Managing Virtual Hybrid Psychiatrist-Patient Relationships in a Digital World

Abstract

The rapid technological transformation of society over the past 3 decades has had significant influence on the practice of psychiatry. 1 In their personal and professional spheres, psychiatrists now must master relationships across multiple technology platforms and settings. To successfully manage these hybrid physician-patient relationships, psychiatrists need to have an appreciation for the strengths, limitations, and adaptations needed for each technology they use to interface with patients. 2 There is a rapidly expanding body of literature informing the use of technology in psychiatric treatment. 3 Certain technologies, such as videoconferencing, or telepsychiatry, are long-standing, have a robust evidence base with numerous published clinical guidelines, and have been widely deployed in practice, while for other technologies, the literature is relatively nascent (eg, mobile apps). 2,4 The general medical literature provides lessons for addressing ethical and boundary issues arising from technology. 5 All psychiatrists should be familiar with technologies in widespread use, or base technologies (eg, email, mobile, electronic health records, videoconferencing), as well as technologies beginning to be more widely adapted, or emerging technologies (eg, patient portals, apps, web-assisted therapy). 2 Psychiatrists should develop expertise with, implement, and continuously monitor technology in their practice and make sure to set clear expectations and direction for their patients around the use of technology in clinician-patient interactions. Proffered here is a progressive 3-step framework to evaluate and manage technology in psychiatric practice in the context of these hybrid physician-patient relationships. These components are (1) administrative, (2) operational, and (3) clinical.Key domains of the administrative components encompass legal, regulatory, and technological requirements. Common considerations across technologies include privacy and security rules (as mandated by federal, state, regulatory bodies, and institutional or organizational policy); technology requirements, such as bandwidth, access, and equipment; and adapting technology to regulatory and malpractice requirements, jurisdiction, and formal or informal processes for patient consent and education. 6 The details of these considerations vary widely across technologies and settings. For example, some states require written informed consent for telepsychiatry services (but not for other technologies [eg, text messaging, patient portals, emails, mobile telephones]), while other states do not. These administrative considerations, especially the legal and regulatory standards, set the foundation and structures for operationalizing a technology into practice.Psychiatrists in solo or group psychiatric practices create the operational components for a technology by accounting for a technology's administrative considerations, intended use, clinical setting, users, and communication protocols, synthesizing these into a functional construct for clinical...

COVID-19 and Telepsychiatry: Development of Evidence-Based Guidance for Clinicians

“…Post–COVID-19, patients will be able to individualize their care, balancing the pros and cons for their own treatment, with many opting for a hybrid model across different remote and in-person settings. Clinicians will need to balance the strengths, limitations, and adjustments needed for each approach and feel competent in using all media [ 34 ].…”

“…Telepsychiatry also offers options for easily combining with other digital technologies. These include platforms for monitoring symptoms such as mood monitoring systems [ 35 ] or combining care with apps [ 34 ]. Smartphone apps offer advantages in accessibility, insights into physical and cognitive behavior, and a range of resources designed to aid health.…”

“…Hybrid care will be key in the way forward post–COVID-19 to allow clinicians and their patients to choose the individual combination of care that offers the most advantages. To do this, mental health clinicians need to become adept at managing hybrid clinician-patient relationships and have a detailed understanding of the advantages and limitations of all the tools they use to care for patients [ 34 ].…”

The Ethical Use of Telepsychiatry in the Covid-19 Pandemic

“…Implementing treatment at a distance requires particular competencies and special knowledge, which, ideally, should be trained, proven, and accredited to further assure standard of clinical care (12). Especially regarding newly emerging technologies such as the use of mobile apps, new competencies and challenges may be faced by clinicians (13). Creating and maintaining a therapeutic relationship in the virtual environment even with a previously-established therapeutic alliance may still give rise to misunderstandings, frustrations, or interruptions due to technological or network failures.…”

“…In such circumstances, the patient’s sense of familiarity or intimacy may change, especially when communicating with a therapist from the privacy of their homes ( 14 ). However, online telepsychiatric care may also offer some advantages for the therapeutic relationship, which can vary depending on the patient’s disorder ( 11 , 13 ). Clinicians should explore capitalizing on these advantages.…”