Sensor, Wearable, and Remote Patient Monitoring Competencies for Clinical Care and Training: Scoping Review.

Sensor, wearable, and remote patient monitoring technologies are typically used in conjunction with video and/or in-person care for a variety of interventions and care outcomes. This scoping review identifies clinical skills (i.e., competencies) needed to ensure quality care and approaches for organizations to implement and evaluate these technologies. The literature search focused on four concept areas: (1) competencies; (2) sensors, wearables, and remote patient monitoring; (3) mobile, asynchronous, and synchronous technologies; and (4) behavioral health. From 2846 potential references, two authors assessed abstracts for 2828 and, full text for 521, with 111 papers directly relevant to the concept areas. These new technologies integrate health, lifestyle, and clinical care, and they contextually change the culture of care and training-with more time for engagement, continuity of experience, and dynamic data for decision-making for both patients and clinicians. This poses challenges for users (e.g., keeping up, education/training, skills) and healthcare organizations. Based on the clinical studies and informed by clinical informatics, video, social media, and mobile health, a framework of competencies is proposed with three learner levels (novice/advanced beginner, competent/proficient, advanced/expert). Examples are provided to apply the competencies to care, and suggestions are offered on curricular methodologies, faculty development, and institutional practices (e-culture, professionalism, change). Some academic health centers and health systems may naturally assume that clinicians and systems are adapting, but clinical, technological, and administrative workflow-much less skill development-lags. Competencies need to be discrete, measurable, implemented, and evaluated to ensure the quality of care and integrate missions.

Caring E-mails for Military and Veteran Suicide Prevention: A Randomized Controlled Trial.

OBJECTIVE: The purpose of this multisite study was to conduct a randomized controlled trial of an e-mail version of the caring letters (CL) suicide prevention intervention to determine whether the intervention is efficacious in preventing suicide behaviors among U.S. service members and veterans. METHOD: Psychiatric inpatients (N = 1,318) were recruited from four military medical centers and two VA hospitals and randomized to receive either 13 caring e-mails over two years or usual care. RESULTS: There were 10 deaths from any cause in the CL group (three suicides) and 14 in the usual care group (seven suicides) during the individual two-year follow-up intervals. There was no statistically significant difference in the rate of all-cause hospital readmission between the study groups (RR = 1.13; 95% CI = 0.94, 1.36). There were no differences observed between groups on self-reported psychiatric hospital readmissions, self-reported suicide attempts, or other measures associated with risk for suicide. CONCLUSIONS: No firm conclusions about the efficacy of the intervention can be made because the study was inadequately powered. There were no adverse events associated with the intervention, and implementation of the procedures was feasible in the military and veteran hospital settings. These results provide important methodological considerations for caring contact trials in military populations.

Implementation and Evaluation of Videoconferencing for Forensic Competency Evaluation.

Background: The demand for court-ordered pretrial forensic evaluations has increased substantially in the United States and has resulted in long waitlists for services. This has caused concerns about the civil liberties of persons who are waiting for evaluations, especially among defendants with severe mental illness or intellectual disabilities. Introduction: This article describes the implementation and results of the first program evaluation of the use of videoconferencing (VC) to conduct adult forensic evaluation services in the State of Washington. Materials and Methods: Four county jails, two state hospitals, two competency restoration residential treatment facilities, and two state offices were connected through secure VC link. Attorneys were allowed to attend sessions by three-way conference. Data were collected during and after each VC session. Results: Fifty competency evaluations to stand trial interviews were completed during the first year of the program. Psychotic symptoms of defendants did not impair interviews, although some network-related technical problems did occur. The overall results provide initial support for the feasibility and safety of forensic competency evaluation services delivered by VC. Discussion: VC can improve the efficiency of pretrial competency to stand trial evaluations. The use of the VC capability to provide training to the forensic evaluators, meetings, and supervision is an additional benefit. Conclusions: The capability to conduct competency to stand trial evaluation interviews through VC has the potential to help meet the growing demand for these services in the State of Washington and beyond.

Forensic Competency Assessment with Digital Technologies.

PURPOSE OF THE REVIEW: We review the application of videoconferencing (VC) to pretrial forensic assessments of competence to stand trial (CST). We summarize the benefits, legal considerations, and reliability of VC evaluations. Based on our experience with VC in forensic settings, we provide illustrations of challenges and recommendations regarding this capability to meet increasing demands for services. RECENT FINDINGS: CST evaluations are the most frequent type of forensic mental health assessment within the American legal system. VC can be a reliable method for conducting interviews with most defendants, including those with psychotic symptoms. Videoconferencing can improve the overall efficiency of evaluations while also improving the safety of the professionals involved with the competency evaluation. VC provides an opportunity to meet the increasing demand for evaluations and improve their efficiency. Forensic clinicians should become familiar with the uses of VC in delivering services so that VC is implemented ethically and effectively.

Development and Evaluation of a Web-Based Resource for Suicidal Thoughts: NowMattersNow.org.

BACKGROUND: Nearly half of people who die by suicide see a health care provider in the month before their death. With the release of new care guidelines, detection of suicidal patients will likely increase. Providers need access to suicide-specific resources that can be used as part of immediate, brief interventions with a suicidal patient. Web-based suicide prevention resources have the potential to address this need. OBJECTIVE: This study aimed to describe the development of the NowMattersNow.org website as a resource for individuals with suicidal thoughts and to evaluate the utility of the site via user experience surveys. METHODS: NowMattersNow.org is an online video-based free public resource that provides evidence-based teachings, examples, and resources for managing suicidal thoughts and intense emotions focused largely around skills from dialectical behavior therapy. Developed with assistance from mental health consumers, it is intended to address gaps in access to services for suicidal patients in health care systems. Visitors stay an average of a minute and a half on the website. From March 2015 to December 2017, a user experience survey measured self-reported changes on a 1 (not at all) to 5 (completely overwhelming) scale regarding intensity of suicidal thoughts and negative emotions while on the website. Longitudinal regression analyses using generalized estimating equations evaluated the magnitude and statistical significance of user-reported changes in suicidal ideation and negative emotion. In secondary analyses, user-reported changes specific to subgroups, including men aged 36 to 64 years, mental health care providers, and other health care providers were evaluated. RESULTS: During the period of analysis, there were 138,386 unique website visitors. We analyzed surveys (N=3670) collected during that time. Subsamples included men aged 36 to 64 years (n=512), mental health providers (n=460), and other health care providers (n=308). A total of 28% (1028/3670) of survey completers rated their suicidal thoughts as a 5 or "completely overwhelming" when they entered the website. We observed significant reductions in self-reported intensity of suicidal thoughts (-0.21, P<.001) and negative emotions (-0.32, P<.001), including decreases for users with the most severe suicidal thoughts (-6.4%, P<.001), most severe negative emotions (-10.9%, P<.001), and for middle-aged men (-0.13, P<001). Results remained significant after controlling for length of visit to website (before the survey) and technology type (mobile, desktop, and tablet). CONCLUSIONS: Survey respondents reported measurable reductions in intensity of suicidal thoughts and emotions, including those rating their suicidal thoughts as completely or almost completely overwhelming and among middle-aged men. Although results from this user-experience survey administered at one point in time to a convenience sample of users must be interpreted with caution, results provide preliminary support for the potential effectiveness of the NowMattersNow.org website as a tool for short-term management of suicidal thoughts and negative emotions.

Should Watson Be Consulted for a Second Opinion?

This article discusses ethical responsibility and legal liability issues regarding use of IBM Watson™ for clinical decision making. In a case, a patient presents with symptoms of leukemia. Benefits and limitations of using Watson or other intelligent clinical decision-making tools are considered, along with precautions that should be taken before consulting artificially intelligent systems. Guidance for health care professionals and organizations using artificially intelligent tools to diagnose and to develop treatment recommendations are also offered.

Predicting post treatment client satisfaction between behavioural activation for depression delivered either in-person or via home-based telehealth.

INTRODUCTION: Treatment engagement, adherence, cancellations and other patient-centric data are important predictors of treatment outcome. But often these data are only examined retrospectively. In this investigation, we analysed data from a clinical trial focused on innovative delivery of depression treatment to identify which patients are likely to prefer either in-home or in-person treatment based on pre-treatment characteristics. METHODS: Patient satisfaction was assessed in a trial of individuals with depression treated using identical behavioural activation therapy protocols in person or through videoconferencing to the home (N = 87 at post treatment: 42 in-person and 45 in-home participants). The Client Satisfaction Questionnaire was administered at the end of the treatment. A Tobit regression model was used to assess moderation using treatment assignment. Regression lines were generated to model treatment satisfaction as a function of treatment assignment and to identify whether and where the groups intersected. We examined the distributions of the contributing moderators to the subsets of participants above and below the intersection point to identify differences. RESULTS: While no significant differences in patient satisfaction were observed between the two groups, or between patients receiving treatment by different providers, baseline characteristics of the sample could be used to differentiate those with a preference for traditional, in-office care from those preferring in-home care. DISCUSSION: Participants who were more likely to prefer in-home care were characterized by larger proportions of veterans and lower-ranked enlisted service members. They also had more severe symptoms at baseline and less formal education. Understanding client reactions when selecting treatment modality may allow for a more satisfying patient experience.

New-Onset Asthma and Combat Deployment: Findings From the Millennium Cohort Study.

Recent reports suggest US military service members who deployed in support of the recent conflicts in Iraq and Afghanistan have higher rates of new-onset asthma than those who did not deploy. However, it is unknown whether combat experiences, in addition to deployment, contribute to new-onset asthma risk. This study aimed to longitudinally determine the risk factors for developing asthma, including combat deployment (categorized as deployed with combat experience, deployed without combat experience, or nondeployed), among participants in the Millennium Cohort Study from 2001 to 2013. A total of 75,770 participants completed a baseline survey and at least 1 triennial follow-up survey on deployment experiences, lifestyle characteristics, and health outcomes. Complementary log-log models stratified by sex were used to estimate the relative risk of developing asthma among participants who reported no history of asthma at baseline. In models with adjustments, those who deployed with combat experience were 24%-30% more likely to develop asthma than those who did not deploy. Deployed personnel without combat experience were not at a higher risk for new-onset asthma compared with nondeployers. Further research is needed to identify specific features of combat that are associated with greater asthma risk to inform prevention strategies.

Measuring Aggregated and Specific Combat Exposures: Associations Between Combat Exposure Measures and Posttraumatic Stress Disorder, Depression, and Alcohol-Related Problems.

Research has shown combat exposure to be associated with negative mental health outcomes. Different combat exposure measures are not composed of the same combat experiences, and few combat exposure measures have been directly compared to another measure. Furthermore, research about the unique associations between specific combat experiences and mental health is lacking. We investigated associations between new-onset posttraumatic stress disorder (PTSD), new-onset depression, and alcohol-related problems and two commonly used measures of combat among a sample of 20,719 recently deployed U.S. military personnel. A 13-item measure assessed both direct and indirect combat exposures, and a 5-item measure assessed only indirect exposures. Both combat measures were associated with all outcomes in the same direction (e.g., PTSD, odds ratio [OR] = 2.97 vs. 4.01; depression, OR = 2.03 vs. 2.42; alcohol-related problems, OR = 1.41 vs. 1.62, respectively, for the 5- and 13-item measures). The 13-item measure had a stronger association with some outcomes, particularly PTSD. Each specific item had significant bivariate associations with all outcomes, ORs = 1.43-4.92. After adjusting for other combat exposures, items assessing witnessing abuse, feeling in danger, and knowing someone injured or killed remained associated with all outcomes, ORs = 1.18-2.72. After this adjustment, several items had unexpected protective associations with some mental health outcomes. Results indicated these two combat exposure measures were approximately equally effective for determining risk for negative mental health outcomes in a deployed population, despite having different content. Additional research is needed to replicate and understand how specific combat exposures affect health.

Unobserved heterogeneity in response to treatment for depression through videoconference.

OBJECTIVE: This study examined treatment response heterogeneity in a recent randomized controlled trial of treatment for depression using videoconferencing technology compared to traditional in-office care. METHOD: Growth mixture modeling was used to identify subgroups of individuals in the trial based on treatment response trajectories. Demographic and baseline characteristics were included to identify correlates of subgroup membership. RESULTS: There were two subgroups based on the trajectories of the Beck Hopelessness Scale. The first subgroup had less symptom severity at baseline, and there was no meaningful difference between the two treatment modalities in change over time. The second subgroup had higher symptom severity at baseline, and individuals who engaged in treatment through the videoconference modality had less symptom improvement than those who underwent the in-office modality. Older participants with higher loneliness and anxiety scores at baseline were more likely to be in the second group. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Treatment of depression using videoconferencing to deliver care to an individual's home offers opportunities for improved access to services, especially among those who are unwilling or unable to seek in-person treatment. However, videoconferencing may not be appropriate for everyone. An individual's symptom level, age, and comorbidities are important clinical considerations when selecting an appropriate treatment modality. (PsycINFO Database Record

Neuropsychological Test Administration by Videoconference: A Systematic Review and Meta-Analysis.

The purpose of the current systematic review and meta-analysis was to assess the effect of videoconference administration on adult neurocognitive tests. We investigated whether the scores acquired during a videoconference administration were different from those acquired during on-site administration. Relevant counterbalanced crossover studies were identified according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Twelve studies met criteria for analysis. Included samples consisted of healthy adults as well as those with psychiatric or neurocognitive disorders, with mean ages ranging from 34 to 88 years. Heterogenous data precluded the interpretation of a summary effect for videoconference administration. Studies including particpants with a mean age of 65-75, as well as studies that utilized a high speed network connection, indicated consistent performance across videoconference and on-site conditions, however studies with older participants and slower connections were more variable. Subgroup analyses indicated that videoconference scores for untimed tasks and those allowing for repetition fell 1/10th of a standard deviation below on-site scores. Test specific analyses indicated that verbally-mediated tasks including digit span, verbal fluency, and list learning were not affected by videoconference administration. Scores for the Boston Naming Test fell 1/10th of a standard deviation below on-site scores. Heterogenous data precluded meaningful interpretation of tasks with a motor component. The administration of verbally-mediated tasks by qualified professionals using existing norms was supported, and the use of visually-dependent tasks may also be considered. Variability in previous studies indicates a need for further investigation of motor-dependent tasks. We recommend the development of clinical best practices for conducting neuropsychological assessments via videoconference, and advocate for reimbursement structures that allow consumers to benefit from the increased access, convenience, and cost-savings that remote assessment provides.

Evaluation of a modified version of the Posttraumatic Growth Inventory-Short Form.

BACKGROUND: Posttraumatic growth is the positive change resulting from traumatic experiences and is typically assessed with retrospective measures like the Posttraumatic Growth Inventory (PTGI). The PTGI was designed to include reference to a specific traumatic event, making it difficult to implement, without change, in prospective survey studies. Thus, a modified Posttraumatic Growth Inventory-Short Form (PTGI-SF) was included in a large prospective study of current and former U.S. military personnel. The current study provides preliminary psychometric data for this modified measure and its ability to assess psychological well-being at a single time point. METHODS: The study population (N = 135,843) was randomly and equally split into exploratory and confirmatory samples that were proportionately balanced on trauma criterion. Exploratory factor analysis and confirmatory factor analysis (CFA) were performed to assess the psychometric validity of the modified measure. The final model was also assessed in a subset of the confirmatory sample with a history of trauma using CFA. RESULTS: Results supported a single-factor model with two additional correlations between items assessing spirituality and items assessing compassion/appreciation for others. This model also fits among the subset with a history of trauma. The resulting measure was strongly associated with social support and personal mastery. CONCLUSIONS: The modified PTGI-SF in this study captures psychological well-being in cross-sectional assessments, in addition to being able to measure posttraumatic growth with multiple assessments. Results indicate that the modified measure is represented by a single factor, but that items assessing spirituality and compassion/appreciation for others may be used alone to better capture these constructs.

Home-based telebehavioral health for U.S. military personnel and veterans with depression: A randomized controlled trial.

OBJECTIVE: Evidence of feasibility, safety, and effectiveness of home-based telebehavioral health (HBTBH) needs to be established before adoption of HBTBH in the military health system can occur. The purpose of this randomized controlled noninferiority trial was to compare the safety, feasibility, and effectiveness of HBTBH to care provided in the traditional in-office setting among military personnel and veterans. METHOD: One hundred and twenty-one U.S. military service members and veterans were recruited at a military treatment facility and a Veterans Health Administration hospital. Participants were randomized to receive 8 sessions of behavioral activation treatment for depression (BATD) either in the home via videoconferencing (VC) or in a traditional in-office (same room) setting. Participants were assessed at baseline, midtreatment (4 weeks), posttreatment (8 weeks), and 3 months posttreatment. RESULTS: Mixed-effects modeling results with Beck Hopelessness Scale and Beck Depression Inventory II scores suggested relatively strong and similar reductions in hopelessness and depressive symptoms for both groups; however, noninferiority analyses failed to reject the null hypothesis that in-home care was no worse than in-office treatment based on these measures. There were not any differences found between treatment groups in regards to treatment satisfaction. Safety procedures were successfully implemented, supporting the feasibility of home-based care. CONCLUSION: BATD can be feasibly delivered to the homes of active duty service members and veterans via VC. Small-group differences suggest a slight benefit of in-person care over in-home telehealth on some clinical outcomes. Reasons for this are discussed. (PsycINFO Database Record

Comparison of Suicide Attempters and Decedents in the U.S. Army: A Latent Class Analysis.

A clearer understanding of risk factors for suicidal behavior among soldiers is of principal importance to military suicide prevention. It is unclear whether soldiers who attempt suicide and those who die by suicide have different patterns of risk factors. As such, preventive efforts aimed toward reducing suicide attempts and suicides, respectively, may require different strategies. We conducted a latent class analysis (LCA) to examine classes of risk factors among suicide attempters (n = 1,433) and decedents (n = 424). Both groups were represented by three classes: (1) External/Antisocial Risk Factors, (2) Mental Health Risk Factors, and (3) No Pattern. These findings support the conceptualization that military suicide attempters and decedents represent a single population.

Telemental Health for Children and Adolescents: An Overview of Legal, Regulatory, and Risk Management Issues.

OBJECTIVE: The use of technology to provide telemental healthcare continues to increase; however, little has been written about the legal and regulatory issues involved in providing this form of care to children and adolescents. METHODS: This article reviews existing laws and regulations to summarize the risk management issues relevant to providing telemental healthcare to children and adolescents. RESULTS: There are several legal and regulatory areas in which telemental health clinicians need to have awareness. These areas include: 1) Licensure, 2) malpractice liability, 3) credentialing and privileging, 4) informed consent, 5) security and privacy, and 6) emergency management. CONCLUSIONS: Although legal and regulatory challenges remain in providing telemental healthcare to children and adolescents, it is possible to overcome these challenges with knowledge of the issues and appropriate risk management strategies. We provide general knowledge of these key legal and regulatory issues, along with some risk management recommendations.

An Evaluation of the Feasibility and Safety of a Home-Based Telemental Health Treatment for Posttraumatic Stress in the U.S. Military.

BACKGROUND: Although home-based telemental health options have the potential to greatly expand the range of services available to U.S. military service members, there remains a need to demonstrate that home-based care is technically feasible, safe, and effective and meets the military health system's standards of care before widespread implementation can be achieved. The purpose of this preliminary study was to evaluate the feasibility and safety of providing U.S. military service members with a behavioral health treatment delivered directly to the home using videoconferencing. MATERIALS AND METHODS: Ten previously deployed soldiers volunteered to complete eight sessions of a novel behavioral activation treatment for posttraumatic stress disorder. The primary clinical outcomes assessed included symptoms of posttraumatic stress and depression. Patient safety data and attitudes about seeking mental health services, treatment satisfaction, treatment adherence, and treatment compliance were also assessed. RESULTS: Clinically significant reductions in posttraumatic stress symptom severity and depression symptoms were observed. Soldiers indicated high levels of satisfaction with the treatment, and there were no adverse events requiring activation of emergency safety procedures. Technical problems associated with the network were observed but successfully mitigated. CONCLUSIONS: The results provide initial support for the feasibility and safety of telemental health treatments delivered by videoconferencing to the homes of soldiers. The optimal technical infrastructure needs to be determined to support expansion of synchronous videoconferencing capabilities to the home. The findings provide preliminary evidence of the feasibility, safety, and high user satisfaction with home-based telemental health in the military setting.