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Advances in technology allow more options for treating patients, tracking medications and preventing errors. What are some of these emerging technologies, and what are their benefits and their drawbacks?
October 2005, Vol. XXII, Issue 12
The role of technology in health care has taken a prominent role in many different specialties including psychiatry. Psychotherapists are using virtual reality to treat posttraumatic stress disorder (Kaplan, 2005). Many mental health clinics have Web sites with online screening tools for depression and anxiety. A few practices are offering online appointment scheduling as well. Electronic medical record systems provide reminders and alerts for lab tests and critical values. There are still many new technological innovations that have potentially groundbreaking implications in the future such as nanotechnology. However, this article will focus on the two technologies that will certainly play a significant role in the future--computer-based therapy and radio frequency identification (RFID).
Many patients with depression or anxiety first seek medical care with their primary care physicians. After a few trials of antidepressant or anxiolytic medications, the primary care physician will make a referral to the psychiatrist for the more difficult cases. Some patients will obtain traditional psychotherapy and medication treatment. However, there are significant numbers of patients who will not seek mental health care. These patients often turn to self-help materials available online or in the bookstore. With today's sophisticated computers and the large amount of storage available on DVDs, computer-based assessment and treatment software is becoming more commonplace.
These programs are quite sophisticated, utilizing specialized heuristic techniques to produce a more natural response to patient-entered information. Natural language processing allows software to determine the nature of queries and responses. Most programs use a cognitive model of treatment, since a more structured therapy lends itself to programming. These software programs present several key concepts, such as the relation between automatic thoughts and feelings, and highlight techniques to control these thoughts. These programs utilize multimedia with audio and video to enhance the experience. They have the ability to store responses to exercises, which creates a more personalized experience and allows the user to proceed at a comfortable pace. Many of the programs implement rating scales to assess depression or anxiety in order to provide feedback. Ratings may also determine the next module for treatment or recommendations for other exercises. Several computer-based therapy Web sites are listed in the Table.
There are numerous advantages to computer-based therapy. Patients can work at their own pace in the privacy of their own home. There are no social cues and dynamics of relationships as in psychotherapy, so patients may disclose feelings that they would normally feel uncomfortable sharing. Patients with panic attacks may benefit since they may initially not be able to travel to therapy. In addition, software programs are not susceptible to the frustrations of traditional treatment such as changed appointments, therapist boredom, absences and ethical misconduct.
Patients have a more active learning role while using a program versus the potential role as dependent in therapy, thereby providing a sense of empowerment. Treatment is accessed with a minimum of delay, and the programs are quite affordable.
Although almost all patients should benefit from self-help, there is a small subset that will not benefit from computer-based therapy. They may be too depressed or anxious in order to focus on the material, which could be exacerbated if they are unable to navigate the program. Age, personality and adaptability play a role in predicting which patients may benefit from self-help treatments. In addition, factors such as poor eyesight, reading skills and computer proficiency may affect use of computer-based therapy. Many patients may not be able to afford sufficiently powerful computers or have a fast enough Internet connection to run these programs.
The literature supporting the effectiveness of computer-based therapy has been growing. One of the first studies compared a six-session, computer-based version of cognitive-behavioral therapy (CBT) with six sessions of therapist-administered CBT and a waiting list control group (Selmi et al., 1990). In this study, both treatment groups were significantly improved on the Beck Depression Inventory (BDI) and the Automatic Thoughts Questionnaire, with no difference between the treatment modalities. Patients at a community mental health center who were waiting for CBT were offered an opportunity to use computerized CBT (van den Berg et al., 2004). This study demonstrated improvements in well-being, problems and functioning in the Clinical Outcomes in Routine Evaluation Outcome Measure, a self-report questionnaire with sub-domains for subjective well-being, problem/symptom severity, life functioning, and risk to self and others. Even use of computer-based therapy in the general practitioner's office has been demonstrated to be effective with significantly lowered ratings on the BDI, Beck Anxiety Inventory, and Work and Social Adjustment Scale (Proudfoot et al., 2003).
Computer-based therapy programs offer many benefits with limited risks. While they are not touted as replacements for traditional therapy, they are very useful supplements. More studies are needed to determine the level of therapist involvement to produce better outcomes for patients using these programs.
Radio frequency identification has been in the media lately and touted as the replacement for bar code scanning. Radio frequency identification is a mechanism to store and retrieve data using devices called tags or transponders. An RFID tag is attached to an object that has an antenna to enable it to receive and respond to radio-frequency queries from an RFID transceiver. There are two types of tags: passive and active. A passive tag has no energy source and transmits information when activated by the minute electrical current induced in the antenna by the incoming radio frequency scan. A passive tag only transmits limited information, and the range of scanning is up to 20 feet. In contrast, an active tag has its own power source and can transmit more information at greater distances of up to 50 feet.
Radio frequency identification technology has tremendous implications for health care. The U.S. Food and Drug Administration is reviewing whether hospitals can use RFID implants to identify patients and allow staff access to medical records without violating patient privacy. In October 2004, the FDA approved the injection of RFID technology in humans. John Halamka, M.D., chief information officer at Harvard Medical School, decided to have an RFID tag from VeriChip Corporation implanted last December to test its use in the emergency setting (Gilbert, 2005).
Last November, the SurgiChip Tag Surgical Marker system was approved by the FDA for marketing. The system consists of a passive RFID tag, a printer, an encoder and an RFID reader. The patient's name and surgical site are printed on the SurgiChip tag. The tag is encoded with the date of surgery, type of procedure and name of surgeon. This information is scanned prior to surgery for verification of data and is adhered to the surgery site on the date of surgery. In the operating room, the tag is scanned, and the encoded information is verified with the patient's chart.
A similar process could be used with psychiatric patients in board-and-care facilities and hospitals using RFID wristbands from Precision Dynamics Corporation to ensure that they received the proper medications. In the emergency room at Mercy Hospital in Coon Rapids, Minn., vulnerable patients who posed a threat to themselves or others were monitored via RFID bracelets using the RF Technologies system (Depass, 2005). When these patients attempted to leave their rooms, radio sensors would trigger alarms that would automatically shut and lock the emergency room doors, preventing escape. If nurses did not reset the alarm within a preset time, guards would then appear as part of the response system. The hospital found that the RFID system decreased one-on-one staffing needs and costs, as well as maintained some privacy for patients since they no longer had a security guard outside their door.
Similarly, patients with Alzheimer's disease living in residential facilities can be monitored. In the Aware Home Initiative, Wendy Rogers, Ph.D., and her team at the Georgia Institute of Technology use RFID tags embedded in the shoes of seniors to monitor their activity level, allowing family members to review their activity remotely. Embedded RFID tags such as those offered by VeriChip may provide critical information in identifying comatose or profoundly psychotic patients who are unable to indicate their past history or drug allergies.
In the hospital setting, RFID-tagged identification cards could serve to authenticate staff for access to electronic medical records, along with a fingerprint scan. Unisys and SupplyScape Corporation have started an "electronic drug pedigree" program using RFID to track the distribution system of oxycodone (Atkinson and Hagans, 2005). The technology will be used to decrease counterfeit medicines and to make obtaining drugs difficult for addicts by accurately tracking the pedigree of the drug, indicating which pharmaceutical entity was in possession of the drug as it moves along the supply chain. The RFID tags can also be embedded in bottle caps to record when medications have been taken from a bottle, creating a compliance record. These are only some of the potential applications of RFID technology in health care.
Despite the numerous potential benefits of RFID technology, the main source of criticism and hindrance to implementation has been the issue of privacy. Tags do not require line-of-sight to be read; therefore they can be scanned without their knowledge and consent. At Brittan Elementary School in Sutter, Calif., the administration attempted to implement the InClass system by InCom Corporation, which would automatically record attendance of the students in class. Parents were extremely upset about the privacy issues with these ID cards and forced the school to withdraw the system in February. Consumers Against Supermarket Privacy Invasion and Numbering (CASPIAN) stands quite firmly against the use of RFID technology on the basis of privacy because purchasing behavior and patterns are monitored. The Electronic Privacy Information Center (EPIC) has proposed a four-tier framework for RFID regulation of medical information that outlines privacy rules for RFID use in patient identification and product distribution. More information regarding this regulation can be found at the EPIC Web site at <www.epic.org>.
In the field of mental health, the topics of computerized therapy and privacy may be not out of the ordinary, but technologies to expand these subjects are making inroads toward everyday patient care. It is difficult to determine how national policies and public opinion will shape the implementation and success of computer-based therapy and RFID. However, the advantages that they offer are powerful and tangible. They are poised to make an impact on health care professionals and delivery of health care, just as the Internet has changed access and distribution of health care information.
Dr. Luo is assistant professor of psychiatry at the University of California, Los Angeles, Neuropsychiatric Institute. He is also president of American Association for Technology in Psychiatry.
Atkinson J, Hagans A (2005), RFID to crack down on fraudulent prescriptions. Available at: www.rfidgazette.org/healthcare. Accessed Sept. 9.
Depass D (2005), Using RFID to keep track of patients. Available at: www.infowars.com/articles/bb/rfid_tracking_patients.htm. Accessed Sept. 9.
Gilbert A (2005), Implanted ID chip finds way into ERs, bars. Available at: http://news.com.com/Implanted+ID+chip
+finds+way+into+ERs,+bars/2100-1041_3-5545802.html. Accessed Sept. 9.
Kaplan A (2005), Virtually possible: treating and preventing psychiatric wounds of war. Psychiatric Times 22(4):1, 7-10.
Proudfoot J, Goldberg D, Mann A et al. (2003), Computerized, interactive, multimedia cognitive-behavioural therapy program for anxiety and depression in general practice. Psychol Med 33(2):217-227 [see comment].
Selmi PM, Klein MH, Greist JH et al. (1990), Computer-administered cognitive-behavioral therapy for depression. Am J Psychiatry 147(1):51-56.
van den Berg S, Shapiro DA, Bickerstaffe D, Cavanagh K (2004), Computerized cognitive-behaviour therapy for anxiety and depression: a practical solution to the shortage of trained therapists. J Psychiatr Ment Health Nurs 11(5):508-513.