After nearly 25 years at Kaiser Permanente, Trina Histon recently took on a new challenge at Woebot Health, the company behind a chatbot for mental healthcare.

Histon's new role as vice president of clinical product strategy will focus on integrating Woebot into clinical care. She previously spent several years at Kaiser developing a process to get digital mental health apps from clinicians into patients' hands. 

Histon sat down with MobiHealthNews to discuss incorporating apps into the provider workflow and the future of digital mental health tools for more severe conditions. 

MobiHealthNews: What are some of the main challenges that you've seen integrating digital tools into clinical care, both from a provider perspective and a patient perspective?

Trina Histon: I characterize the early days of this work in Kaiser Permanente as sort of the era of discovery. Back then – and it's not that long ago, but with the pandemic, time has done funny things – I would say there was an interest within Kaiser Permanente to add digital tools to become a standard of care.

So how do you do that? What does good look like? What is a good tool? That was a big question that we had at KP, being an evidence-based organization. Do clinicians have confidence and believe that these tools are good? You know the App Store has millions of apps. So how do you know as a consumer what's good? And then you're bringing that into that sacred space between the clinician and the patient. 

And then I think the other piece, where great apps can live or die, is in workflow. Have you considered the context of care? So the process we used in Kaiser Permanente, leveraging human-centered design, was to go deep with a small group of clinicians to really understand the context of care: the patients they were seeing, what they had in their toolbox today, what their receptivity was to adding a digital layer, given the majority of people do have smartphones and are willing to use apps and leverage them.

So really understanding from the clinician's perspective how they're spending their time. What might an optimal referral look like in an electronic medical record? And that will be a little different if you're a primary care doctor versus a therapist or psychologist or even a psychiatrist.

So deeply doing that, and then prototyping optimal flow and making that referral, building out prescription pads that are like tear pads. So, as a clinician, you can say, "I want you to start in this module. I want you to do this many minutes a week, this many times a week." And at the same time, understanding the human beings coming in for care who are feeling very vulnerable, who've probably waited a long time to talk about this issue. How do we design to make it easy for them to receive that referral? 

So once you go through the health system door, then it's on us as Woebot Health to bring that person through that user experience. But if you haven't optimally designed to get them to that front door, they may not ever know how to find the handle and walk in, so to speak.

MHN: A lot of this process was developed before the pandemic, and then once 2020 hit you were rolling that out to more primary care providers and other specialties. What was that sudden scale-up process like? 

Histon: If anything, the silver lining of the pandemic was that healthcare – which is a pretty risk-averse industry – really innovated a decade's worth within a year. The reality on the ground was that we had built out a lot of our toolset for face-to-face visits. The patient education materials, obviously a lot could be done via text or via secure message. But we then had to pivot to virtual care very quickly.

So we switched a lot of the flows and a lot of how a patient would receive it to that virtual modality, leveraging a lot of QR codes. So then, in a video visit, you could hold up your phone and get the Kaiser door to the app of choice that way. And then we had to make sure that those QR codes would render, depending on the different kinds of video capabilities a member would have. 

The other piece was I was getting calls from senior leaders saying, "Please, people are very, very stressed and anxious when they're coming to see me. Can I get this too?" So essentially, on a Monday, I might get a call from a senior leader. We would work with the team in that local geography. They would run a sprint, and it would be live on Sunday night. So literally, within a week, the capability was there. 

So what was nice about how we built it is you could take it, and then build it out, and either give the particular clinical set – whether it was primary care, OB-GYN or family medicine – a subset of the apps, or you could give them all, depending on what they desired. And then, working with the primary care doctors that we had partnered with in piloting, we developed some very quick physician education, like a brief six-minute video to say, "Here's how I do it in my practice," and walking them through the workflow. So again, because we'd worked in pilot with those doctors, it was very quick to turn around this educational piece.

MHN: A lot of digital tools are geared toward lower-acuity mental health concerns. How do you think about ramping up care for higher-acuity populations?

Histon: I think the past maybe seven to 10 years was broadly depression and anxiety. So I think that's what we're going to see more and more of, an evolution and maturing in the digital mental health field, including more solutions for severe mental illness as well. 

And I think in the next one to three years you're going to see more and more movement in that space, because there is a desire. I'd like to think we've come through maybe some of the high levels of skepticism. You still have folks that are skeptical, and that's okay, but I think there's a higher acceptance that these tools have a place. 

And I think the work ahead of us now – with Woebot Health in partnership with health systems – is, how do we deepen where these tools live in a care pathway? How do we, in a more discerning way, understand who are they best for? For how long? For whom? And then, when do you need to change things up a little bit? And I feel that that is the road ahead.