Evidence-Based Reviews

Telepsychiatry: Overcoming barriers to implementation

Current Psychiatry. 2012 December;11(12):10-16

Providing treatment via videoconferencing can improve access to care

References

1. President’s New Freedom Commission on Mental Health. Subcommittee on rural issues: background paper. Rockville MD: Substance Abuse and Mental Health Administration; 2004.

2. Antonacci DJ, Bloch RM, Saeed SA, et al. Empirical evidence on the use and effectiveness of telepsychiatry via videoconferencing: implications for forensic and correctional psychiatry. Behav Sci Law. 2008;26(3):253-269.

3. American Psychiatric Association. Resource document on telepsychiatry via videoconferencing. http://www.psychiatry.med.uwo.ca/ecp/info/toronto/telepsych/Appendix%20II.htm. Accessed November 5 2012.

4. Grigsby J, Rigby M, Hiemstra A, et al. Telemedicine/telehealth: an international perspective. The diffusion of telemedicine. Telemed J E Health. 2002;8(1):79-94.

5. Krupinski E, Nypaver M, Poropatich R, et al. Telemedicine/telehealth: an international perspective. Clinical applications in telemedicine/telehealth. Telemed J E Health. 2002;8(1):13-34.

6. Diamond JM, Bloch RM. Telepsychiatry assessments of child or adolescent behavior disorders: a review of evidence and issues. Telemed J E Health. 2010;16(6):712-716.

7. Buono S, Città S. Tele-assistance in intellectual disability. J Telemed Telecare. 2007;13(5):241-245.

8. Manguno-Mire GM, Thompson JW, Jr, Shore JH, et al. The use of telemedicine to evaluate competency to stand trial: a preliminary randomized controlled study. J Am Acad Psychiatry Law. 2007;35(4):481-489.

9. Fortney JC, Maciejewski ML, Tripathi SP, et al. A budget impact analysis of telemedicine-based collaborative care for depression. Med Care. 2011;49(9):872-880.

10. Pyne JM, Fortney JC, Tripathi SP, et al. Cost-effectiveness analysis of a rural telemedicine collaborative care intervention for depression. Arch Gen Psychiatry. 2010;67(8):812-821.

11. Morland LA, Greene CJ, Rosen CS, et al. Telemedicine for anger management therapy in a rural population of combat veterans with posttraumatic stress disorder: a randomized noninferiority trial. J Clin Psychiatry. 2010;71(7):855-863.

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20. American Telemedicine Association. Medicare payment of telemedicine and telehealth services. http://www.americantelemed.org/files/public/membergroups/businessfinance/reimbursement/
BF_MedicarePaymentofTelemedicine.pdf. Published May 15 2006. Accessed November 5, 2012.

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Although many states have substantial health services in urban areas, these services—particularly mental 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 underserved areas.² Psychiatry is one of the biggest users of telemedicine, which refers to any combination of communication technology and medicine.^3-5 This article discusses telepsychiatry’s effectiveness in providing psychiatric diagnosis and treatment, and the clinical implications of this technology, including improving access, cost, and quality of mental health services.

Outcomes comparable to face-to-face care

Telepsychiatry is used primarily in rural areas or correctional institutions or with underserved populations such as veterans with posttraumatic stress disorder or children. Although the literature generally is weak, there has been more research on psychiatry than other medical specialties because psychiatric clinicians rely on mental status examinations and verbal communications, not physical exams. Telepsychiatry can be considered a part of an evolving “connected health” system that offers many benefits to patients and clinicians (Table).

Table

Benefits of telepsychiatry as part of a ‘connected health’ system

Available to everyone
Health care is provided at the point of convenience
Patients are informed and empowered
Facilitates patient compliance, continuing education, ease of access into the health care system, and healthy behaviors
Clinical data are integrated with longitudinal electronic health records
Data are available to patients via his or her personal electronic medical record and authorized clinical providers
Data and transactions are secure to greatest practical extent
Other telehealth applications with demonstrated efficacy—eg, telephone, internet, e-mail, and text messaging interventions—can be used as well

Previously, we have reviewed evidence on the use and effectiveness of telepsychiatry in providing mental health care for children,⁶ adolescents,⁶ and adults.² The literature includes studies of feasibility,⁷ acceptance and satisfaction,⁸ and cost.^9,10 Although limited, comparison of telepsychiatry with similar face-to-face interventions continues.^11,12 Researchers have examined telepsychiatry in several patient populations for assessment and treatment goals. In virtually all cases, telepsychiatric assessments and/or interventions have been comparable with face-to-face assessments and/or interventions. Although the research methodology used in some studies has been weak, there is no evidence that therapeutic alliance,^13,14 therapist fidelity,¹⁵ patient satisfaction, or outcomes with telepsychiatry are inferior to those seen in comparable face-to-face treatment.

Barriers to implementation

Although telepsychiatry offers tremendous promise, implementation has not been widespread or easy. Potential barriers to implementation, such as cost and resistance to change, are associated with acceptance of new technology or practice in health care. In addition, there are several legal, regulatory, and technical barriers.

Institutional barriers. Physicians and other providers may not have access to timely, evidence-based information and may face challenges, such as time constraints, access to technical support, and complexity of large health care institutions, when integrating this information into clinical practice.¹⁶ Two studies¹⁷ found that after controlling for other barriers—eg, reimbursement and regulatory issues—providers are the most significant initial gatekeepers that affect telemedicine use. When designing a telemedicine system, project managers should prioritize providers’ needs, such as ease of use and incentives.¹⁸

Clinical Point

Studies found that providers are the most significant initial gatekeepers that affect telemedicine use

Reimbursement. Medicare started reimbursing providers for telemedicine in 1999, and some limitations in the payment scheme have been addressed.^19,20 Approximately one-half of state Medicaid programs and many third-party payers reimburse for telehealth services, with similar limitations in Medicare.²⁰ A “fee-for-service” approach reimburses the consulting psychiatrist or mental health professional for his or her time. Telepsychiatry reimbursement typically is provided for a diagnostic interview, pharmacologic management, and individual psychotherapy provided by psychiatrists and clinical psychologists. Differences among payers and supporting documents are available on the American Psychiatric Association’s Telepsychiatry Internet Resources site (see Related Resources).

States do not cover services provided by other mental health providers, except for Utah’s coverage for social workers. The American Psychiatric Association has 2 suggestions regarding this issue³:

reimbursement for telepsychiatry services should follow customary charges for delivering the appropriate current procedural terminology code(s)
a structure for reimbursement of collateral charges, such as technician and line time, should be identified.

Impact on practice. Changing workplace behaviors requires restructuring daily workflow and routine procedures to make it easy for clinicians to provide telepsychiatric care. For successful implementation, clinicians and patients must regard telepsychiatry as a treatment approach that will enhance success, access, and quality of care. As with patient behaviors,²¹ to change practice behaviors, the intention to change must be combined with the necessary skill, and environmental constraints that prevent new behaviors must be absent or removed. In general, telepsychiatry is accepted. In our experience, usually a reluctant clinician, not the patient or his or her family, hampers acceptance of telepsychiatry.