient and clinician in a clinical setting. So when discussing the role of technology in mental health care treatment, research continues to show us that technology alone is insufficient. Specifically when examining mental health applications, sustaining patient engagement remains a significant obstacle. For example, one recent study has reported that around only 4% of people with mental health applications installed on their phone actually open the app on any given day. Furthermore, they found that daily minutes spent on apps with peer support were significantly higher than apps without. So in this way, this study is just one of many examples highlighting the drop off that occurs in patient engagement with mental health applications while also emphasizing how integral human interaction is and human integration is into mental health care treatment, even when using technological interventions. So in this way, the involvement of human interaction is critical to sustaining patient engagement, so we suggest an integrative care model. As you can see in this figure, the digital navigator serves as support for both patient and clinician through synchronous care as well as asynchronous care when interacting with the technological intervention being used. At our lab, we have created an integrative model called the digital clinic that I'm going to tell you about. The digital clinic seeks to reduce barriers to treatment access as well as empower patients with technology enhanced care. The digital clinic is fully virtual and uses traditional telehealth therapy as well as app integration in the treatment. So patients meet weekly with their clinician as well as weekly with a digital navigator to support patients both technologically with utilizing the app as well as interpreting the information that the app is collecting to both patients and clinicians. To give you an even better idea of how the digital clinic functions, we'll go through this figure together. We begin in the upper left quadrant with the telehealth visit where patient and clinician agree upon treatment goals and determine what are they trying to get out of the technological intervention being utilized. Then a digital navigator can come in and support app setup as well as customizing the app to meet the patient's needs and desires. The patient will continue to meet with their clinician through telehealth or traditional in-person therapy and use the app outside of those sessions so as to integrate asynchronous and synchronous care. And then lastly, this ongoing support surrounding the app usage helps to increase patient engagement both in their sessions with their clinician but also outside of that setting. So when diving deeper into the role of a digital navigator in this clinical setting, we see that the digital navigator serves as the bridge between the telehealth therapy sessions and the smartphone app itself. So in this way we see the app is collecting active data from patients which I will further explain in a moment as well as data that patients are putting into the app deliberately as well as collecting data in the background further informing their care. So I'm going to now tell you about the application or technological intervention that we use at our lab at the digital clinic and it's called Mind Lamp. So Mind Lamp is a smartphone application that was developed at our lab that is capable of tracking symptoms and delivering customized interventions to users in both research and clinical settings and it utilizes something called digital phenotyping which I'm going to explain to you. So digital phenotyping can be defined as moment by a moment quantification of the individual level human phenotype in pseudo using data from personal digital devices. In other words, digital phenotyping can be described as the digital collection of observable and measurable characteristics, traits or behaviors of an individual. So we'll get into some examples of digital phenotyping and what that really means in this real world setting. So our app Mind Lamp collects data in two different ways which we'll outline here. Firstly it collects passive data which is information that's collected in the background. So the patients do not need to be deliberately interacting with the app in order for this information to be collected. So some examples of this could be your step count, sleep tracking, exercise tracking, your GPS location, app usage and overall screen time just to name a few. The other type of data collection that Mind Lamp collects is just any information that patients are putting into the app deliberately. So this may look like surveys, activities, engaging with psychoeducational materials on the app and again one amazing feature about Mind Lamp is that it's extremely customizable to the needs of the patient. So here are some examples of what some of the active data can look like on Mind Lamp. So you can see here there are some surveys specifically measuring symptoms of anxiety or depression as well as many other activities that we offer and this is just showing a few. We also have here on, you'll see to the right the learn section has many psychoeducational materials and the manage tab has many CBT and DBT based activities for patients to engage with which clinician and digital navigator have access to in addition to the patient. So in this way we look at the vast benefits of having both access to active and passive data. With active data we have the ability to have real time symptom reporting from our patients rather just in those weekly sessions or monthly sessions and additionally patients are more likely to engage in treatment and through having the support of both the digital navigator and clinician involved in the app integration. And then we also get a better picture of the patient's day to day life which the passive data also assists in. So I would now like to invite you to take you all to scan either the iOS QR code if you have an Apple device or the Android to download Mind Lamp right now if you'd like to and see what the app looks like from the patient perspective. So I'll give you all a moment to download the app. And you can look up Mind Lamp space the number 2 on the App Store or Google Play Store. And then once you've downloaded it, it may ask you whether to allow connection with Bluetooth. It may ask you for different permissions and you're free to click no. If you were a patient we would ask you to allow those because that is how we collect that passive data that I was referring to. So when logging into Mind Lamp you'll want to leave the server address blank and your username will be APA2024 and password will be the same, all lowercase letters. So if you have logged into Mind Lamp and even if you haven't that's fine, you can see that it's comprised of five different tabs. We're looking at the assess tab in the middle which has many different weekly and daily surveys that patients are able to interact with, and this helps their clinicians to better understand their symptoms on a weekly and daily basis. And then in the Manage tab is where you'll see more of those interactive activities. The Learn tab has those psychoeducational materials, and then the Feed tab shows patients the surveys and activities that are assigned to them, which is all of this is completely customizable and adaptable to what your patient needs and what you may need as a clinician. And then lastly the Portal tab displays what activities or surveys you've interacted with. So better understanding the role of the digital navigator in the digital clinic is crucial as the digital navigator supports the integration of technology into the clinic by improving patient engagement as well as summarizing the data that's being collected. So in this way the digital navigator is meeting with patients on a weekly basis to interpret the data that's being collected in Mind Lamp on a passive level, which we'll go into later on in this presentation, and they also provide technological support for any troubleshooting that goes on at any time throughout the week. When it comes to the role of the digital navigator in regards to the clinician, at our digital clinic we hold something called Digital Rounds, which is a weekly meeting where digital navigators and clinicians will connect to go over patient data visualizations, which we're going to do a mock data visualization as if we were in Digital Rounds together after this. So Digital Rounds offers a unique opportunity to bridge the use of Mind Lamp and the data that's being collected there and really leaning on that knowledge and expertise of that digital navigator to inform clinicians about the broader picture of their client's lifestyle and information that's being collected through this technological intervention that we would not have otherwise. So welcome to Digital Rounds today. We're looking at a patient who has just completed their time at the digital clinic and this is pulled from a fully anonymized but patient who was in the digital clinic. We're looking at a 22 year old white woman who has just finished their bachelor's degree. So we would first turn to the overall assessment that we that we have patients take at intake halfway through their time at the digital clinic and completion. So you're looking at this triangle that's measuring anxiety, symptoms of anxiety, depression and dysfunction. So we're seeing that the larger the triangle is the more severe the symptoms are. So this patient has shown significant progress over the course of their treatment at the digital clinic as we can see they began with extremely high anxiety and as well as significant symptoms of depression. We're seeing over time their symptoms have decreased. We also take a look at the air at these five areas of growth for patients to measure their strengths and see how those have progressed over the course of the digital clinic. In contrast to the first graph that we were looking at instead of the triangle shrinking we hope that this Pentagon expands over the course of the digital clinic so we can see here the smallest Pentagon was at intake. It looked like this patient was lacking in self efficacy had more room for improvement in terms of their motivation as well as their emotional self-awareness. So we do see significant increases in those over the course of their treatment. You can also see digital literacy remained the same throughout treatment and that is something that we often see for patients who have higher digital literacy for patients who begin with less digital literacy lower digital literacy. We often see patients gain a lot of confidence over the course of their treatment when it comes to digital literacy because of the technological intervention being used and through that support of the digital navigator likely teaching them new skills related to technology that they didn't have to start. We also have access to the activity calendar where we see patients engagement with mind lamp. So sometimes if we have patients who may need some more support or encouragement to engage with activities the digital navigator is a great resource to help encourage and be supportive of patients in setting goals and slowly working their way up to whatever goals they have agreed upon with their clinician. This patient did do an outstanding job of completing their surveys so as to provide more insight to their treatment. We also see here the weekly surveys we have patients take the PHQ-9 and GAD-7 each week so as to measure their progress and we can see here that their scores did decrease over the time at the digital clinic and we do in digital rounds we may see. For example the spike in anxiety right before January 15th. We may ask the clinician to get some background to see if that aligns with with what they're observing in their sessions with the patient. So in this way we have not not only the subjective information but also insight from clinician to see if this information is congruent and aligns. We also look at something called a correlation matrix which we use to better understand the relationship between passive and active variables that we're measuring in mind lamp. So active data inputs that we're looking at are those anxiety depression and symptoms of difficulty functioning. That's information that we're getting from the patient deliberately answering surveys in the app. The rest of the variables is through passive data measurement. So for example home time entropy screen duration to name a few as well as steps. So we can see here we're looking for the strongest correlations on this matrix so those are going to be those rectangles that are the darkest blue and lightest yellowish green. So we can see here that this patient has a very strong positive correlation between anxiety and depression symptoms. We often see that these two symptoms go hand in hand for many of our patients in the digital clinic. When looking at a passive variable related to one of those mental health symptoms we can look at home time and anxiety for example. You can see the negative point for eight between home time and anxiety indicating a negative relationship between them. So as this patient is spending more time at home they're reporting less anxiety. So it's interesting for digital navigator to inform clinician that this is a objective measurement that we're looking at in the correlation matrix and better understanding if this is something that they're also observing in their weekly clinical sessions. And then lastly we turn to something called a calendar plot which gives us a bird's eye view of how patients are doing on a day to day basis not only with these symptoms of anxiety depression and difficulty functioning but as well as those other passive variables. So on the key here for each graph is the darker the color the less severe the symptom is and the brighter the color the more severe. So we may see that when the patient is going through a harder week we may see more of a lighter color in difficulty functioning or anxiety depending on what they may be struggling with. So I know that was a lot of information and I hope that gives you a little bit of a taste of what digital rounds and what a digital data visualization looks like at the digital clinic. So we are not expecting you to go back to your work and completely start using mind lamp and be interpreting data visualizations to your patients and colleagues. But we do hope that you consider integrating technology in some way into your own practice whether that be if you're a clinician yourself or maybe you're just interested in using mental health applications. So what really separates our app mind lamp from all of these this plethora of mental health applications out there is this digital phenotype thing. So this are this integrative care approach is our lab is just one example of how this is being applied. This is an emerging field and there are many other clinics like around the world that are using this integrative model. For example one Australian research group is using web based interventions with the support of a junior clinician to use this integrative care model. So this may be completely new to you but this is something that is happening all over the world. So we ask that you continue to learn more about this model and the digital clinic. And again we emphasize the role the customizability of the digital navigator role and the adaptability of mind lamp and how it can be used in your particular setting. Thank you so much. So my name is Jonathan Chavinsky a psychiatry resident set to start child and adolescent psychiatry fellowship at Boston Children's Hospital the upcoming July and I also work in the digital psychiatry lab at Beth Israel Deaconess Medical Center. Before I proceed. So we have this QR code and it links to online questions dot org in the interest of digital literacy. We love QR codes as you've seen already from this presentation. So for our Q&A we're going to ask that you either go to online questions dot org or scan the QR code to get there. And our event number is 6 1 1 1 9. It'll link to the Web site. You can post new questions and I'll be facilitating our Q&A through those questions. And I'll also come back to that QR code a little bit later if if you're not able to access it right now. So I'm just going to talk a little bit about you know a summary of what was discussed already and a little bit about how you guys can start incorporating this into your own practice. Some technical steps that you can do even as early as today. So the first thing that we heard presentation about was the current state of digital psychiatry and where things are right now. So in the current digital landscape you need access and you need to be able to actually use the technologies. So this is the digital divide. Essentially that for pretty much everything in life right now you need access to some sort of a technology a physical device a smartphone or a computer. And you also need access to the Internet. So that's the access issue. And what we talked a lot more about was the actual use issue. How we can make it so that the folks that do have access are able to use these technologies appropriately. We then talk about implementation of digital tools into care and kind of broke it down in this framework of how we can support anyone to use their own smartphone towards recovery helping to navigate and find useful apps and increasing engagement and benefit from technology. So for this support role we had a discussion about our doors program the digital opportunities for outcomes and recovery services are eight week interactive course which we teach individuals the essential digital skills based on an adapted curriculum semi-structured with ample opportunity for answering questions with the goal of trying to have it be as one on one improving in the areas that folks actually need improvement in separate curricula already exist for smartphones both Android and Apple. And we also have a curriculum for laptops that are that's available and it's facilitated by our digital navigators in our clinic. And it's already ongoing. We've had a lot of success. So the next step to try to help with navigation and finding useful apps. We talked to our presentation presenters a little bit earlier talked about the digital navigator and digital navigators are trained members of a care team and their role is surrounding bridging the digital divide. It can be anybody as part of the care team. So it can be anyone in this audience. It can be anybody as part in part of your clinic. It can be somebody who is a research assistant. It can be somebody who has been a seasoned psychiatrist for many years. And the goal is to try to help with troubleshooting teaching digital literacy. It's very adaptable adaptable and one thing that we really like about it is that it capitalizes on the innate technological knowledge of so many young folks in society to help bridge the digital literacy divide for some of the folks that did not grow up with these technologies. And then we also had a little bit of a discussion of the mind apps database which is our online framework for app evaluation. And we talked through some test cases, but it's essentially structured on the core tenets of safety, efficacy, usability, and interoperability. And it's our way of comparing apps based on a number of different sliders. Highly encourage everybody to use it regularly, especially if you're trying to come up with recommendations for your own clients in terms of what apps might be suitable for them. If you just go to the Apple Store or you go to Google Play without any sort of guidance, there's gonna be 100,000 apps there and it's really hard to know what's good and what's not. And this is a way of actually trying to separate that out a little bit better. And so as we saw through the demonstrations, there's a number of different sliders. You can kind of customize it to whatever you're trying to treat, however you're trying to treat it based on safety and cost. And then finally, we talked a little bit about how to increase engagement and benefit from technology. So we talked about our digital clinic, how it functions, where we offer short-term free virtual therapy delivered in conjunction with our mental health app, the Mind Lamp app, which again, also encourage you to take a look at if you haven't had a chance to yet. So our lab and our virtual therapy sessions are weekly Zoom sessions with the clinician and we also have separate weekly Zoom sessions with the digital navigator. And these significantly increase patient engagement and treatment. This is a way of reaching folks that otherwise might not be able to access care. You know, we all know that there's areas of the country where access to care is pretty limited based on the number of psychiatrists around, especially if you get more subspecialized, availability gets lower and lower. So this is a way to help bridge that divide. And then as was discussed a little bit earlier, Mind Lamp, through its collection of active and passive data sources, helps us create what we call a digital phenotype, which we can use for treatment moving forward, especially as the research on digital phenotyping improves. And so SMI Advisor, I don't know if any of you were able to stop by the stand. There's been a stand at APA. They're very lovely. I recommend going up to them saying hi. So we've collaborated with the SMI Advisor folks. So SMI Advisor is a clinical support system for serious mental illness and it's APA and SAMHSA initiative. And so it offers a whole lot of functionality so you can access a consultation clinician to clinician through their database. They also have an SMI Advisor app, which you can download as well. I know we're gonna have you downloading nine or 10 apps by the time we're done here, but all of them have useful features. So what I like about the SMI Advisor app is so you can directly access some of these features like how to titrate clozapine based on a whole number of these different factors. There's also an LAI conversion tool for long acting injectables and there's some clinician rating skills. But what I wanted to discuss is the SMI Advisor Digital Health Navigator Training. So any one of you and anybody in your clinic can register for the SMI Advisor Digital Health Navigator Training. Actually have a flyer in the back on the chair in the center that you can also pick up. This training is a six module training. It takes about five to six hours to complete. And it essentially teaches you all the skills that you would need in order to help do this digital health navigation role. And so teaches you how to teach digital literacy to others. And so highly recommend looking into it if anybody is interested in incorporating this into their practice. And with that, so we have our QR code for our presentation resources. And again, we have the QR code for any questions that you'd wanna submit virtually. And with that, I wanted to actually open it up to our panel first because we have a distinguished group of folks who have a tremendous amount of experience actually implementing these digital literacy skills. And I'm curious, what are some of the biggest barriers that you've come across in terms of digital literacy for folks that you've worked with in the clinic? So from the DOORS groups, we work with people, can everyone hear me? We work with people with varying levels of serious. I can't hear you. Oh, sorry. Does this work? It feels like in the DOORS, it's so cold in here. Yeah, feel free to open it. Definitely. I would say, yeah, there's definitely a huge variation. Like we talked about, some people, again, can't even turn it on, let alone if it's their first time with a smartphone, like knowing what the home screen is, what the home button is, how to navigate back there. It's definitely something that we see. But then we also work with people, oftentimes they're a little bit younger and do have a device, and they're really interested in how do I access my patient portal, or how do I meet with my clinician virtually. So Zoom is something we teach a lot as well. Great. I see some submitted questions. One person asks about the digital navigator. They're asking about the cost, if there is any cost for using the digital navigator, and how many patients each digital navigator would work with. So at our digital clinic, we have volunteer digital navigators who may be students in their undergraduate looking to get some more experience interacting with patients, as well as working in a lab. So for us, we've been able to find help through volunteers. As well, for the number of patients that a digital navigator can see, for students who are also in school, they may have three patients, three or four patients at a time. But for me, for someone who is full-time working at the lab can see about 10 patients as a digital navigator. Each session can range from 15 to 30 minutes long each week. So it doesn't take like 45 minutes or an hour, like a clinical session. Yes. First of all, thank you for an excellent presentation. I've used the earlier version of the MIND website. I found it frustrating to use 100 filters, and so I appreciate that there's now a simple one. I would suggest you flip-flop it so that it defaults to the simple one. And if you're obsessive, click here to find out. You really wanna know. But I was curious if with the training for the digital navigators, if you worked out how to convince any health system that there's a role to this, and like legally, how would we do this? Because we could train, I could see how we could train people but I'm just curious if I'm gonna convince the hospital bureaucracy to say that this is a legitimate thing. And what sort of accreditation, just like we have new medicine that's going to the pharmacy and therapeutics committee, is there something that you attempted, or how is it vetted even at your hospital? Yeah, yeah, so this is a fairly new initiative and it's growing tremendously. We're partnering with APA and SAMHSA to try to create this validated training. So it is on the SMI Advisor, which is a place where a lot of these trainings that are kind of proliferated are found. I think that what we kind of hearken to is the data in terms of the digital literacy divide, the gaps in care. And so we've actually had a lot of positive feedback in our own institution. But it is gonna be a challenge in order to get it accredited. Sorry, so your strategy, how do you document you told your patient to use this, and how do you document that there's some digital navigator who is part of the care model? Yeah, so this is just a supplement that we add on, kind of free of charge as part of our clinic. I think that there can be an incorporation into a care model where it could be outside of that role. But essentially in our virtual clinic, it's just part of our role. And we just document that it is something that happens. I appreciate that. It sounds like somehow you've avoided the lawyers. We emphasize that digital navigators do not offer any clinical care at all. Like they're just there for the digital troubleshooting aspect and maybe interpreting data, but not making any clinical claims from that data, if that makes sense. So the clinician can also act as a digital navigator, and then they could kind of integrate that more. But for someone who's like a college volunteer, or we have clinician volunteers from everywhere, we are never asking them to make a clinical judgment. There was another question about physician-resistant to technology approaches to patient's treatment and our thoughts about this. And yeah, I think with any new technology, right, medical record when they get implemented or attempts to introduce new technologies, there's always a lot of pushback. I think that it's just being open and honest about the fact that this is going to be the wave of the future. This is going to be a necessity. And the fact that if we don't kind of meet people where they're at and try to get them caught up in terms of digital technology approaches, the divide is just going to get larger and larger. So, again, most of the conversation that we've had, and I imagine folks that are in this room are interested in this topic, so you'd probably agree of the importance of kind of remediating these gaps. But I think everybody recognizes that this is just going to continue to grow in importance. And as these gaps in care across the country exist, digital approaches are just going to become more and more necessary. I don't know if any of y'all have any thoughts. It's well said. Yeah. Oh, one question that somebody posed is, are there any fun apps for peer support that folks use alongside Mind Lamp? Fun apps? Yeah, like they said, it's- There are many fun apps. They're curious if there are any fun apps to pair with Mind Lamp, you know, to kind of improve engagement. Improve engagement. Yeah. The chapter with that one, that may come in handy. Oh, okay. I mean, on the Mind Apps database, we may add a fun filter, if that is what our people are looking for, but. The question around this is, so you brought up the thing, the great piece of evidence that, oh, people only use their self-guided app maybe only 4% of the time, and it is the problem with, John has brought up in many lectures that engagement will always be one of our greatest challenges, probably to do anyhow. And you brought up to the point that when you add human to something, it helps. So I wonder about, I do think that just an aggregator is doing something that's helping with stickiness, you're adding another human to it, but on an ongoing basis, so like months after they've come up with it, so like six months, a year, I guess I'm just wondering about pairing like a peer support, or VR, something like VR chat, or some other, you know, they're doing peer supports, but I guess I just don't know if there's data on apps, like mental health peer supports. Yeah, so I do have some experience trying out different apps that do actually offer some kind of human interaction on the app. For example, there was one app that treated specifically social anxiety, and actually offered for the user to have like a practice, like phone call with another human, which I found to be, in theory, possibly a great idea, but also I think the larger issue is who are these people that these apps are hiring to interact with users, as well as, you know, when it comes to those AI or chatbots, we have a filter, of course, on MindApps where we identify those apps, but that's a whole nother layer, you know, as the technology is advancing, better understanding the security and safety of those chatbots, as well as, you know, people who are providing human interaction in apps, so I think that ideally, hopefully, we can move towards a space where there can be safe, secure, clinically reliable support in apps, and I also know that there are some apps that will provide like Zoom meetings, like weekly Zoom meetings where users can log on to meet with the person who created the app, answer questions about whatever the therapeutic approach it is that's being offered through that app, but oftentimes, those are applications that ask patients to pay a subscription fee, so again, going back to accessibility. And the next question that I see here, I think, is in reference to the MindLamp app, and it asks that this app allows us to have access to the patient's information, but they were curious about apps for actually improving patient recovery or treatment, and how we pair other apps for treatment with the MindLamp. Well, in the digital clinic, we mainly focus on using MindLamp alone, not to say that we discourage patients from utilizing other apps, but we don't pair MindLamp with other apps, but if the patient brings up that they're finding benefits or they ask the digital navigator, oh, I'm seeking out an app that could offer this, or if the digital navigator may have an idea of an app that could be helpful or specific to the patient, they can offer that, but we also do rely a lot upon the customizability of MindLamp. If there's a specific feature that a patient is looking for, if they're having troubles with their sleep, we've integrated a sleep survey to better monitor how that patient is doing with their insomnia, for example, so we often do try to use MindLamp to cover many facets of the treatment. Yeah, and the last question is, do we have these slides available for y'all? And I would encourage you to scan the QR code. It gives access to a whole bunch of the presentation resources from today, but if anybody has specific questions or wants access to any of these specific slides that we have, you can come up to us afterwards and we can try to set you up. They'll be posted on the website. Yeah. Of that. All right, well, thank you very much. Thank you.

digital technologies

mental health care

telehealth

digital navigator

Mind Lamp app

digital phenotyping

digital literacy

DOORS curriculum

APA app evaluation

MindApps database

integrative care models

SMI Advisor