Evidence-Based Reviews

Telepsychiatry: Overcoming barriers to implementation

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

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.

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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.

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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.

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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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15. Morland LA, Greene CJ, Grubbs K, et al. Therapist adherence to manualized cognitive-behavioral therapy for anger management delivered to veterans with PTSD via videoconferencing. J Clin Psychol. 2011;67(6):629-638.

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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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Licensure. A physician conducting a telemedicine session with a patient in another state must be licensed in both his or her state and the patient’s state. Nurses and other allied health professionals have similar state licensing constraints. Sanders²² suggests 3 potential solutions:

establishing a national licensing system
assigning the responsibility of care to the referring physician, with the consulting physician’s opinion serving as “recommendation only”
determining that the patient is being “electronically transmitted” to the consultant’s state.

Clinical Point

Technological solutions such as encryption can help maintain patient privacy during telepsychiatry

Patient privacy and security. Privacy considerations unique to telepsychiatry include the potential for nonclinical technical or administrative personnel to view telepsychiatry sessions.²³ Increased videoconferencing over public networks also creates the potential for unauthorized access to protected health information. Technological solutions such as encryption and virtual private networks should be implemented (Box). Once these technological solutions are in place, providers need to be trained in proper data storage and retrieval and medicolegal and ethical issues related to maintaining patient privacy.

Box

The technology behind telepsychiatry

Although telemedicine has embraced many communication technologies, live, interactive, 2-way, audio-video communication—called videoconferencing—is broadly synonymous with telemedicine and, more specifically, telepsychiatry.

Telepsychiatry primarily uses interactive audiovisual conferencing systems over high-bandwidth networks. The central component of interactive telepsychiatry is the codec (coder/decoder), which provides compression, decompression, and synchronization of audio and video signals; both patients and clinicians need a codec. A codec can be a separate device, but personal computer-based codecs are being used more frequently. A typical setup also includes a video camera, microphone, speakers or headset, and 1 or 2 display monitors at both the clinician’s and patient’s end of the system. Often, separate displays or a picture-in-picture display are used to see both outgoing and incoming video. Another consideration is pan-zoom-tilt control of video cameras. This allows clinicians to remotely control his or her view of the patient’s site or control the view being transmitted to the patient.

Historically, interactive telepsychiatry applications have used point-to-point network connections, usually as full or fractional T-1 or integrated services digital network circuits. However, the rapid diffusion of internet and ethernet networks has led to the development of videoconferencing systems that can work over internet protocol (IP) networks. If using an IP network, ensure security by using encrypted codecs or by setting up a virtual private network and/or a virtual local area network (LAN). The principal advantage of IP networks is that by implementing proper security solutions, they can be shared by several applications—eg, internet, e-mail, LAN, etc. This means that the telecommunications network costs can be shared or considered a sunk cost (ie, not an additional cost of the telepsychiatry application).

Infrastructure. Costs associated with infrastructure development and maintenance of telepsychiatry typically are not reimbursable. Individual contracts, managed care, third-party payers (in a few states), or, in limited situations, Medicaid and Medicare may reimburse these costs. A structure for reimbursing collateral charges, such as technician and line time, needs to be developed.

Clinical Point

The costs of telepsychiatry infrastructure typically are not reimbursable

The U.S. Federal Communications Commission’s (FCC) Universal Service Fund (USF) subsidies can reduce the cost of telepsychiatry network connections. The FCC implemented the USF to bring high bandwidth telecommunications to rural schools, libraries, and health care providers. Funding for the USF is generated from fees paid by telecommunications providers. However, the USF subsidies are not being widely used for several reasons, including a cumbersome application process, limitations on eligible facilities and locations, and questions regarding costs to the health care provider.¹⁹

Individual states also have developed funding streams to support telemedicine. The Centers for Medicare and Medicaid Services will pay a facility site fee to the host site (where the patient is located), but only if the site is in a rural area. Providers can charge patients a fee to support telepsychiatry infrastructure and maintenance, but typically this arrangement is not affordable and is not standard practice.

The future

Telepsychiatry’s ability to improve access to mental health care to underserved populations is becoming more evident. Technology is adequate for most uses and is constantly advancing. Numerous applications already have been defined, and more are ripe for exploration. Barriers to implementation are primarily of the human variety and will require a combination of consumer, provider, and governmental advocacy to overcome.

Related Resources

American Telemedicine Association. www.americantelemed.org.
International Society for Telemedicine & eHealth. www.isfteh.org.
American Psychiatric Association. Telepsychiatry internet resources. www.psychiatry.org/practice/professional-interests/underserved-communities/telepsychiatry-internet-resources.
Mossman D. Practicing psychiatry via Skype: Medicolegal considerations. Current Psychiatry. 2011;10(12):30-32,39.