TELEPSYCHIATRY: What you need to know TELEPSYCHIATRY: What you need to know Evidence suggests that this tool is effective, cost-efficient, and well-accepted

Bradford Frank, MD, MPH, MBA he need for mental health services has never been greater. Clinical Assistant Professor Unfortunately, many patients have limited access to psychiatric Department of University of North Dakota School of Medicine treatment, especially those who live in rural areas. Telepsychiatry— and Health Sciences the delivery of psychiatric services through telecommunications technol- Grand Forks, North Dakota T ogy, usually video conferencing—may help address this problem. Even Thomas Peterson, MD before the onset of the coronavirus disease 2019 (COVID-19) pandemic, Clinical Assistant Professor Department of Psychiatry telepsychiatry was becoming increasingly common. A survey of US men- University of North Dakota School of Medicine tal health facilities found that the proportion of facilities offering telepsy- and Health Sciences chiatry nearly doubled from 2010 to 2017, from 15.2% to 29.2%.1 Grand Forks, North Dakota In this article, we describe examples of where and how telepsychiatry Sanjay Gupta, MD Clinical Professor is being used successfully, and its potential advantages. We discuss con- Department of Psychiatry cerns about its use, its impact on the therapeutic alliance, and patients’ Jacobs School of Medicine and and clinicians’ perceptions of it. We also discuss the legal, technological, Biomedical Sciences University of Buffalo and financial aspects of using telepsychiatry. With an increased under- Chief Medical Officer standing of these issues, psychiatric clinicians will be better able to inte- BryLin Health System grate telepsychiatry into their practices. Buffalo, New York Timothy Peterson, MD Clinical Assistant Professor Department of Psychiatry How and where is telepsychiatry being used University of North Dakota School of Medicine In addition to being used to provide , telepsychiatry is and Health Sciences Grand Forks, North Dakota being employed for diagnosis and evaluation; clinical consultations; research; supervision, mentoring, and education of trainees; develop- Disclosures Drs. Frank, Thomas Peterson, and Timothy Peterson are ment of treatment programs; and public health. Telepsychiatry is an staff physicians at Rural Psychiatry Associates, whose excellent mechanism to provide high-level second opinions to primary telepsychiatry practices are described in this article. care physicians and on complex cases for both diagnostic Dr. Gupta reports no financial relationships with any companies whose products are mentioned in this article, purposes and treatment. or with manufacturers of competing products. Evidence suggests that telepsychiatry can play a beneficial role in a variety of settings, and for a range of patient populations. continued

Current Psychiatry

NICK LOWNDES/SCIENCE SOURCE Vol. 19, No. 6 17 Table 1 de facto mental health hospitals. This situ- Telepsychiatry’s benefits for ation presents many challenges, including patients access to mental health care and the need to avoid medications with the potential for Improves access to mental health specialty abuse. Using telepsychiatry for psychiatric care that might not otherwise be available (eg, in rural areas) consultations in correctional facilities can improve access to mental health care. Brings care to the patient’s location Telepsychiatry: Geriatric patients. A systematic review Helps integrate behavioral health care and What you need primary care, leading to better outcomes of 76 studies evaluating telepsychiatry for to know Reduces the need for trips to the emergency older patients found this approach was well- department accepted for inpatient and nursing home Reduces delays in care consultation, cognitive testing, dementia Improves continuity of care and follow-up diagnosis and treatment, depression in inte- Reduces the need for time off work, childcare grated and collaborative care models, and services, etc., to access appointments far away psychotherapy.6 Another review of telepsy- Reduces potential transportation difficulties chiatry for geriatric patients found that it Clinical Point Reduces stigma as a barrier to receiving care supports mental health practice, especially 7 Using telepsychiatry Source: Reference 15 when face-to-face therapy is not possible. The main drawbacks were technical prob- for psychiatric lems and lack of support from staff. consultations in the Children and adolescents. The Michigan ED could result in a Emergency departments (EDs). Using tele- Child Collaborative Care (MC3) program quicker disposition psychiatry for psychiatric consultations in is a telepsychiatry consultation service that EDs could result in a quicker disposition of has been able to provide cost-effective, of patients patients and reduced crowding and wait timely, remote consultation to primary care times. A survey of on-call clinicians in a pedi- clinicians who care for youth and perinatal atric ED found that using telepsychiatry for women.8 New York has a pediatric collabora- on-site psychiatric consultations decreased tive care program, the Child and Adolescent patients’ length of stay, improved resident Psychiatry for Primary Care (CAP PC), that on-call burden, and reduced factors related incorporates telepsychiatry consultations for to physician burnout.2 In this study, telepsy- families who live >1 hour away from one of chiatry use reduced travel for face-to-face the program’s treatment sites.9 evaluations by 75% and saved more than 2 Patients with cancer. A literature review hours per call day.2 that included 9 studies found no statistically Medical clinics. Using telepsychiatry to significant differences between standard deliver cognitive-behavioral therapy signifi- face-to-face interventions and telepsychiatry cantly reduced symptoms of depression or for improving quality-of-life scores among anxiety among 203 primary care patients.3 patients receiving treatment for cancer.10 Incorporating telepsychiatry into existing Patients with insomnia. Cognitive- integrated primary care settings is becoming behavioral therapy for insomnia (CBT-I) is more common. For example, an integrated- often recommended as a first-line treatment, care model that includes telepsychiatry is but is not available for many patients. A serving the needs of complex patients in recent study showed that CBT-I provided a high-volume, urban primary care clinic via telepsychiatry for patients with shift in Colorado.4 work sleep disorder was as effective as face- Discuss this article at Assertive Community Treatment (ACT) teams. to-face therapy.11 Increasing the availability www.facebook.com/ Telepsychiatry is being used by ACT teams of this treatment could decrease reliance on MDedgePsychiatry for crisis intervention and to reduce inpatient pharmacotherapy for sleep. hospitalizations.5 Patients with opioid use disorder (OUD). Correctional facilities. With the downsizing Treatment for patients with OUD is limited and closure of many state psychiatric hospi- by access to, and availability of, psychiatric tals across the over the last sev- clinicians. Telepsychiatry can help bridge this Current Psychiatry 18 June 2020 eral decades, jails and prisons have become gap. One example of such use is in Ontario, Box 1 Using telepsychiatry during the COVID-19 pandemic

s part of the efforts to contain the spread • Health Insurance Portability and MDedge.com/psychiatry Aof coronavirus disease 2019 (COVID-19), the Accountability Act requirements, specifically use of telemedicine, including telepsychiatry, has those for secure communications, will not be increased substantially. Here are a few key facts enforced when is used under the new to keep in mind while practicing telepsychiatry waiver. Because of this, popular but unsecure during this pandemic: software applications, such as Apple’s • The Centers for and Medicaid FaceTime, Microsoft’s Teams, or Facebook’s Services relaxed requirements for telehealth Messenger, WhatsApp, and Messenger Rooms, starting March 6, 2020 and for the duration can be used. of the COVID-19 Public Health Emergency. • Informed consent for the use of Under this new waiver, Medicare can pay for telepsychiatry in this situation should be office, hospital, and other visits furnished via obtained from the patient or his/her guardian, telehealth across the country and including in and documented in the patient’s medical patient’s places of residence. For details, see record. For example: “Informed consent www.cms.gov/newsroom/fact-sheets/medicare- received for providing services via video telemedicine-health-care-provider-fact-sheet. teleconferencing to the home in order to This fact sheet reviews relevant information, protect the patient from COVID-19 exposure. including billing codes. Confidentiality issues were discussed.” Clinical Point Evidence suggests treatment delivered Canada, where more than 10,000 patients were more evident in rural communities, and via telepsychiatry is with concurrent opiate abuse and other men- having a multistate center was less expensive at least as effective tal health disorders have received care via than each state operating independently.16 as traditional face- telepsychiatry since 2008.12 Most importantly, evidence suggests that to-face care treatment delivered via telepsychiatry is at least as effective as traditional face-to-face Increasing access to cost-effective care. In a review that included >150 stud- care where it is needed most ies, Bashshur et al17 concluded, “Effective There is a crisis in mental health care in approaches to the long-term management rural areas of the United States. A study of mental illness include monitoring, sur- assessing delivery of care to US resi- veillance, mental health promotion, men- dents who live in rural areas found these tal illness prevention, and biopsychosocial patients’ mental health–related quality of treatment programs. The empirical evidence life was 2.5 standard deviations below the … demonstrates the capability of [telepsy- national mean.13 Additionally, the need for chiatry] to perform these functions more effi- treatment is expected to rise as the number ciently and as well as or more effectively than of psychiatrists falls. According to a 2017 in-person care.” National Council for Behavioral Health report,14 by 2025, demand may outstrip supply by 6,090 to 15,600 psychiatrists. Clinician and patient attitudes While telepsychiatry cannot improve this toward telepsychiatry shortage per se, it can help increase access Clinicians have legitimate concerns about the to psychiatric services. The potential ben- quality of care being delivered when using efits of telepsychiatry for patients are sum- telepsychiatry. Are patients satisfied with marized in Table 115 (page 18). treatment delivered via telepsychiatry? Can a Telepsychiatry may be more cost-effective therapeutic alliance be established and main- than traditional face-to-face treatment. A cost tained? It appears that clinicians may have analysis of an expanding, multistate behav- more concerns than patients do.18 ioral telehealth intervention program for A study of telepsychiatry consultations rural American Indian/Alaska Native popu- for patients in rural primary care clinics lations found substantial cost savings associ- performed by clinicians at an urban health ated with telepsychiatry.16 In this analysis, the center found that patients and clinicians Current Psychiatry estimated cost efficiencies of telepsychiatry were highly satisfied with telepsychiatry.19 Vol. 19, No. 6 19 continued Box 2 NC-STeP: A statewide telepsychiatry program

he North Carolina Statewide Telepsychiatry to the health care delivery system through TProgram (NC-STeP) began in 2013 by overturned involuntary commitments, providing telepsychiatry services in hospital improved ED throughout, and reduced emergency departments (EDs) to individuals patient boarding time; and has achieved experiencing an acute behavioral health crisis. high rates of patient, staff, and clinician Telepsychiatry: In 2018, the program expanded to include satisfaction. Highlights of the program community-based primary care sites using a include: What you need “hybrid” collaborative-care model. This model • 57 hospitals and 8 community- to know benefits patients by improving access to mental based sites in the network (as of health specialty care; reducing the need for January 1, 2020) trips to the ED and inpatient admissions, thus • 8 clinical hubs are operational, with decompressing EDs; improving compliance with 53 consultant clinicians treatment; reducing delays in care; reducing • 40,573 telepsychiatry assessments stigma; and improving continuity of care and (as of January 1, 2020) follow-up. East Carolina University’s Center for • 5,631 involuntary commitments Telepsychiatry and E-Behavioral Health is the overturned, thus preventing unnecessary home for this program, which is connecting hospitalizations representing a saving of Clinical Point hospital EDs and community-based primary $30,407,400 to the state care sites across North Carolina. • Since program inception, >40% of Studies have found NC-STeP provides patients with a face- ED patients who received telepsychiatry that patients are to-face interaction with a clinician through services were discharged to home real-time video conferencing that is facilitated • 32% of the patients served had no generally satisfied using mobile carts and desktop units. A web insurance coverage portal combines scheduling, electronic medical • Currently, the average consult elapsed with telepsychiatry, records, health information exchange functions, time (in queue to consult complete) is 3 but not all patients and data management systems. hours 9 minutes. NC-STeP has significantly reduced patient For more information about this program, will find it acceptable length of stay in EDs, provided cost savings see www.ecu.edu/cs-dhs/ncstep.

Both patients and clinicians believed that A study of using telepsychiatry to treat telepsychiatry provided patients with bet- unipolar depression found that patient sat- ter access to care. There was a high degree isfaction scores improved with increasing of agreement between patients and clini- number of video-based sessions, and were cian responses.19 similar among all age groups.22 An analysis of In a review of 452 telepsychiatry stud- this study found that total satisfaction scores ies, Hubley et al20 focused on satisfaction, were higher for patients than for clinicians.23 reliability, treatment outcomes, implemen- In a study of satisfaction with telepsychia- tation outcomes, cost effectiveness, and try among community-dwelling older vet- legal issues. They concluded that patients erans, 90% of participants reported liking or and clinicians are generally satisfied with even preferring telepsychiatry, even though telepsychiatry services. Interestingly, clini- the experience was novel for most of them.24 cians expressed more concerns about the As always, patients’ preferences need potential adverse effects of telepsychia- to be kept in mind when considering what try on therapeutic rapport. Hubley et al20 services can and should be provided via found no published reports of adverse telepsychiatry, because not all patients will events associated with telepsychiatry use. find it acceptable. For example, in a study of In a study of school-based telepsychiatry veterans’ attitudes toward treatment via tele- in an urban setting, Mayworm et al21 found psychiatry, Goetter et al25 found that interest that patients were highly satisfied with was mixed. Twenty-six percent of patients both in-person and telepsychiatry services, were “not at all comfortable,” while 13% and there were no significant differences were “extremely comfortable” using telepsy- in preference. This study also found that chiatry from home. Notably, 33% indicated a telepsychiatry services were more time- clear preference for telepsychiatry compared Current Psychiatry 20 June 2020 efficient than in-person services. to in-person mental health visits. Box 3 Our practice’s use of telepsychiatry

ur practice (Rural Psychiatry Associates, on-site visits, alternating monthly. In this model, MDedge.com/psychiatry OGrand Forks, North Dakota) and our we also typically alternate one physician with close associates have provided telepsychiatry one nonphysician clinician at each facility. For services to >200 mental health clinics, continuity of care, the same clinicians service hospitals, Native American villages, prisons, the same facilities. For very distant facilities and nursing homes, mostly in rural and with only a few patients, only telepsychiatry underserved areas. To provide these services, is utilized. However, initial services are in addition to physicians, we also utilize always provided by a physician to establish a nurse practitioners and physician assistants, relationship, discuss policies and procedures, for whom we provide extensive education, and evaluate patients face-to-face. training, and supervision. We also provide Telepsychiatry is increasingly used for education to the staff at the facilities where education and mentoring. We have found we provide services. telepsychiatry to be especially useful when For nursing homes, we often use what is working with psychiatric residents on a real- referred to as a “blended mode,” where we time basis as they evaluate and treat patients combine telepsychiatry visits with in-person, at a different location. Clinical Point Some states

Legal aspects of telepsychiatry relevant state medical board where you offer specific When conducting telepsychiatry services, intend to practice. telepsychiatry clinicians need to consider several legal Because state laws related to telepsychia- licenses that allow issues, including federal and state regula- try are continuously evolving, we suggest clinicians to practice tions, as well as professional liability. In a that clinicians continually check these laws across state lines 2017 article, Vanderpool26 provided a com- and obtain a regulatory response in writing prehensive overview of the legal aspects so there is ongoing documentation. For more of telepsychiatry. In March 2020, due information on this topic, see “Telepsychiatry to the COVID-19 pandemic, several key during COVID-19: Understanding the rules” federal telehealth regulations were sus- at MDedge.com/psychiatry. pended. Telehealth service locations were Malpractice insurance. Some insurance broadened to allow patients to be inter- companies offer coverage that includes the viewed at their homes. In addition, Health practice of telepsychiatry, whereas other Insurance Portability and Accountability carriers require the purchase of additional Act (HIPAA) requirements were loosened coverage for telepsychiatry. There may be to allow for nonsecure communications additional requirements for practicing across with patients in certain settings. Box 1 state lines. Be sure to check with your insurer. (page 19) highlights these changes and offers tips for using telepsychiatry during the COVID-19 pandemic. Technical requirements and costs Licensure. State licensing and medical In order to perform telepsychiatry, one regulatory organizations consider the care needs Internet access, appropriate hard- provided via telepsychiatry to be rendered ware such as a desktop or laptop computer where the patient is physically located when or tablet, and a video conferencing applica- services are rendered. Because of this, psy- tion. Software must be HIPAA-compliant, chiatrists who use telepsychiatry generally although this requirement is not being need to hold a license in the state where their enforced during the COVID-19 pandemic. patients are located, regardless of where the Several popular video conferencing plat- is located. forms were designed for or have versions Some states offer special telemedicine suitable for telemedicine, including Zoom, licenses. Typically, these licenses allow clini- Doxy.me, Vidyo, and Skype. cians to practice across state lines without The use of different electronic health having to obtain a full professional license record (EHR) systems by various health care Current Psychiatry from the state. Be sure to check with the systems is a barrier to using telepsychiatry. Vol. 19, No. 6 21 continued Table 2 homes, hospitals, medical clinics, and cor- Telepsychiatry: 8 Steps to rectional facilities, offer lump-sum fees consider before starting to clinicians for providing contracted services. Some clinicians are providing Define the telepsychiatry project and its telepsychiatry as direct-bill or concierge objectives services, which require direct payment Review all relevant laws in the states of interest from the patient without any reimburse- and where you are located, and understand all Telepsychiatry: legal requirements. This needs to be revisited ment from insurance. What you need often Medicare Part B covers some telepsy- to know Assess the ability of your practice to meet the chiatry services, but only under certain legal requirements conditions.28 Previously, reimbursement Ensure your practice will be able to meet was limited to services provided to the standard of care, which is the same for patients who live in rural areas. However, telepsychiatry as for in-person treatment on November 1, 2019, eligibility for tele- Require patients to sign a consent for health services for Medicare Advantage telepsychiatry that includes basic information (MA) recipients was expanded to include on its limitations as well as the technology used Clinical Point patients in both urban and rural locations. Formulate a plan in the event there is an Patients covered by MA also can receive Some facilities offer emergency during a telepsychiatry visit (eg, ensure that a patient has access to emergency telehealth services from their home, lump-sum fees care should he/she become suicidal) instead of having to drive to a Centers for to clinicians for Provide documentation for all telepsychiatry Medicare and Medicaid Services–qualified providing contracted visits telehealth service center. telepsychiatry Evaluate ongoing feedback from the patients Medicaid is the single largest payer for mental health services in the United services States,29 and all Medicaid programs reim- burse for some telepsychiatry services. As with all Medicaid health care, fees paid for One potential solution is to use a web portal, telepsychiatry are state-specific. Since 2013, such as the one developed by East Carolina several state Medicaid programs, includ- University’s North Carolina Statewide ing New York,30 have expanded the list of Telepsychiatry Program (NC-STeP), which eligible telehealth sites to include schools, connects hospital EDs and community-based thereby giving children virtual access to primary care sites with remote psychiatric mental health clinicians. clinicians, allowing them to share secure electronic health information across different EHRs.27 Box 2 (page 20) provides more details Getting started about this program. Clinicians who are interested in starting to Our practice has extensive experience provide treatment via telepsychiatry can with telepsychiatry (Box 3, page 21), and for begin by reviewing the American Psychiatric us, the specific costs associated with provid- Association’s Telepsychiatry Toolkit at ing telepsychiatry services include mainte- www.psychiatry.org/psychiatrists/practice/ nance of infrastructure and the purchase telepsychiatry/toolkit. This toolkit, which is of hardware (eg, computers, smartphones, being continually updated, features numer- tablets), a video conferencing application ous training videos for clinicians new (some free versions are available), EHR sys- to telepsychiatry, such as Learning To Do tems, and Internet access. Telemental Health (www.psychiatry.org/ psychiatrists/practice/telepsychiatry/ toolkit/learning-telemental-health) and The Reimbursement for telepsychiatry Credentialing Process (www.psychiatry. Private insurance reimbursement for treat- org/psychiatrists/practice/telepsychiatry/ ment delivered via telepsychiatry obvi- toolkit/credentialing-process). Before start- ously depends on the specific insurance ing, also consider reviewing the steps listed Current Psychiatry 22 June 2020 company. Some facilities, such as nursing in Table 2. References 1. Spivak S, Spivak A, Cullen B, et al. Telepsychiatry use in Related Resources U.S. mental health facilities, 2010-2017. Psychiatr Serv. 2019;71(2):appips201900261. doi: 10.1176/appi.ps.201900261. • Von Hafften A. Telepsychiatry practice guidelines. American Psychiatric Association. https://www.psychiatry. 2. Reliford A, Adebanjo B. Use of telepsychiatry in pediatric MDedge.com/psychiatry emergency room to decrease length of stay for psychiatric org/psychiatrists/practice/telepsychiatry/toolkit/ patients, improve resident on-call burden, and reduce practice-guidelines. factors related to physician burnout. Telemed J E Health. • Centers for Disease Control and Prevention. Telehealth 2019;25(9):828-832. and telemedicine: a research anthology of law and policy 3. Mathiasen K, Riper H, Andersen TE, et al. Guided internet- resources. https://www.cdc.gov/phlp/publications/topic/ based cognitive behavioral therapy for adult depression and anxiety in routine secondary care: observational study. anthologies/anthologies-telehealth.html. Reviewed July 31, J Med Internet Res. 2018;20(11):e10927. doi: 10.2196/10927. 2019. 4. Waugh M, Calderone J, Brown Levey S, et al. Using • American Telemedicine Association. https://www. telepsychiatry to enrich existing integrated primary care. americantelemed.org/. Telemed J E Health. 2019;25(8):762-768. 5. Swanson CL, Trestman RL. Rural assertive community treatment and telepsychiatry. J Psychiatr Pract. 2018;24(4): 269-273. 6. Gentry MT, Lapid MI, Rummans TA. Geriatric telepsychiatry: systematic review and policy considerations. Am J Geriatr Psychiatry. 2019;27(2):109-127. 17. Bashshur RL, Shannon GW, Bashshur N, et al. The empirical 7. Christensen LF, Moller AM, Hansen JP, et al. Patients’ and evidence for telemedicine interventions in mental disorders. providers’ experiences with video consultations used in Telemed J E Health. 2016;22(2):87-113. the treatment of older patients with unipolar depression: 18. Lopez A, Schwenk S, Schneck CD, et al. Technology-based Clinical Point a systematic review. J Psychiatr Ment Health Nurs. mental health treatment and the impact on the therapeutic 2020;27(3):258-271. alliance. Curr Psychiatry Rep. 2019;21(8):76. Medicare Part B 8. Marcus S, Malas N, Dopp R, et al. The Michigan Child 19. Schubert NJ, Backman PJ, Bhatla R, et al. Telepsychiatry Collaborative Care program: building a telepsychiatry and patient-provider concordance. Can J Rural Med. 2019; covers some consultation service. Psychiatr Serv. 2019;70(9):849-852. 24(3):75-82. 9. Kaye DL, Fornari V, Scharf M, et al. Description of a multi- 20. Hubley S, Lynch SB, Schneck C, et al. Review of key telepsychiatry university education and collaborative care child psychiatry telepsychiatry outcomes. World J Psychiatry. 2016;6(2): access program: New York State’s CAP PC. Gen Hosp 269-282. services, but only Psychiatry. 2017;48:32-36. 21. Mayworm AM, Lever N, Gloff N, et al. School-based 10. Larson JL, Rosen AB, Wilson FA. The effect of telehealth telepsychiatry in an urban setting: efficiency and satisfaction under certain interventions on quality of life of cancer patients: a with care. Telemed J E Health. 2020;26(4):446-454. systematic review and meta-analysis. Telemed J E Health. conditions 22. Christensen LF, Gildberg FA, Sibbersen C, et al. 2018;24(6):397-405. Videoconferences and treatment of depression: satisfaction 11. Peter L, Reindl R, Zauter S, et al. Effectiveness of an online score correlated with number of sessions attended but not CBT-I intervention and a face-to-face treatment for shift with age [published online October 31, 2019]. Telemed J E work sleep disorder: a comparison of sleep diary data. Int J Health. 2019. doi: 10.1089/tmj.2019.0129. Environ Res Public Health. 2019;16(17):E3081. doi: 10.3390/ 23. Christensen LF, Gildberg FA, Sibbersen C, et al. Disagreement ijerph16173081. in satisfaction between patients and providers in the use of 12. LaBelle B, Franklyn AM, Pkh Nguyen V, et al. Characterizing videoconferences by depressed adults. Telemed J E Health. the use of telepsychiatry for patients with opioid use 2020;26(5):614-620. disorder and cooccurring mental health disorders in 24. Hantke N, Lajoy M, Gould CE, et al. Patient satisfaction with Ontario, Canada. Int J Telemed Appl. 2018;2018(3):1-7. services via video teleconference. Am J 13. Fortney JC, Heagerty PJ, Bauer AM, et al. Study to promote Geriatr Psychiatry. 2020;28(4):491-494. innovation in rural integrated telepsychiatry (SPIRIT): 25. Goetter EM, Blackburn AM, Bui E, et al. Veterans’ prospective rationale and design of a randomized comparative attitudes about mental health treatment using telehealth. effectiveness trial of managing complex psychiatric J Psychosoc Nurs Ment Health Serv. 2019;57(9):38-43. disorders in rural primary care clinics. Contemp Clin Trials. 2020;90:105873. doi: 10.1016/j.cct.2019.105873. 26. Vanderpool D. Top 10 myths about telepsychiatry. Innov Clin Neurosci. 2017;14(9-10):13-15. 14. Weiner S. Addressing the escalating psychiatrist shortage. AAMC. https://www.aamc.org/news-insights/ 27. Butterfield A. Telepsychiatric evaluation and consultation addressing-escalating-psychiatrist-shortage. Published in emergency care settings. Child Adolesc Psychiatr Clin N February 12, 2018. Accessed May 14, 2020. Am. 2018;27(3):467-478. 15. American Psychiatric Association. What is telepsychiatry? 28. Medicare.gov. Telehealth. https://www.medicare.gov/ https://www.psychiatry.org/patients-families/what-is- coverage/telehealth. Accessed May 14, 2020. telepsychiatry. Published 2017. Accessed May 14, 2020. 29. Centers for Medicare & Medicaid Services. Behavioral 16. Yilmaz SK, Horn BP, Fore C, et al. An economic cost Health Services. https://www.medicaid.gov/medicaid/ analysis of an expanding, multi-state behavioural telehealth benefits/bhs/index.html. Accessed May 14, 2020. intervention. J Telemed Telecare. 2019;25(6):353-364. 30. New York Pub Health Law §2999-cc (2017).

Bottom Line Evidence suggests telepsychiatry can be beneficial for a wide range of patient populations and settings. Most patients accept its use, and some actually prefer it to face-to-face care. Telepsychiatry may be especially useful for patients who have limited access to psychiatric treatment, such as those who live in rural areas. Factors to consider before incorporating telepsychiatry into your practice include Current Psychiatry addressing various legal, technological, and financial requirements. Vol. 19, No. 6 23