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Telepsychiatry: Overcoming Barriers to Implementation

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Telepsychiatry: Overcoming Barriers to Implementation Telepsychiatry: Overcoming barriers to implementation Providing treatment via videoconferencing can improve access to care lthough many states have substantial health services in urban areas, these services—particularly men- Atal health care—are relatively scarce in rural areas.1 Telepsychiatry, in which clinicians provide mental health care from a distance in real time by using interactive, 2-way, audio-video communication (videoconferencing), could mitigate workforce shortages that affect remote and un- derserved areas.2 Psychiatry is one of the biggest users of telemedicine, which refers to any combination of communi- cation technology and medicine.3-5 This article discusses tele- psychiatry’s effectiveness in providing psychiatric diagnosis and treatment, and the clinical implications of this technol- ogy, including improving access, cost, and quality of mental © OCEAN/CORBIS health services. Sy Atezaz Saeed, MD Professor and Chair Richard M. Bloch, PhD Outcomes comparable to face-to-face care Professor and Director of Research Telepsychiatry is used primarily in rural areas or correc- John M. Diamond, MD tional institutions or with underserved populations such Professor and Director as veterans with posttraumatic stress disorder or children. Division of Child and Adolescent Psychiatry Although the literature generally is weak, there has been • • • • more research on psychiatry than other medical special- Department of Psychiatric Medicine ties because psychiatric clinicians rely on mental status Brody School of Medicine examinations and verbal communications, not physical East Carolina University Greenville, NC exams. Telepsychiatry can be considered a part of an evolv- ing “connected health” system that offers many benefits to patients and clinicians (see the Table at CurrentPsychiatry. com). Previously, we have reviewed evidence on the use and ef- fectiveness of telepsychiatry in providing mental health care Current Psychiatry 28 December 2012 for children,6 adolescents,6 and adults.2 The literature includes Box The technology behind telepsychiatry lthough telemedicine has embraced pan-zoom-tilt control of video cameras. This Amany communication technologies, live, allows clinicians to remotely control his or her interactive, 2-way, audio-video communication— view of the patient’s site or control the view being called videoconferencing—is broadly transmitted to the patient. synonymous with telemedicine and, more Historically, interactive telepsychiatry specifically, telepsychiatry. applications have used point-to-point network Telepsychiatry primarily uses interactive connections, usually as full or fractional T-1 audiovisual conferencing systems over high- or integrated services digital network circuits. bandwidth networks. The central component However, the rapid diffusion of internet and of interactive telepsychiatry is the codec ethernet networks has led to the development (coder/decoder), which provides compression, of videoconferencing systems that can work decompression, and synchronization of audio over internet protocol (IP) networks. If using an and video signals; both patients and clinicians IP network, ensure security by using encrypted need a codec. A codec can be a separate codecs or by setting up a virtual private network device, but personal computer-based codecs and/or a virtual local area network (LAN). The are being used more frequently. A typical setup principal advantage of IP networks is that by also includes a video camera, microphone, implementing proper security solutions, they speakers or headset, and 1 or 2 display monitors can be shared by several applications—eg, Clinical Point at both the clinician’s and patient’s end of the internet, e-mail, LAN, etc. This means that the system. Often, separate displays or a picture- telecommunications network costs can be Studies found that in-picture display are used to see both outgoing shared or considered a sunk cost (ie, not an providers are the and incoming video. Another consideration is additional cost of the telepsychiatry application). most significant initial gatekeepers that affect studies of feasibility,7 acceptance and sat- evidence-based information and may face telemedicine use isfaction,8 and cost.9,10 Although limited, challenges, such as time constraints, access comparison of telepsychiatry with similar to technical support, and complexity of face-to-face interventions continues.11,12 large health care institutions, when integrat- Researchers have examined telepsychiatry ing this information into clinical practice.16 in several patient populations for assess- Two studies17 found that after controlling ment and treatment goals. In virtually all for other barriers—eg, reimbursement and cases, telepsychiatric assessments and/or in- regulatory issues—providers are the most terventions have been comparable with face- significant initial gatekeepers that affect to-face assessments and/or interventions. telemedicine use. When designing a tele- Although the research methodology used in medicine system, project managers should some studies has been weak, there is no evi- prioritize providers’ needs, such as ease of dence that therapeutic alliance,13,14 therapist use and incentives.18 fidelity,15 patient satisfaction, or outcomes with telepsychiatry are inferior to those seen Reimbursement. Medicare started re- in comparable face-to-face treatment. imbursing providers for telemedicine in 1999, and some limitations in the pay- ment scheme have been addressed.19,20 Barriers to implementation Approximately one-half of state Medicaid Although telepsychiatry offers tremen- programs and many third-party payers re- dous promise, implementation has not imburse for telehealth services, with similar See this article at been widespread or easy. Potential bar- limitations in Medicare.20 A “fee-for-ser- CurrentPsychiatry.com riers to implementation, such as cost and vice” approach reimburses the consulting for a table of the benefits resistance to change, are associated with psychiatrist or mental health professional of telepsychiatry acceptance of new technology or practice for his or her time. Telepsychiatry reim- in health care. In addition, there are several bursement typically is provided for a legal, regulatory, and technical barriers. diagnostic interview, pharmacologic man- agement, and individual psychotherapy Institutional barriers. Physicians and other provided by psychiatrists and clinical Current Psychiatry providers may not have access to timely, psychologists. Differences among payers Vol. 11, No. 12 29 and supporting documents are available include the potential for nonclinical tech- on the American Psychiatric Association’s nical or administrative personnel to view Telepsychiatry Internet Resources site (see telepsychiatry sessions.23 Increased video- Related Resources). conferencing over public networks also cre- States do not cover services provided by ates the potential for unauthorized access to other mental health providers, except for protected health information. Technological Utah’s coverage for social workers. The solutions such as encryption and virtual Telepsychiatry American Psychiatric Association has 2 private networks should be implemented suggestions regarding this issue3: (Box, page 29). Once these technological • reimbursement for telepsychiatry ser- solutions are in place, providers need to be vices should follow customary charges for trained in proper data storage and retrieval delivering the appropriate current proce- and medicolegal and ethical issues related dural terminology code(s) to maintaining patient privacy. • a structure for reimbursement of col- lateral charges, such as technician and line Infrastructure. Costs associated with time, should be identified. infrastructure development and mainte- Clinical Point nance of telepsychiatry typically are not Technological Impact on practice. Changing workplace reimbursable. Individual contracts, man- behaviors requires restructuring daily aged care, third-party payers (in a few solutions such as workflow and routine procedures to make states), or, in limited situations, Medicaid encryption can help it easy for clinicians to provide telepsychi- and Medicare may reimburse these costs. maintain patient atric care. For successful implementation, A structure for reimbursing collateral privacy during clinicians and patients must regard telepsy- charges, such as technician and line time, chiatry as a treatment approach that will needs to be developed. telepsychiatry enhance success, access, and quality of care. The U.S. Federal Communications As with patient behaviors,21 to change prac- Commission’s (FCC) Universal Service Fund tice behaviors, the intention to change must (USF) subsidies can reduce the cost of tele- be combined with the necessary skill, and psychiatry network connections. The FCC environmental constraints that prevent new implemented the USF to bring high band- behaviors must be absent or removed. In width telecommunications to rural schools, general, telepsychiatry is accepted. In our libraries, and health care providers. Funding experience, usually a reluctant clinician, not for the USF is generated from fees paid by the patient or his or her family, hampers ac- telecommunications providers. However, ceptance of telepsychiatry. the USF subsidies are not being widely used for several reasons, including a cumbersome Licensure. A physician conducting a tele- application process, limitations on eligible medicine session with a patient in another facilities
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