Telepsychiatry:
Promises and Pitfalls
Peter Della Bella, MD
Clinical Assistant Professor, NYU School of Medicine
Staff Psychiatrist, Acadia Hospital, Bangor, Maine
Tuesday, April 29, 2014
2014 YAI International Conference
New York Hilton Midtown, New York, NY
All slides are available at
www.dellabella.us
I have no conflicts of
interest to report.
Outline
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Definition and terms
Survey
Benefits, State mandates, outcomes
Mechanics
Implementation
Barriers & Pitfalls
Resources
Definition of Telepsychiatry
A specifically defined form of video conferencing
that can provide psychiatric services to patients
in remote locations or underserved areas. It can
connect patients, psychiatrists, physicians, and
other healthcare professionals through the use
of cameras and microphones.
-American Psychiatric Association
WALL STREET JOURNAL – 1/14/2014
For the Mentally Ill, Finding Treatment Grows Harder
New health-care law may add to crunch for enough treatment
• Between 20052010, US
population grew
by 4.7%, while
the # of
psychiatrists
stayed the same
at 38,000.
Terms
• E-health – svcs through any electronic media: phone, fax,
videoconference, internet, apps
• ITV – real time information sharing
• Telemedicine – ITV for medical care
• Telepsychiatry/telemental health – psychiatry or
broader mental health services
More Terms
PATIENT SITE
PROVIDER SITE
Centers for
Medicare and
Medicaid (CMS)
ORIGINATING SITE
DISTANT SITE
New York State
Dept. of Health
SPOKE
HUB
Survey Question 1
e-Health
How many of you work in or get services from
an organization with:
1. Telescheduling or tele-check-in services?
2. Electronic health records?
3. Real-time clinical telehealth services?
Survey Question 2
telehealth
How many of you are providers who engage
directly in telehealth services?
Survey Question 3
telemental health
How many of you would be willing to engage in
tele-psychotherapy from home via encrypted
communication, if it spared you a 30 minute
commute?
1 hour commute?
2 hour commute?
Non-encrypted? (eg Skype or Facetime?)
How Common is Telepsychiatry?
• 1950s Univ of Nebraska – closed circuit
• 1973 “telepsychiatry” - Mass General to another site
consultation
• 1970s – consultation between Mount Sinai Hospital and a
child guidance clinic in NYC
• 1990s – technology availability expands interest
• 1995 – 50 telepsych programs in US
• 2003 – ~25 states provide to medicaid pts.
• 2005 – 116 programs in US
What are the major benefits?
• Access to care
– Remote sites, underserved, military, children,
homebound, ERs, prison
• Enables agencies to meet service mandates
• Integration of care
– 2nd opinions; specialist input & learning
– Multi-provider collaboration
Access
• First programs: major medical centers provide
services to rural communities
• Then subspecialists (child, forensics,…)
• Crisis services, underserved populations
• CMHCs, peds clinics, day care, rural schools,
correctional facilities, disaster sites
• Private practice
STATE LAWS MANDATING TELEMEDICINE
National Conference of State Legislatures
2014 State Telemedicine Legislation Tracking (as of 4/25/2014)
STATES
Mandated
3rd Party
Coverage
Mandated
Medicaid
Coverage
NOTES
NY
proposed
Some, +
proposed
A09129 and S04337b - Requires
telemedicine coverage under private
insurance and Medicaid; S04023 - Medicaid
reimbursement for capital costs related to
telemedicine
NJ
no
no
OTHER: S 1204 and AB 2161 - Medicaid
coverage and reimbursement of telemental
health in FQHCs
CT
proposed
no
OTHER: HB 5378 - Medicaid demo for
FQHCs; HB 5445 - Medicaid coverage of
home telemonitoring
American Telemedicine Association
NYS DOH Coverage
as per 10/1/2011, Medicaid Redesign Team
• “Hubs”: Art. 28 Hospitals, D&TCs, and FQHCs that have
opted into APGs
• “Spoke” patient sites: same
• Providers: Physician specialists, including psychiatry, CDEs,
CAEs; must be medicaid licensed, must be credentialled at
both hub and spoke sites
• Must be real-time, not “store and forward”
• Telepsych: both consultations and “therapy”
Outcomes?
• Literature: case reports, program descriptions and
implementation, specific disorders (PTSD, chronic pain,
alcoholism, schizophrenia, depression, the use of CBT with
child behavior problems)
• Outcomes: focus on patient and family satisfaction.
Newer outcome studies look at efficacy in specific disorders.
• Few equivalency comparisons of telepsych vs.
in-person care: 2005 Meta-analysis of 14 such studies
CNS Spect. 2005; 10(5): 403-413
How Does It Work?
• HUB. Provider and computer with camera,
separate computer with electronic medical
record
• SPOKE. Patient with camera, computer with
image of provider. Picture-in-picture.
Assistant. Camera moves, zooms.
• Dedicated rooms with proper lighting, typical
availability of nursing
Clinical Advantages?
• Novelty effect with the technology
• Less overwhelming and threatening for many
psychiatry patients
• Working in Teams
Clinical Limitations
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Fear of the technology
Visual information
Other sensory information
Motor data and vitals testing
Off-screen activities & communications
“Bonding”
Implementing A Telepsychiatry Service*
Step 1
❶ Do your homework
 Legal and regulatory issues
 Billing
*Adapted from American Acad of Child and Adolescent Psychiatry Practice Parameters
Implementing A Telepsychiatry Service
Step 2
❷ Establish need and feasibility
 Are both hub and spoke ready, willing, and able?
 What’s the treatment model?
 Define the population served, including
inclusion/exclusion
 Infrastructure: sq footage, technology, EHR, staffing
 Is it sustainable?: start-up, ongoing costs; grants vs. revenue
Treatment Models
1) CONSULTATION MODELS
 Referrer is present
(Maine ERs, Canada; NYCaT program;
referrer handles Rxs)
 Not present (more common in US, good for ERs; Texas; disaster
sites)
2) ONGOING CARE MODELS
 Direct care by psychiatrist (rural US)
 Physician extender is present (Bangor; specialty services)
 Team presence (academic centers)
Implementing A Telepsychiatry Service
Step 3
❸Establish your management controls
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Site Champions
Front and back office
Informed consent/assent
Workflow protocols for each site
Prescriptions, Labs, Emergencies, Back-up plans
Billing
Implementing A Telepsychiatry Service
Step 4
❹ Measure Quality, Utilization, Outcome
 A Lexicon of Assessment and Outcome Measures
for Telemental Health (2013, American Telemedicine
Association)
 Stakeholder satisfaction ratings
 Other
Implementing a Telepsychiatry Service
Step 5
❺ Fine tuning
Relationship with staff at spoke site
 Pre-, post-, weekly reviews
 Ribbon cutting
 Site champions
Physical arrangements
 Audio, visual, zoom checks, helpdesk numbers
 Camera placement, background, overhead lighting, echo, noise, screen
size of provider, using picture-in-picture, orientation to new patients
Barriers
• PRIVACY REQMTS – HIPPA compliant encrypted
communication over a virtual private network (VPN)
• CONSENTS – may be a challenge for non-competent
patients
• LICENSING/CREDENTIALLING – provider generally must
be licensed in both states, credentialed at all sites (and
oriented to P&P at all sites!)
• STAFF BUY-IN (12/2009 ER adoption study by California
HealthCare Foundation)
Credentialing of Providers
The Centers for Medicare and Medicaid Services’ (CMS)
final rule on credentialing and privileging requirements
for telehealth practitioners was made effective on July
5, 2011.
Establishes a process for originating site hospitals (location of the patient) to
rely on the credentialing and privileging decisions of the distant site hospital
(location of the specialist) for telehealth practitioners.
…contractual arrangements, processes for ensuring quality
Pitfalls
• Hub provider has no local knowledge
• Inadequate training (recommendation is for “layered” training
and skill-buildup)
• Not adequate technology support (need to be able to
provide ongoing support for lighting, cameras and audio, hardware,
software across both hub and spoke sites)
• Keeping on top of billing requirements (regs and laws are
changing quickly)
• Commoditization of providers
Future?
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Look at EHR/lab industry as models
Major internet companies get involved
Better standards and technology
Expansion of telehealth services and
reimbursement
• More at home, more eHealth self service
• Replacement of locums providers
• Commoditization of providers
Resources
• American Telemedicine Association: www.atmeda.org
• American Psychiatric Association: links to telemedicine
practice guidelines, reimbursement, program development
http://www.psychiatry.org/practice/professionalinterests/underserved-communities/telepsychiatry-internetresources
• Center for Telehealth and e-Health Law: http://ctel.org/
• American Association for Technology in Psychiatry:
http://tecpsych.com/techpsych/
• Telehealth Technical Assistance Manual, by the National Rural
Health Association:
http://199.237.254.34/pubs/pdf/Telehealth.pdf