Increasingly, both military and civilian healthcare settings are transitioning service delivery from in-person to telehealth platforms to the extent possible. As a result, healthcare providers are trying to get spun up on various topics related to telehealth service delivery. Technology can have an important role to play in assisting patients achieve good clinical outcomes. This blog will focus on the benefits and ethics of utilizing mobile apps while providing telehealth services, using the CBT-I Coach mobile app as an example.
Summary of Mobile App Benefits and CBT-I Coach Research
As mobile apps become more prevalent, research is also providing a clearer picture regarding their benefits. The U.S. Department of Defense Mobile Health Practice Guide (2018) notes that benefits of mobile app technology include increasing access to care (e.g., geographically dispersed patients and those who are reluctant to seek in-person treatment), expanding health care beyond face-to-face visits, increased patient compliance and engagement in care, improving data quality of patient self-reporting, and being identified as a best practice by clinicians. These findings are consistent with sleep-specific research examining the utility of the CBT-I Coach app. Reilly et al (2019) found that military patients preferred internet-delivered treatment to in-person or group treatment. The authors also found that patients who utilized the CBT-I Coach mobile app for a period of 6 weeks without other treatment reported improvements in subjective ratings of insomnia severity, sleep quality, and functional sleep outcomes. Miller et al (2017) surveyed clinician’s use of the CBT-I Coach mobile app and found that clinicians reported greater sleep diary completion, homework compliance, and patient engagement when using the mobile app with patients.
General Ethical Considerations for Using Mobile Apps
Frequently-cited barriers to utilizing mobile apps in treatment include the lack of time to learn how to use the mobile app, security and privacy concerns, and confusion about a healthcare setting’s policy regarding use of mobile app technology. The first barrier, lack of time to learn how to use a mobile app, raises the important ethical issue related to competency. Mobile apps have different features such as self-assessment measures, psychoeducation, specific coping tools or suggestions, and options for social support or contact resources. Rather than simply prescribing the use of the app, it is important to assess a patient’s level of comfort with the technology, provide a rationale for incorporating the mobile app into treatment, discuss what features patients should utilize, and review how to do so. Some mobile apps are based on specific evidence-based treatments, like the CBT-I Coach or the PE Coach. Providers need to be competent in delivering the treatment such as CBT for Insomnia or Prolonged Exposure to effectively use these mobile apps as a part of treatment. For example, providers need to understand the treatment interventions and be able to answer questions patients may have. In addition to the content, healthcare providers using mobile apps need to know how to address privacy and security issues. The Defense Health Agency (DHA) Connected Health recommends the following guidelines for addressing security and privacy issues (2018):
For patients with particular concerns about security and privacy, it is important to note that DoD/VA mobile apps do not access the data generated by a user without their permission.
Specific Considerations of Using CBT-I Coach App and Telehealth
Considerations for utilizing mobile apps as part of a patient’s treatment is mostly the same for in-person and telehealth service delivery. You need to consider the patient’s level of comfort with the technology, the rationale for using it, what features you want patients to use, and ensure that they know how to use the app effectively. The sessions below are a sample CBT-I protocol and are offered with specific commentary about how to incorporate the CBT-I Coach app. For an overview of the CBT-I Coach app please check out our blog at https://deploymentpsych.org/blog/staff-voices-cbt-i-coach-review.
Session 1: Consider how patients will complete sleep diaries or sleep logs (e.g., will they use the app or other form of sleep diaries). CDP has a webpage (https://deploymentpsych.org/telesleep) with videos that patients and providers can reference to score various sleep logs and also provides access to several different sleep logs. The CBT-I Coach has a section called My Sleep where patients can complete sleep diaries and the Insomnia Severity Index (ISI). Providers need to clearly instruct patients if they want them to complete the ISI as an outcome measure for the course of treatment via the app, and if so, how frequently.
Session 2 – Psychoeducation, Stimulus Control & Sleep Restriction: Continue with the sleep logs. The CBT-I coach requires at least 5 days’ worth of data in order to provide a sleep prescription for patients. You can also assign topics under the Learn section to reinforce important psychoeducation topics such as Sleep 101 (i.e., What is CBT-I?, Why Do We Sleep?, Stages of Sleep, Sleep Regulators, Sleepiness vs Tiredness, Weapons and Sleep, and Medications) and Habits and Sleep (i.e., using the bedroom for two activities only). CBT-I Coach does not have information related to sleep restriction.
Session 3 – Sleep Titration & Sleep Hygiene: Continue with the sleep logs. Under the Tools section of the CBT-I coach there is a Create New Sleep Habits section that reviews topics related to good sleep hygiene.
Session 4 – Sleep Titration & Relaxation: Continue with the sleep logs. Under the Tools section of the CBT-I Coach app there is a Quiet Your Mind section that includes a guided deep breathing exercise, a guided progressive muscle relaxation exercise, and different guided imagery exercises. It is important to note that the CBT-I coach app does not have a reminder function for these.
Sessions 5-7 - Sleep Titration & Cognitive Therapy: Continue with the sleep logs, titrating the patient’s sleep schedule accordingly. Continue to utilize the Quiet Your Mind section that includes features to schedule worry time, change your perspective by viewing alternative beliefs about your sleep, and the Observing Thoughts: Clouds in the Sky exercise (from an ACT perspective). The CBT-I Coach does not have traditional CBT handouts or exercises available. The app does have a reminder function for worry time, but not the other cognitive skills.
Session 8 – Relapse Prevention: By this point most patients have learned to not only monitor their sleep, but also how to make appropriate adjustments. Under the Tools section of the CBT-I Coach there is a Prevent Insomnia in the Future feature. This part of the app involves an assessment of problems related to sleep and gives guidance on how to address them if a patient starts to experience a relapse of their insomnia symptoms.
In closing, it is important to remember that technology is not treatment. Competent clinicians can use mobile apps like CBT-I Coach to help conduct assessments (i.e., Sleep Diaries and the Insomnia Severity Index), help review important treatment concepts, and help patients build cognitive and relaxation skills outside of sessions to enhance treatment outcomes. This blog also highlights various resources to help providers providing telehealth services for patients struggling with insomnia.
1) https://deploymentpsych.org/telesleep CDP website with videos showing patients how to complete various forms of sleep diaries, as well as copies of different sleep logs for patients and providers to access. This can be helpful to direct patients to for instructional purposes or for handouts.
2) https://deploymentpsych.org/content/insomnia-tools CDP website with various handouts and educational information related to the treatment of insomnia
3) https://archive.healthit.gov/providers-professionals/how-can-you-protect-and-secure-health-information-when-using-mobile-device: A US government website with a lot of information on how to protect health information when using mobile devices.
4) https://deploymentpsych.org/blog/staff-voices-cbt-i-coach-review: Another CDP Blog that provides an overview of the CBT-I coach mobile app.
5) https://health.mil/About-MHS/OASDHA/Defense-Health-Agency/Operations/Clinical-Support-Division/Connected-Health: DHA Connected Health is a DoD entity that is responsible for reviewing, evaluating, and integrating the use and development of health technology supporting Military Health System (MHS beneficiaries). They provide trainings and offer various resources related to telehealth and use of mobile apps.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Timothy Rogers, Ph.D., is currently is employed by the Henry Jackson Foundation as a Senior Military Internship Behavioral Health Psychologist for the Uniformed Services University Center for Deployment Psychology assigned to the 59th Mental Health Flight, Wilford Hall Ambulatory Surgical Center (WHASC), Lackland AFB, TX
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