Are You a Digital Native or Digital Immigrant?

I first heard the terms “digital native” and “digital immigrant” from Dr. Jay Shore, the chair of the APA Telepsychiatry Work Group. Dr. Shore gave a presentation about telepsychiatry to the Board of Trustees in June and explained that “digital natives” are people who started using their first computer or cellphone by age 15 (or soon after). Jay explained that for those of us who are “digital immigrants,” it may be harder to adjust to the world of telehealth. For example, when we discussed the use of telepsychiatry, some of the “immigrants” on the Board of Trustees spoke about how telepsychiatry will never replace face-to-face contact with a patient. They opined that the information that you get by relating directly to patients and experiencing their anxiety in the room cannot be replicated over a computer screen. In contrast, the “digital natives” in the group (many of our younger Board of Trustees members) said that they have had good experiences with telepsychiatry and were easily able to establish rapport.

Research studies on this issue are inconclusive. Some studies from the VA suggest that patients and physicians appeared more comfortable using telepsychiatry with patients who had PTSD, depression, and anxiety than with substance abuse or psychosis. But other research suggests that patients with all diagnoses have a good response to telepsychiatry, but more studies need to be done.

Although experiments in telemedicine date back to the late 1950s, new technologies have enabled telemedicine to become one of the fastest growing sectors in health care. In fact, the telemedicine market was measured at $9.8 billion in 2010. Next year, the forecast for the market is $27.3 billion. In 2013, health care providers treated almost 350,000 patients worldwide using telehealth technology. By 2018, that number is expected to grow to 7 million. One of the barriers to the use of telehealth technology has been in the area of reimbursement. But this is changing. For example, this year Medicare increased the number of telehealth services it will reimburse by about 10 percent.

Telepsychiatry will help increase access to psychiatric care. According to an analysis by the Health Resources and Services Administration, 96.5 million Americans live in areas with shortages of mental health providers. We know that 40 percent of adults with a diagnosable mental illness are not getting treatment, and access is one of the barriers to that care. Seeing patients remotely, particularly in their homes, increases access and makes treatment more convenient for parents, caretakers, and people who have mobility problems or other disabilities. Telepsychiatry also addresses the still-existing stigma of receiving treatment by removing the possibility of being seen at a psychiatrist’s office. Plus, younger patients—“digital natives”—are quite familiar with the technology and may prefer using computers rather than face-to-face visits.

Telepsychiatry is only one of many avenues that will improve access to care. Integrating mental health care in the primary care setting is another avenue, and telepsychiatry can be part of the integrated care model. For example, through the advent of telepsychiatry, a primary care physician may be able to arrange for a patient (while still in his or her office) to be interviewed by a psychiatrist who is geographically distant.

I have also heard adult psychiatry colleagues struggle about whether they should treat a child patient if they are not boarded in child psychiatry. Their dilemma is that the child may not receive any treatment if they do not provide it. Telepsychiatry may provide at least a partial solution, by providing for a remote consultation with a boarded child psychiatrist.

One of my initiatives as president of APA is to help our members learn more about telepsychiatry so that we can use this technology when appropriate. Although patients can continue to choose in-person psychiatric care, telepsychiatry may be advantageous in specific circumstances such as those detailed above. An APA telepsychiatry work group was appointed and began meeting in March. The work group will give presentations about the practice of telepsychiatry at APA meetings, including the annual meeting in Atlanta next May. The work group is also charged with creating a section on the APA website with a telepsychiatry toolkit for members. This section will include relevant information about issues such as licensing, HIPAA compliance, and equipment.

Just as our immigrant ancestors had to learn English when they came to this country, those of us who are “digital immigrants” will have to learn how to use telepsychiatry if we want to help our patients for whom it is indicated. As a “digital immigrant” myself, I look forward to the opportunity. ■