Evidence-Based Reviews

Telepsychiatry: Ready to consider a different kind of practice?

Current Psychiatry. 2015 March;14(3):32-33, 36, 52

References

1. Shore JH. Telepsychiatry: videoconferencing in the delivery of psychiatric care. Am J Psychiatry. 2013;170(3):256-262.
2. Konrad TR, Ellis AR, Thomas KC, et al. County-level estimates of need for mental health professionals in the United States. Psychiatr Serv. 2009;60(10):1307-1314.
3. Vernon DJ, Salsberg E, Erikson C, et al. Planning the future mental health workforce: with progress on coverage, what role will psychiatrists play? Acad Psychiatry. 2009;33(3):187-192.
4. Carrns A. Understanding new rules that widen mental health coverage. The New York Times. http://www. nytimes.com/2014/01/10/your-money/understanding-new-rules-that-widen-mental-health-coverage.html. Published January 9, 2014. Accessed February 10, 2015.
5. Myers KM, Valentine JM, Melzer SM. Feasibility, acceptability, and sustainability of telepsychiatry for children and adolescents. Psychiatr Serv. 2007;58(11):1493-1496.
6. Nelson EL, Barnard M, Cain S. Treating childhood depression over videoconferencing. Telemed J E Health. 2003;9(1):49-55.
7. Boydell KM, Hodgins M, Pignatiello A, et al. Using technology to deliver mental health services to children and youth: a scoping review. J Can Acad Child Adolesc Psychiatry. 2014;23(2):87-99.
8. Pakyurek M, Yellowlees P, Hilty D. The child and adolescent telepsychiatry consultation: can it be a more effective clinical process for certain patients than conventional practice? Telemed J E Health. 2010;16(3):289-292.
9. Poon P, Hui E, Dai D, et al. Cognitive intervention for community-dwelling older persons with memory problems: telemedicine versus face-to-face treatment. Int J Geriatr Psychiatry. 2005;20(3):285-286.
10. Rabinowitz T, Murphy KM, Amour JL, et al. Benefits of a telepsychiatry consultation service for rural nursing home residents. Telemed J E Health. 2010;16(1):34-40.
11. Deslich SA, Thistlethwaite T, Coustasse A. Telepsychiatry in correctional facilities: using technology to improve access and decrease costs of mental health care in underserved populations. Perm J. 2013;17(3):80-86.
12. James DJ, Glaze LE. Mental health problems of prison and jail inmates. U.S. Department of Justice, Office of Justice Programs. http://www.bjs.gov/content/pub/pdf/mhppji. pdf. Updated December 14, 2006. Accessed February 10, 2015.
13. Hilty DN, Ferrer DC, Parish MB, et al. The effectiveness of telemental health: a 2013 review. Telemed J E Health. 2013;19(6):444-454.
14. Maheu MM, Mcmenamin J. Telepsychiatry: the perils of using skype. Psychiatric Times. http://www. psychiatrictimes.com/blog/telepsychiatry-perils-using-skype. Published March 28, 2013. Accessed February 10, 2015.
15. Knoedler DW. Telepsychiatry: first week in the trenches. Psychiatric Times. http://www.psychiatrictimes.com/ blogs/couch-crisis/telepsychiatry-first-week-trenches. Published January 22, 2014. Accessed February 15, 2015.
16. Secure Telehealth. Medicaid reimburses for telehealth in 41 states. http://www.securetelehealth.com/medicaid-reimbursement.html. Updated January 15, 2015. Accessed February 10, 2015.
17. Federation of State Medical Boards. Telemedicine overview: Board-by-Board approach. http://library.fsmb.org/pdf/ grpol_telemedicine_licensure.pdf. Updated June 2013. Accessed February 10, 2015.
18. Joint Commission Perspectives. Accepted: final revisions to telemedicine standards. http://www.jointcommission. org/assets/1/6/Revisions_telemedicine_standards.pdf. Published January 2012. Accessed February 10, 2015.
19. Hyler SE, Gangure DP. Legal and ethical challenges in telepsychiatry. J Psychiatr Pract. 2004;10(4):272-276.
20. Kornbluh RA. Staying true to the mission: adapting telepsychiatry to a new environment. CNS Spectr. 2014;19(6):482-483.

Other common concerns about telepsychiatry are stable access to videoconferencing and the safety from hackers of necessary hardware. Medical device companies have created hardware and software for use in telepsychiatry that provide a Health Insurance Portability and Accountability Act-compliant high-quality, stable, videoconferencing visit.

Do patients benefit?
Clinically, patients have fared well when they receive care through telepsychiatry. In some studies, however, clinicians have expressed some dissatisfaction with the technology¹³— understandable, given the value that psychiatry traditionally has put on sitting with the patient. As Knoedler¹⁵ described it, making the switch to telepsychiatry from in-person contact can engender loneliness in some physicians; not only is patient contact shifted to videoconferencing, but the psychiatrist loses the supportive environment of a busy clinical practice. Knoedler also pointed out that, on the other hand, telepsychiatry offers practitioners the opportunity to evaluate and treat people who otherwise would not have mental health care.

Obstacles—practical, knotty ones
Reimbursement and licensing. These are 2 pressing problems of telepsychiatry, although recent policy developments will help expand telepsychiatry and make it more appealing to physicians:
• Medicare reimburses for telepsychiatry in non-metropolitan areas.
• In 41 states, Medicaid has included telepsychiatry as a benefit.¹⁶
• Nine states offer a specific medical license for practicing telepsychiatry¹⁷ (in the remaining states, a full medical license must be obtained before one can provide telemedicine services).
• The Joint Commission has included language in its regulations that could expedite privileging of telepsychiatrists.¹⁸

Even with such advancements, problems with licensure, credentialing, privacy, security, confidentiality, informed consent, and professional liability remain.¹⁹ I urge you to do your research on these key areas before plunging in.

Changes to models of care. The risk that telepsychiatry poses to various models of care has to be considered. Telepsychiatry is a dramatic innovation, but it should be used to support only high-quality, evidence-based care to which patients are entitled.²⁰ With new technology—as with new medications—use must be carefully monitored and scrutinized.

Although evidence of the value of telepsychiatry is growing, many methods of long-distance practice are still in their infancy. Data must be collected and poor outcomes assessed honestly to ensure that the “more-good-than-harm” mandate is met.

Good reasons to call this shift ‘inevitable’
The future of telepsychiatry includes expansion into new areas of practice. The move to providing services to patients where they happen to be—at work or home— seems inevitable:
• In rural areas, practitioners can communicate with patients so that they are cared for in their homes, without the expense of transportation.
• Employers can invest in workplace health clinics that use telemedicine services to reduce absenteeism.
• For psychiatrists, the ability to provide services to patients across a wide region, from a single convenient location, and at lower cost is an attractive prospect.

To conclude: telepsychiatry holds potential to provide greater reimbursement and improved quality of life for psychiatrists and patients: It allows physicians to choose where they live and work, and limits the number of unreimbursed commutes, and gives patients access to psychiatric care locally, without disruptive travel and delays.

Bottom Line
The exchange of medical information from 1 site to another by means of electronic communication has great potential to improve the health of patients and to alleviate the shortage of psychiatric practitioners across regions and settings. Pediatric, geriatric, and correctional psychiatry stand to benefit because of the nature of the patients and locations.

Related Resources
• American Telemedicine Association. Practice guidelines for video-based online mental health services. http://www. americantelemed.org/docs/default-source/standards/practice-guidelines-for-video-based-online-mental-health-services. pdf?sfvrsn=6. Published May 2013. Accessed February 10, 2015.
• Freudenberg N, Yellowlees PM. Telepsychiatry as part of a comprehensive care plan. Virtual Mentor. 2014;16(12):964-968.
• Kornbluh R. Telepsychiatry is a tool that we must exploit. Clinical Psychiatry News. August 7, 2014. http://www. clinicalpsychiatrynews.com/home/article/telepsychiatry-is-a-tool-that-we-must-exploit/28c87bec298e0aa208309fa 9bc48dedc.html.
• University of Colorado Denver. Telemental Health Guide. http:// www.tmhguide.org.

Disclosure
Dr. Kornbluh reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Telepsychiatry: Ready to consider a different kind of practice?

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