Telepsychiatry

Episode 58: Lorenzo Norris, MD, welcomes James "Jay" Shore, MD, to talk about telepsychiatry and Dr. RK says to never give up.

Show Notes
By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington.

Guest
Jay Shore, MD, MPH, director of telemedicine and medical director, Steven A. Cohen Military Family Clinic at University of Colorado at Denver, Aurora. Dr. Shore is chair of the American Psychiatric Association’s Committee on Telepsychiatry.

Updates in telepsychiatry

• First wave initially funded by federal research grants.
• Second wave occurred at institutions with the advent of the Internet and cheaper technology.
• Third wave has been underway since 2015 with Web-based apps that are accessible to nearly everyone.
  • Care is now delivered into clinical settings and into diverse “clinically unsupervised” settings, such as patients’ homes, schools, etc.

Videoconferencing tools recommendations

Look for applications that offer Web-based telehealth, for example, device-to-device and “clinical-based” apps, which allow you to go from clinic to clinic with a specific telehealth technology setup.

Basic components

• Clinicians must use videoconferencing platform that is HIPAA compliant:
  • Platforms must have a business associates’ agreement, outlining how patient data should be shared securely and delineating any penalties for breach.
• Bandwidth capabilities. Clinicians need to understand their Internet speed/bandwidth and see which platform meets their bandwidth needs:
  • Within an institution, IT support can help with selection.

Fundamental considerations when implementing a telemental health practice

• Technical guidelines – Choose a platform and understand how the telemedicine platform will integrate into other technological parts of practice, like email and the EMR patient portal.
• Administrative issues – Be sure to consider malpractice insurance, state-licensure requirements, and billing & reimbursement. Each of these elements differs by state and by insurance company.
• Clinical considerations – Understanding workflow is critical:
  • How are emergencies handled?
  • How should clinical styles change to fit the telehealth platform and the clinical setting in which the clinician is seeing the patient?

Many resources are available to guide clinicians. The American Psychiatric Association has a telepsychiatry toolkit, and the American Telemedicine Association has guidelines.

New patient visits using telepsychiatry

Clinical considerations

• Studies suggest that telepsychiatry is as effective as in-person treatment, even when seeing new patients.
• Telepsychiatry makes it easier to use an EMR while using the screen to see the patient.
  • Anecdotally, telepsychiatry may be more efficient, because the EMR information is available to you while you use the videoconferencing platform.

Administrative concerns

• Each state regulates the medical licensure. The psychiatrist must be licensed in the state in which the patient lives.
• State recommendations differ on what needs to be done in a first visit.
  • Some jurisdictions recommend you see a patient in person for the first visit.
  • Some states mandate that written consent be completed in advance of a telehealth visit, so this would require that the patient be seen in person for the first visit.

How to deal with emergencies

A telepsychiatry practice must have a detailed emergency protocol in place. Screen for patients who are appropriate for telepsychiatry, and then decide who may be eligible for home visits vs. satellite clinic visits.

• If a patient is at an affiliated clinical site, a staff member will be on premises to address the emergency:
  • Staff can be in the room with the patient or simply available onsite.
• Telepsychiatry also may be offered to patients in their homes, so you should establish options for dealing with an emergency in that setting:
  • 911 calls are “local,” so the clinician must know the emergency number of the city/county in which the patient is located.
  • At home, consider having a “patient support person” available in the house or nearby in case of emergency.

Telepsychiatry and access to mental health treatment

• Expanding access to mental health care was the initial driver for expanding telepsychiatry:
  • Rural areas that may have few psychiatrists spread out at great distances.
  • Urban areas in which travel time, rather than distance, can be an obstacle to mental health.
• Seeing a clinician digitally decreases stigma for people who do not want to go to a mental health clinic:
  • Telepsychiatry protects confidentiality and decreases stigma, especially in rural areas, where people may not want to seek treatment within their close-knit community or social network.
  • Telepsychiatry offers a way for more medical providers to get mental health treatment for themselves without risk of a confidentiality breach in a local clinic.
• Workforce decline – Telepsychiatry is not necessarily a solution to the psychiatric workforce shortage, since it changes the distribution of care without creating new providers. Telepsychiatry is a “force multiplier,” however, because it can extend psychiatrists’ reach in medicine:
  • Telepsychiatry addresses workforce issues when used within integrated care models.
  • Telehealth allows psychiatrists to do one-time consultations or work with primary care teams.
• Digital immigrants vs. digital natives:
  • There may be a generation gap for people who have limited exposure to the Internet.
  • Younger patients will demand telehealth from their providers.
• Telepsychiatry is growing and clinicians should be familiar with the guidelines and regulations in order to implement this technology in an ethical and safe way.

Resources

APA Telepsychiatry Toolkit

American Telemedicine Association

Shore JH. The evolution and history of telepsychiatry and its impact on psychiatric care: Current implications for psychiatrists and psychiatric organizations. Int Rev Psychiatry. 2015 Jun;27(6):469-75.

Shore JH et al. Best practices in videoconferencing-based telemental health April 2018. Telemed J E Health. 2018 Nov;24(11):827-32.