Hello and welcome. My name is Gabriel Gutierrez, Jr., and I am the Managing Director of the Division of Diversity and Health Equity at the American Psychiatric Association. I am pleased that you are joining us for today's Striving for Excellence series, Technology Acceptance and the Digital Divide. Dr. Bell, if we can go to slide two, please. Funding for the Striving for Excellence series was made possible by grant number H79FG000591 from SAMHSA of the U.S. Department of Health and Human Services. The contents are those of the authors and do not necessarily represent the official views nor an endorsement by SAMHSA, HHS, or the U.S. government. Dr. Bell, slide three, please. Today's webinar has been designated for one AMA PRA category one credit for physicians. Participation for participating in today's webinar will be available for 60 days. Slide number four, Dr. Bell, please. The PDF of the slides will be available on the chat tab, so please make sure you find that, that you locate on the Zoom. And now for slide number five. Captioning for today's presentation is available. To enable the captions, click show captions at the bottom of the screen, click the arrow and select view full transcript to open the captions in the side, in the side window. And now for slide number six. Please feel free to submit your questions throughout the presentation by typing them in the question area found in the attendee control panel. We'll reserve 20 to 30 minutes at the end of the presentation for Q&A. And now for slide number five. It's my absolute pleasure to introduce Dr. Bell. Dr. Iverson Bell Jr. is a teacher, a training director, a community and private practice psychiatrist and believes in using technology to provide outreach in those fields. He was a training director for psychiatry at the University of Tennessee Health Science Center and was in the position for 13 years. He previously taught at Morehouse School of Medicine and has been teaching using teleconferencing to teach and practicing telepsychiatry since 1984. Dr. Bell began using telepsychiatry for counseling at a college in 1999 and later at the University of Tennessee. He has also used teleconferencing technology to teach health care professionals in Ethiopia. Dr. Bell completed his undergraduate degree from Morehouse College and received his medical degree from Vanderbilt University School of Medicine. He received psychiatry training at the University of Illinois, Chicago and specialty training at Emory University in psychiatry. He is a distinguished life fellow of American Psychiatric Association, a member of the Black Psychiatrists of America, the American Telemedicine Association and the American Association of Directors of Psychiatry Resident Training. And now I will pass the virtual mic to Dr. Bell and thank you for being with us here today. Thank you very much. I'm Dr. Iverson Bell, as he just stated. I have no financial relationships to disclose. And the objectives of this are to discuss the factors in the growth of telepsychiatry, to discuss the digital desert, I'm sorry, and possible remedies, and identify the limits of technology with the medical professional and the patient consumer. Past issues. Although telepsychiatry has been used for actually much longer time than I have, it's been thought of as having a digital divide, basically along the racial or socioeconomic differences in the ability to have internet or computer access. This has been written about in terms of education, keeping up with the current events in education and general knowledge, as well as medical access. Healthcare disparities, as you know, still do exist, but the divide is much more complex than it used to be. This is the equipment that I started using in 1984. You'll notice a screen, an old-fashioned screen. It's monochromatic, only one color. Started out with white, I graduated to having orange. This was using two disk drives, floppy disk drives, and an Apple clone for a laptop. It did not have megabytes of memory, it had kilobytes of memory. Very rudimentary compared to today's equipment. The first psychiatry computer board was called Headboard. It was created, as I said, in 1984, and it was limited to asynchronous and written communication only. This was before the internet. What that means with asynchronous communication is somebody would essentially call up the computer from their computer modem, type a message, and hang up, and later on somebody would respond. It was suggested to me that this might be a good way to reach some adolescents, and I followed up on that, and actually it worked rather well. The age average was about 17, range was from 12 to 40. About 90% of the users were Caucasian, and the remaining 10% was divided between African-American, Hispanic, and Vietnamese. This was based in the Atlanta area, and it was limited to the Georgia population. 99% of the users were male. This included one airline pilot and one astronaut. I have that demographic information because anybody that used my bulletin board had to leave a phone number that I could verify and make sure that if they had something important to say, such as even suicidal thoughts, that I would be able to respond not as a therapist, but to direct that person to the nearest community mental health center. 20% of the people that used it had psychiatric therapy in the past and had very negative feelings about it, but were willing to talk to each other. Again, I was not providing therapy. I was merely a moderator. They were providing very useful advice to each other. It should be noted that as I started, there were only a few people using it, word of mouth spread, and by several months into this, 300 people were using it on a regular, at least once a month basis, and at the end of two years, I've had 13,000 phone calls. And I tracked them all. Well, that was the demographics for when things started. Again, this was pre-internet. The demographics post-internet were divided along gender routes. 75% of the general US population, 74% of all women, about 76% of all men. Again, the racial breakdown was primarily Caucasian. As you can see, the age spread was primarily young people, then back in the 80s as well as now, and it's improved as far as older people as time's gone on, and the numbers have gotten better. The asterisk I have beside the 50s and the 60s represent the baby boomers. There were 72% back then in 2008, and over 65 is 37%. This chart is a previous chart from the Pew Research Center, percent of adults using the internet by racial breakup was about 78% to 82% white male, and lower than that, somewhere around 70% on black males and Hispanic. This has improved over the years. Despite growth, rural America has had consistently lower levels of technology ownership than urbanites and lower broadband adoption than suburbanites. You'll notice that the breakdown continues up until 2021, when the last survey that I could find was done. Home broadband, 79%, suburban, and 72% rural. And let me see, smartphone, 89%, it's easier to use a smartphone, and 80% in the rural area. Tablets, much fewer people had tablets in 2021 than now. This was at the beginning of COVID. It's certainly increased since then. And desktop laptop usage was, as you can see it, 80% and 72%. So let's get to the present issues. There's about a 10% difference in usage of the internet by education, about a 10% difference by race, and it's obviously much improved since 1987. These differences compound each other. Access to care is also dictated by those that are insured versus those that have cash payments. With any third-party payers, about 56% of all psychiatrists accept insurance or any third-party payer. That leaves about 44% that do not and only take cash. In the Memphis, Tennessee area, it's about 50% of the psychiatrists do not take any form of insurance. And the number on the bottom actually has increased with over 60,000 psychiatrists, less than, actually it's around 1,000 are Black. So not only is there a disparity in the number of people that can use the internet, but there's a disparity in the number of psychiatrists. Let's talk about the rural area. And you will notice this is rural Tennessee, one of the local pictures, not too far from where I have a rural clinic. And you'll notice people are somewhat scattered out. In some places in the United States, of course, they're much more scattered out than this. In my geriatric day clinic in this rural area, the visits are usually by telepsychiatry at the day program. Sometimes virtual visits must be made at home because people can't make it in, either transportation, people not feeling well, or other issues like that. The virtual visits at home especially are dictated by the educational level. Technophobia, there are those that are just really anxious about using computers. Complexity of equipment, cost of online data use as well. Wi-Fi, satellite TV, cable or telephone line is necessary for connection, if it's available. This is how we'd like to think of telepsychiatry, person sitting with their laptop perched somewhere talking to the doctor. That would be the ideal situation. This person has Wi-Fi and they have nice connection. You can kind of make out that they're talking to a doctor in the background. This is much more frequent. People are talking on their cell phones and only have to press a few buttons. You might notice that the fewer buttons that people have to click on, the easier and more frequently they'll use the internet. And this is what happens a lot of times. Plain old telephone lines, we make telephone connections. Now, this has some impact on billing because while telepsychiatry at least is supposed to be billable on third-party payers, telephone calls until COVID were hardly billable at all, depending on the insurance company, did not pay much. And they're still billable until around the end of the year. The COVID emergency has officially ended as of May, but there's been an extension up until December when you can bill at the standard rate for telephone call connections. Obviously, telephone calls are not as good as the telephone with visual, and that's not as good as being able to see somebody on a computer. And of course, that's not as good as being able to see someone in person, but as we've said, it's not always possible. Telepsychiatry provides outreach. Going back to a previous statement that I made, a Forbes article entitled, Is a Digital Divide Hindering COVID-19 Vaccine Access for Seniors? That refers to the age divide. It tells the story of a mother in her late 70s. She falls within the phase 1A category to receive the COVID-19 vaccine. Most of these appointments to receive vaccines were actually made with pharmacies. And I'm not sure if you have any experience with that or not, but to make the most appointments with pharmacies requires an internet connection, and it is often rather confusing. She expressed frustration that she was having trouble getting an appointment or even getting through by phone to various entities administering the virus. Another example of computer difficulties would be contacting Medicare, Medicaid, and Social Security. It's not uncommon for someone to have a 45-minute wait or longer to talk to somebody after one presses a number of different buttons to talk to a live person. So doing it on the internet is quicker and easier, but one has to not only have access to the internet but be somewhat familiar with which buttons to click on and that sort of thing. Now, I've worked with an urban psychiatric clinic, several, as a matter of fact. Visits by telepsychiatry were either, well, use Wi-Fi. Their electronic medical records and commonly used HIPAA-compliant videoconferencing programs. Issues involved the politics of funding, on-site Wi-Fi difficulties, Wi-Fi access in one's home, and EMR or electronic medical record difficulties for their doctor, as well as staff training and staff comfort. The staff have to be comfortable setting things up. They have to be accessible if one has, if the doctor has any need to talk to the staff person, and they have to be trained in how to use everything. As we all know, electronic medical records can be difficult to use, and I'm familiar with at least three. I don't like any of them, as most of you all don't. Electronic medical records are one of the prime causes of physician burnout. So that and doing it online can be difficult. I mentioned the politics of funding. One clinic that I worked at was the psychiatrist. Actually, there was a part-time psychiatrist that worked two hours, and a resident and I provided eight hours of psychiatric care to their clinic via telepsychiatry and some in-person care. Well, I went on a business trip for two weeks. While I was gone, there was some sort of political upheaval in the clinic. All of the administrative C staff were replaced. CEO, the CIO, all those people were replaced, and my contract was ended. No idea why other than probably something to do with wanting to save money. Since then, and this has been well over seven years ago, they now have only two hours of psychiatric care per week, and that's remotely, not by me, it's by another practitioner, but it's gone from having over 12 hours of psychiatric care down to two because of their decision. One way that we don't have here in Tennessee that provides access to the communities is by a Wi-Fi bus. I'm not sure whether the service is provided within the bus or nearby to the bus. But regardless, this provides access to the computers, but it's only within a limited span of time. Now I've worked with my psychiatry training clinic. It's an urban clinic. We have patients from the urban local area as well as suburban areas. It's actually a tri-state area. We see patients from Tennessee, Arkansas, which is literally right across the river, and Mississippi, which is five miles south of our clinic. So it's truly a tri-state area. We have the usual electronic medical record difficulties and video conferencing difficulties, but at least we have access to IT. We still have patient acceptance issues, state license and insurance issues, and these are because we're located in a tri-state area. Now I've been licensed in Mississippi as well as Tennessee, so we were able to do telepsychiatry for myself, but not for the residents between Mississippi and Tennessee. The malpractice for the residents does not cover Mississippi or Arkansas, so we are only able to provide telepsychiatry within the state. That's a pretty common issue of state line differences. If one practices in a certain state, one has to have a license in that state. So I no longer have a license in Mississippi, but we no longer have a contract with the program in Mississippi, so we don't have to worry about that. But we still have to consider license and insurance issues. All right, disparities. The population is aging, and older patients have technology issues and funding. Data costs money. I have access through an unlimited data plan. I'm fortunate to have that. Most people have to pay per minute. They get data plans. So the question is, how does one spend one's money? Talking to family and friends in their virtual chats or making doctor's visits. Most people would prefer to not spend a lot of time on doctor's visits online and would rather talk to family. Internet deserts, that's areas without Wi-Fi or much Internet connectivities, that's decreasing thanks to recent infrastructure law. But rural access remains a big issue. Affordability, equity of access, as well as technology skills and fears of technology. Urban city and county clinics have their own priorities. Politics can color decisions for funding as well. A clinic may require a satellite clinic for telepsychiatry. This avoids the patient access issue to some extent and also decreases the technophobia issue. But the clinic still requires technology and tech people. This requires money. And so therefore, an issue is money. I would have to mention that I had access to doing telepsychiatry while in the Army, and it was wonderful. Instead of dealing with webcams, we had a nice television sort of hookup, and we talked between Walter Reed Army Hospital and upstate New York. And I was able to see children in upstate New York. Made it easy for them because they were rural and easy for us. So we didn't have to have somebody immediately present in their area. Well, that was wonderful the first time that I did it with this particular family. The second time, in spite of being at Walter Reed Army Hospital, all of the tech people were in a meeting, and we had no video connection. We ended up making the connection by a plain old telephone system, POTS, to do our interview, which of course is nowhere near as friendly or as close as using video conferencing. So one has to consider IT as well as everything else. At one point, as was mentioned, I did some conferencing with Ethiopia. At the time, Skype was HIPAA compliant, and I was able to make a great connection with some of the paramedical folk there. The only difficulty is Ethiopia has the second worst internet connectivity in the continent of Africa, and we often had some connectivity problems even with Skype, which doesn't require that much broadband. There's also only one company that runs the internet in Ethiopia, so if someone has political difficulties, they could just shut off all of internet access fairly easily. So internationally, that can be a problem. So future difficulties. 3D doctor visits or holographic. This is a screen grab that I got of hologram doctors being to the space station to visit astronauts. So you can't make it out very well, but this person is talking to somebody on the ground. You might also notice there are wires and everything. It's very technological to be able to do a holographic visit. There's a very high cost to it. It requires a lot of bandwidth, and technophobia would obviously be a major issue. Who would be able to pay for this? Would it be acceptable? It's an old Peanuts cartoon. Face-to-face psychiatric care versus the screen on the right, which shows a doctor talking to somebody that's wearing a video conferencing mask, a 3D or a virtual reality mask, and talking to the patient. The issue with that is that each person would see exactly what you see on the screen. You're not really seeing the face. You're seeing one screen and mask talking to another. Obviously, it would be better if one could have a screen hookup like this, where it looks like one's talking to a television screen, or it could be 3D. I can tell you that 3D conferencing is being worked on by Google and a number of other companies. I tried to speak to several people about and a number of other companies. I could get absolutely no information from anybody. I'm thinking that they're protecting their proprietary rights to whatever technology they're working on. In the not-too-distant future, we'll have access to one of these technologies, 3D or holographic. Again, it gets back to people have to have familiarity with the technology, be comfortable with it, and there has to be IT backup. In summary, you could say the new technology infrastructure has a cost, but who can afford it? Will insurance pay, or there's some other subsidy for healthcare? Right now, insurance pays essentially in parity for telepsychiatry than it does for regular in-person contact, which makes it easier on the person that would have to drive somewhere and park somewhere and deal with weather and traffic and all that. It's much nicer to be able to do a telepsychiatric visit, although it's not in-person and it lacks that in-person feel, but it still provides a lot of ability to do outreach. I've mentioned IT a number of times. Will they be as necessary as first or second responders? When I started out doing telepsychiatry using the asynchronous connection, every evening I went over every message. There were a couple of messages on there hinting at suicidal thoughts, where people were supposed to understand that the headboard was not for emergencies. There were a couple of times when people mentioned episodes of child abuse. I got around the, I'll say, first responder, second responder issue by having phone numbers to everybody. When I saw something that was of particular concern, I talked to the person and also had a list of every community mental health center in Georgia so I could direct them to get access. Again, I was not there to provide care. I was there only to direct them to care. If one is doing regular telepsychiatry, one has to have access to IT, even if it's connecting with somebody in another state at a university. Is IT going to be considered as necessary as a second responder? What degree of technical education will be necessary to use any of these technologies, or the current technology? Back in the late 80s, Medical College of Georgia had a telepediatrics program. Well, it was free for doctors throughout the state to use with their patients. Patients would come in to a satellite clinic and see their doctors. All of this was funded through grants. It was a complete failure. Most doctors were not interested in it, although the patients were much more interested. At that time, 70% to 80% of patients were much more willing to use telepsychiatry than the doctors, which were at 40% to 50%. We have as much technophobia as anyone else. We do not like the technology behind electronic medical records and telepsych, although it's considerably easier now using a webcam and maybe a microphone. It still requires knowledge to be able to do that. A number of the older patients that I've dealt with had a neighbor to come by and explain how to use everything, and they wrote everything down. They still had to call us up and ask, well, I heard I had to press this button, but I'm not sure where this button is. And it became difficult from that. One has to have some amount of technology education. Will there be an algorithm of some sort to provide access? Right now, with the shortage of physicians willing to take any form of insurance, the shortage of psychiatrists specifically to take insurance in the metropolitan Memphis area, as I said, 50% of the doctors of the psychiatrists do not take any insurance. The primary psychiatrists that take insurance are at our clinic in the University of Tennessee. So in our area, it's very limited. Most of the psychiatrists live on the periphery of urban Memphis, and that does make it a little harder for people to get to. So will there be an algorithm helping doctors to decide who they can afford to treat? Because of course, doctors have expenses as well as patients. And how will access to care be dispensed to address all these disparities? So getting back to the digital divide, it started out with people considering the racial and socioeconomic differences, primarily a lot of economic factors and having access to computers, whether it was pre-internet or recently. But that has improved. There's still the age digital divide because of unfamiliarity with technology. This can cause one to become, there's a new term called a digital immigrant, those that have to immigrate into using technology. This has been written about in terms of education, but it helps one to keep up with current events, keep up with their education, general knowledge and medical access. And as mentioned, even getting immunizations often requires internet access. Healthcare disparities still exist and will continue until recognized and addressed. The divide still exists and is more complex than previously considered. It used to be people would talk about computer users being in their basements and off by themselves, perhaps eating Cheetos or some snack and not having interaction with anybody else. Well, that's how my contact with people started. It was mostly adolescents. A lot of them were in their basement eating snacks and they did not want to come out of their homes to see a psychiatrist, a counselor, a social worker, anything like that. At least now people can have like that. At least now people can have access via using telepsychiatry or even telephone if necessary. So we now have the advantage of being able to use technology, but one has to be comfortable using it for the doctor as well as for the patient. Thank you. Thank you so much, Dr. Bell. Definitely a wonderful presentation. I feel like you gave me a walk down memory lane. For as long as I can remember in my lifetime, we've been discussing for decades now, how do we go about closing a digital divide? And, you know, as you mentioned, we've been going through this entire process and now we find ourselves, as you described and adequately captured, what is at the digital divide now and what are the opportunities that we have to do something about it in order to be able to provide equitable telehealth opportunities for all patients that seek care and that require care. So thinking about health equity and thinking also about digital gap, what would you recommend for individuals such as yourself who are psychiatrists that are trying to serve the people and serve the population? But when we're thinking about rural communities, once you mentioned, and also in my past, I've worked with tribal communities, what would be some, a couple of maybe action steps or maybe lessons learned that you could be able to expand on and how best to serve and provide a service to them that we know, based on the research and the literature, that it's much needed? Well, one simple way would be, at some expense, setting up satellite clinics with a nurse practitioner, a nurse, even perhaps a social worker at some site that people can come to that don't have internet access. I mean, something also as simple as a Wi-Fi bus that people can use. Now, obviously one has to be concerned with privacy issues and you have to consider what is available. I've spoken to a number of patients that were in a car with somebody else when they would talk with me and you're not supposed to have to do that. But the reality is they couldn't get complete privacy. So that's better than nothing at all. So again, a satellite setup is the easiest for someone that's in a really rural or deserted area. Next to that, a lot of people have access to satellite TV or cable TV. And fortunately, that's becoming more accessible. One of my goals over the years has been to try to make things as simple and as inexpensive as possible. Now, laptops obviously have helped a lot with that. Cell phones have helped even more. So a quick and easy solution, actually, to most of the world's population right now would be to find ways of providing tele-access via cell phones. And for instance, in the continent of Africa, about 50% of the population have cell phones. They may not have much other internet access, but they have access to cell phones. So if one is doing, I'll say, a low bandwidth communication, not much in the background, and they are able to spend a lot of time talking and not having to worry too much about visual, using a cell phone is a pretty good solution as well. But again, you have to keep in mind that digital minutes cost. So if perhaps there is some way of helping people to fund this. And there are advances being made in infrastructure in the United States and elsewhere as far as internet access and as far as funding for cell phone time. So we're making progress. But I guess right now, satellites and cell phones are our best. Satellite centers and cell phones are our best connection. Hope that answered your question. They're great suggestions. And I think those are great actionable pieces that clinics or practices can actually put into play. And I think you're absolutely right. Hopefully, the $40 billion that the White House administration is putting into this will be sufficient. We're about to find out how that plays out. But before I go further, I do apologize to the audience. I should have said, if you have any questions, please join the conversation and post your Q&As. We would love to include your questions in the conversation that we're having. And we'd like you to be part of it. Another item that you raised, Dr. Bao, was privacy. And I think one of the things we've also seen and heard and witnessed is that for a lot of homes, well, for quite a few homes, we also deal with multi-generational households. I'm not sure if there's a way to best describe or maybe suggest ways to navigate that space. But privacy is removed as individuals are trying to seek the care they need when they can't step out of a home, or maybe they have their grandkids or grandparents and so on. Any further advice on that or things that you've learned and witnessed and also navigated? One of the trainees in another department had some issues with a girlfriend. And this particular resident was working in rural Tennessee and was living in rural Tennessee. Now, his emergency came up because, as I said, it was a breakup in a relationship. So it disrupted his being able to go to the clinic. He wasn't able to do that because he was too emotionally distraught at the time. I happened to be the psychiatrist over student health and resident health at that time. And we'd set up a telepsychiatry way to have access for residents and students. We're spread out throughout Georgia. I'm sorry, Tennessee. Well, I was at a convention in Philadelphia. And I had to find a corner where I could talk to this guy using Facebook, FaceTime, I'm sorry, which is not HIPAA compliant. But this was an emergency. And we were able to walk through two different sessions. We were able to walk through the emergency. So what this leads to is saying that people can sometimes get access to a bathroom or go outside, do the best they can to sequester a little room to themselves where they can talk to their doctor or nurse or whomever they need to talk to. But again, privacy is necessary but not always available. As I said, I've talked to people in cars riding with somebody else and kind of had to figure out what they're talking about. That's not ideal, but that may be all that's available. Talk to people at work. And the same issue, trying to get a little privacy. So people on their cell phones can often go somewhere. So cell phones have more mobility than laptops. So that's the only way that I can suggest at this point, unless somebody has a fancy Apple Watch that they can talk into that. But that's still just audio, and it's not video. So those are the best suggestions I have at this point. Thank you so much. I didn't know. Hopefully, I'm pronouncing the last name correct. Roper, Roper. And they're also highlighting how telepsychiatry has gained popularity and acceptance due to numerous advantages, particularly in addressing some of the challenges in traditional face-to-face mental health care. But they also do mention it's important to note that telepsychiatry has its limitations. And that's a lot of the conversation that's been having, that we're having today. So if there's questions around that, please do let us know and I will include it. I see a question here from Jordan White. For patients or clients with comorbid conditions, have there been key gaps or challenges that have emerged in telehealth context? Dr. Bell? When I started doing this, I was always of the mind that somebody who was paranoid, schizophrenic, would be a little afraid of the television talking to them. That's never been the case. People have been able to separate a delusion or a hallucination from their talking to their doctor. At least so far, that's been my experience. As far as other difficulties, sometimes people don't want to talk on. I've had people that refuse to talk on video. That's rare, but it happens. Not just talk to them on the phone. You make do with the best that you can. Those are the only issues that I've had so far. Haven't used a telephone because they don't want to be seen on video, I guess. Or the other issues. Thank you. And something that wasn't lost on me, and I think it's worth highlighting, I did really appreciate the history of computers and when you went back to 1984. And at that time, it was probably the floppy disk. And then we had the hard disk. But something to keep in mind, and I think you definitely did an amazing job of reminding individuals, is even though our smartphones, when we compare it to 1984 to now, our phones are almost in themselves a supercomputer that we could have never dreamed we would have had back then. But there are limitations, as you mentioned. And I think a lot of individuals in rural and tribal communities, they live with the fact that a lot of their connections almost feel like they're dial-up, if not 3G. Some of the things that we take for granted, outside of those communities where we do have maybe 5G and LTE and all these other technologies. Are there platforms, because you did mention platforms, in addition to the limitations of data, is there other things you'd like to expand on as we think about platforms and how it's delivered? Because I think there has to be some conscious thought into how do you protect patient privacy, but also how do you deliver and execute a platform that's accessible to all these various broadband challenges? Well, when I started out, there was no such thing as broadband. People could spend a fortune on an ISDN line or something like that. Universities like Yale and Harvard that were doing telepsychiatry had satellite centers that used real live satellites to connect with each other. The time was $20,000 a month or sometimes thousands of dollars per day to make a connection with that satellite clinic. Of course, it was grant funded. Now, we can go back to the way I started out and use something, either chat is no longer asynchronous. People can chat with each other right now. And there are still computer bulletin board systems. So some sort of hybrid between the two would make it a pair of some sort available to a lot of people that don't have much 3G, 4G or anything. As long as you can have a cell phone connection, you can usually text. And if you can text, you can do a computer bulletin board essentially. So I'm thinking about setting something like that up again. You just have to figure out how to do that. At least now you can spread the word. It doesn't have to be by mouth. It could be on Facebook or something like that. You still have to be concerned about HIPAA violations and that sort of thing. I contacted every single person that used the special section of my computer bulletin board. If we're gonna have patients, we can contact with them and make sure that they have access to, it's have to make sure that it's that individual talking to that doctor rather than some hacked connection. I think that can be worked around. So what I'm saying is that using something that's a hybrid of past computer bulletin board systems, it provided service back then, way back in the 80s. I think something like that could be workable now. And I definitely appreciate that because I think sometimes we always think about what is the next thing being created and what's the evolution but sometimes there has to be a balance, especially if we're being very mindful and intentional about serving everyone, not just those that make it easier with us because they have the access and the digital means to do so. So speaking of recent fads, I'm not sure if this has come across your desk or you've had conversations around this, but I know a lot of us are hearing about this CHAP-GPT, artificial intelligence. Yes, yes, I'm familiar. It's gonna be a general question. What are your thoughts and do you think there's a place for something like that in the evolving telemedicine field? Well, currently, AI, artificial intelligence, such as CHAP-GPT and BARD and things like that, I think that's Amazon's thing. There are a number of different ones. Anyway, the problem is they have hallucinations. They make up information that sounds real to the reader and it's, I mean, people have had articles that have been written for them that come up with make-believe reference articles complete with author names and all that information. It's like a hallucination. That's what they call it on artificial intelligence. So I see artificial intelligence, CHAP-GPT and things like that as being much further down the road for psychiatry because it's not reliable. It's not trustworthy. It's very creative, but certainly doesn't take the place of somebody's intuition, feel from patients in the past and all those things that aren't quite based on immediate facts, but experience. And perhaps that's doable in the not too distant future, but it's definitely not doable now. I roll my eyes when people start talking about CHAP-GPT. People apply to programs. I think they're using CHAP-GPT and programs like that to write wonderful little personal statements that aren't so personal. That's why we still have to have interviews in person and not just by CHAP-GPT. So it has its limitations and I worry about them. I agree and I appreciate your candid response because I think as we're also thinking about the digital divide and, oh wait, there is a question. I think that the excessive and uncontrolled use that has been given to GPT-CHAP in certain ways scare me. So as many of the young people use this type of service as if they were a real person or the easy way to many situations. I think that's a good point. And it kind of almost segues into the next conversation. Well, next question I was going to ask, how do we help individuals? Because technology, there's good and bad to everything. And I think one of the things that I roll my eyes about is when people say, well, let me tell you what I Googled about my condition. So how can physicians navigate that space in a very culturally aware and also very humbling way to where working with patients, you come across as both knowledgeable but also non-condescending and non-confrontational in this to help steer them to the right places where they should be gathering their information and utilizing technology in a beneficial way to them? Well, over 60% of, I'll loosely use the word consumer that I don't really like, but it fits. Over 60% of consumers use the internet, whether it's Google or something else to get medical information and medical-like information. And a lot of times, obviously, it's not quite correct. It's based on somebody's feelings. Like COVID can cause testicles to explode and weird things like that that I've heard about. All one can do is ask the patient. Okay, now I've been telling you this. What have you been reading about? What are your concerns? If you're upfront and you ask the people, they'll usually tell you, well, I read such and such. I've had patients tell me some interesting and useful information that they found online that I wasn't necessarily able to find in a research study, but they were able to find, 300 patients complained of X, Y, and Z, and it may not have had a paper written about it, but it's still something one needs to be concerned about. So asking people what they've read or heard is pretty necessary nowadays. Like I said, the majority of people, including doctors, check things out on the internet rather than bother their friends or things like that. Internet is neutral, so obviously they won't make any judgment, but obviously the internet can be very, very wrong. Absolutely, and I would be remiss as we're speaking about technology. For individuals watching this, I encourage you to visit psychiatry.org because there are resources here on our website where you can also read further about telepsychiatry, but you can even read about telemedicine and some of the advocacy work being done around that, that physicians can do to really be a voice in this space, such as Dr. Bell is. So Dr. Bell, last, well, we still have a few minutes, so it's not gonna be that last. So what would be the number one takeaway from this conversation that you hope individuals will take with them? If there was one thing that you really want them to walk away with, what would that be? Probably the last thing that you talked about, in that most people seek information on the internet. It doesn't have anything necessarily to do with telepsychiatry, but people find information on the internet, and we need to be asking people about that because we can miss out on a lot of misstatements, misrepresentations that cloud patients' compliance with medication or compliance with therapy. So that's not directly telepsychiatry, but that's worried me much more than chat GPT. I'll leave my AI concerns for a separate thought, but that would be the first thing. The second thing is keep in mind that a lot of patients, most patients don't wanna spend a lot of money on, don't wanna spend any more extra money on doctor care, but having to have a telepsych hookup is reasonable, and people have to be careful about their minutes. So just saying that, yes, we offer telepsychiatry doesn't really address a lot of the population because they won't, one, they may not know exactly what telepsychiatry is, but also people don't wanna spend all their data minutes on conversations with a doctor. They'd rather talk to their family and friends. Yeah, and I think the last thing also very much segues into the sense of we don't do enough conversations around the fact that there is a wealth gap here in our country. And I think when you do speak to, you're directing the comments to individuals have to make choices on limited resources. Those limited resources also are paid through limited financial means that they may have. So I think you're absolutely right that individuals are making decisions. So it's how can this good really be proposition to them in a way where when they're making those difficult decisions, they choose to maybe go this route through telemedicine because they know it's gonna have a long lasting effect, but so is human connection with families as you gave examples of and using that time to speak about that. Well, I appreciate this conversation, Dr. Bell. We have a few more slides to get through, which is all gonna be housekeeping, but I will give you a virtual round of applause because I very much enjoy this conversation and I am very thankful of everyone that attended. But if we go to the next slide, Dr. Bell, I'll do some housekeeping. Okay. And then you are also invited to attend our next conversation. Thank you again for joining this webinar. We'll be having an additional webinar on Wednesday, July 26, from 3.30 p.m. to 4.00 p.m. Eastern time titled equity. I'm not sure if that's 3.30 to 4.00 p.m. or if it's meant to be 4.30, but we'll find out. Equity and access to self-assessment for modification of anti-racism tool, also known as SMART and the level of care utilization system LOCAS. We hope you can join us for the webinar. Thanks again and take care. And thank you so much, Dr. Bell. Thank you. Take care, everyone. ♪♪

telepsychiatry

digital divide

limitations

funding

rural access

affordability

healthcare disparities

artificial intelligence

technology education