Section 6.7 Optimize
Optimization Strategies for Telehealth and
Home Monitoring
This tool will increase your knowledge of telemental health, including benefits, challenges and
implementation readiness and strategies.
Time needed: 6 hours
Suggested other tools: NA
Introduction
The American Psychiatric Association notes that “telepsychiatry is currently one of the most
effective ways to increase access to psychiatric care for individuals living in underserved areas.”
(See: http://www.psych.org/practice/professional-interests/underserved-communities/telepsychiatry)
However, telemental health is actually reaching many people who need of mental health and
substance abuse services in addition to those in rural or underserved areas. A study conducted by the
University of Arizona and funded by the Robert Wood Johnson Foundation (J. Chong and F.
Moreno. Telemedicine and e-Health. May 2012, 18(4): 297-304. doi:10.1089/tmj.2011.0126)
suggests that telemental health improves access and reduces stigma to getting care. A recent
workshop conducted by the Institute of Medicine (IOM) observed that “mental health has a unique fit
for telehealth in that most of mental health care can be accomplished in some form over
videoconferencing (see: http://www.iom.edu/Reports/2012/The-Role-of-Telehealth-in-an-EvolvingHealth-Care-Environment.aspx).
The cost of telehealth technology is significantly lower today than in the past, security is by far more
sophisticated, and many believe it is a way to overcome the increasing shortage of mental health
professionals. Challenges to telemental health remain, especially in the area of reimbursement.
How to Use
1. If unfamiliar with telemental health or telehealth in general, review the glossary of terms.
2. Review current literature relating to benefits and challenges in using telemental health.
3. Understand the current state of telemental health technology and its relationship to electronic
health records (EHR), health information exchange (HIE), and other health information
technology (HIT).
4. Plan to adopt telemental health for targeted patients, recognizing the needed to address
obtaining consent, emergency management, technology implementation, workflow changes,
and documentation.
Glossary of Terms
The following terms are defined by the Guidelines for the Practice of Telepsychology from the
American Psychological Association, Adopted July 31, 2013 (available at:
http://www.apapracticecentral.org/ce/guidelines/telepsychology-guidelines.pdf):
Telepsychology is the provision of psychological services using telecommunication technologies.
Telepsychology and telepsychiatry are often considered among the key specialties served by
telemedicine.
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Telehealth reflects the broadest scope of providing therapeutic services, triage, monitoring, and
mentoring. It is within this context that the term telemental health has been derived, sometimes also
called e-therapy.
Telecommunications technologies, which may be used in various combinations including to augment
in-person therapy, include but are not limited to telephone, mobile devices, interactive
videoconferencing, email, chat, text, and Internet (e.g., self-help Web sites, blogs, and social media).
Also defined by the American Telemedicine Association (ATA) is the term telematics – which refers
to the use of information processing, based on a computer in telecommunications, and the use of
telecommunications to permit computers to transfer programs and data to one another.
The interoperability of telecommunications with EHR, use of HIE, and other HIT, as well as clinical
monitoring devices (e.g., automated blood pressure cuffs, scales, etc.), is becoming increasingly
important in health care.
Benefits and Challenges in Telemental Health
Benefits
The American Psychiatric Association website, psych.org, identifies the following benefits:
 Capability to provide an array of services, including but not limited to diagnosis and
assessment, medication management, and individual and group therapy.
 Opportunity for consultative services between psychiatrists, primary care physicians and
other health care providers. Pediatricians have been found to be especially receptive to
telepsychiatry. One psychiatrist who works for Youth Health Services in Elkin, West
Virginia, finds that children with anxiety disorders become more animated when they see him
on television (see:
http://www.computerworld.com/s/article/print/9224091/Web_based_counseling_Telepsychia
try_is_taking_off?taxonomyName=Healthcare+IT&taxonomyId=132).
 Provision of second opinions in areas where only one psychiatrist is available.
 Improvement in collaborative services between professionals. Studies indicate that health
care professionals feel telepsychiatry gives them an opportunity to work more effectively as a
team. Patients surveyed say they feel communication between their physicians had improved
their outcomes.
Additional benefits include:
 Ability for police and fire departments and case managers to use lightweight, accessible, and
affordable telehealth technology to connect to mental health professionals anywhere patients
may be, including emergency departments, rural health clinics, nursing homes, their own
homes, homeless shelters, schools, correctional facilities, and cruise ships.
 Overcoming the shortage of trained mental health professionals. (See iHealthBeat for recent
statistics, at: http://www.ihealthbeat.org/insight/2013/telepsychiatry-poised-to-take-off-butobstacles-remain).
 Reduction in in-patient visits (by as much as 25 percent) has been cited by the Department of
Veterans Affairs and the Department of Defense, which were early adopters of telehealth for
mental health care for soldiers and veterans.
 In response to needs and requests of mental health providers and organizations, the ATA
formed a committee to develop evidence-based telemental health guidelines, which were
published in July 2009 (see: http://www.americantelemed.org/docs/defaultSection 6 Optimize—Optimization Strategies for Telehealth and Home Monitoring - 2
source/standards/evidence-based-practice-for-telemental-health.pdf?sfvrsn=4). An extensive
literature review was included in these guidelines.
Barriers
There are barriers and challenges to providing telepsychiatry services:
 Reimbursement is most often cited as the biggest barrier.
o Medicare reimburses for telepsychiatry at the same rate as face-to-face treatment, but
the consumer must be located in a non-metropolitan statistical area, treated in a
qualifying facility, accompanied by a qualified staff person, and provided an
approved procedure. See the following for a summary additional information:
http://www.securetelehealth.com/medicare-reimbursement.html;
o http://www.americantelemed.org/docs/default-source/policy/medicare-payment-oftelemedicine-and-telehealth-services.pdf?sfvrsn=14
o Medicaid reimbursement varies by state, with only 40 states reimbursing for the
encounter and supervision on the client side. See the following for a summary of
additional information: http://www.securetelehealth.com/medicaidreimbursement.html
o Commercial payers are also starting to provide reimbursement at the same rate as
face-to-face treatment. The American Psychiatric Association maintains a Private
Payer Reimbursement Information Directory (see:
http://www.psychiatry.org/practice/professional-interests/underservedcommunities/telepsychiatry-internet-resources)
 There is no national licensing system, so mental health professionals can only treat patients in
states where they hold a license.
 Ubiquity of technology is necessary. Clients cannot be expected to travel to a clinic to log
onto a webcam. However, the digital divide has significantly lessened, with many more
Americans having smart phones and accessibility to computers with broadband connectivity.
Free phone service through the Internet, such as Skype, also improves access. However,
reimbursement mechanisms typically require supervision on the client side, so the technology
alone is not the answer.
An article by Stacie Deslich, “Telepsychiatry in the 21st Century: Transforming Healthcare with
Technology” in the summer 2013 issue of Perspectives in Health Information Management cites
patient safety, security, and confidentiality as important challenges (see
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3709879/). This article notes that during
consultations, providers and patients engage in a great deal of nonverbal communication. Although
much research supports the use of telepsychiatry as being equivalent to face-to-face treatment, it is
important to be aware of any potential differences with telepsychiatry that would decrease the
perceived value of the interaction or otherwise put the patient at risk for self-harm. Confidentiality
and security remain concerns, although this article also suggests that the improper storage of
transcribed paper documents is as great a risk as the improper storage of video or voice recordings.
As with all use of EHR and HIE, proper physical and technical security controls must be in place to
assure the confidentiality of the session and the documentation.
In late 2012, the Institute of Medicine (IOM) published The Role of Telehealth in an Evolving Health
Care Environment (available at: http://www.iom.edu/Reports/2012/The-Role-of-Telehealth-in-anEvolving-Health-Care-Environment.aspx). It identified some additional technical challenges:
Section 6 Optimize—Optimization Strategies for Telehealth and Home Monitoring - 3
 Using off-the-shelf devices, such as mobile phones, gaming systems, social media, etc. to
connect to providers is rapidly becoming feasible, but to connect with EHRs and participate
in HIE, these devices should be compliant with health care interoperability standards, such as
Health Level Seven (HL7) Data Communications Protocol.
 Managing data flowing in from all the devices and presenting the information to providers in
a meaningful and actionable way.
 Lack of broadband connectivity in some rural and underserved population areas. (See the
Federal Communications Commission Eighth Broadband Progress Report, June 2011,
available at: http://www.fcc.gov/reports/eighth-broadband-progress-report).
Telemental Technology
The following terms are defined by the American Telemedicine Association in its Practice
Guidelines for Videoconferencing-Based Telemental Health (available at:
http://www.americantelemed.org/docs/default-source/standards/home-telehealth-clinicalguidelines.pdf?sfvrsn=2). These are in addition to the terms discussed in Section 1.3 Interoperability
for EHR and HIE.
Asynchronous means that transmission of information occurs in one direction at a time.
Asynchronous transmission is used in the telehealth encounter type called Store and Forward (S&F).
Bandwidth is a measure of the information carrying capacity of a communications channel that is a
practical limitation with respect to size of images that can be communicated, cost, and capability of
telehealth services.
Broadband refers to communications (e.g., broadcast television, microwave, and satellite) capable of
simultaneously transmitting several messages.
CODEC is an acronym for coder-decoder and is the capability of converting analog video and audio
signals into digital video and audio code – essential for transmission of data and its storage (such as
in an EHR).
Data compression refers to the ability to reduce the volume of data to smaller packets that can
facilitate data transmission. Technical standards exist for various types of data compression.
Document camera is one that can display written or typed information, photographs, graphics, and—
in some cases—x-rays.
Fiber optic cables transmit data, voice, Internet access, and video with speeds in excess of 100
megabits per second (Mbps) [for comparison, see “plain old telephone system” (POTS) and Trunk or
Digital Subscriber Lines]; the services are very expensive and are usually used either by the
telephone company itself to support other services, or local campus connectivity.
Integrated Services Digital Network (ISDN) is a common dial-up transmission path for interactive
video (ITV). Per minute charges accumulate at a contracted rate and are billed to the site placing the
call.
Interactive video/television is analogous with video conferencing technologies that allow for twoway, synchronous, interactive video and audio signals for delivering telehealth. It is often
abbreviated ITV, IATV, or VTC (video teleconferencing).
Plain old telephone system (POTS) is a telephone service providing voice and data transmission at
speeds of 33 to 64 kilobits per second (Kbps).
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Synchronous means transmission of information can occur in both directions at the same time,
supporting interactive video connections. Synchronous transmission is used in the telehealth
encounter or consult type called Real Time.
Trunk or Digital Subscriber Lines from the telephone company offer high-speed data, voice, or
compressed video access in two directions. T1/DS1 has a transmission rate of 1.544 Mbps and
T3/DS3 has much faster (and costlier) service speeds of 45 Mbps.
Telematics refers to the use of information processing based on a computer (e.g., EHR) in
telecommunications, and the use of telecommunications to permit computers to transfer programs
and data to one another.
Universal Service Administration Company (USAC) administers the Universal Service Fund, which
provides affordable health, education and other telecommunication services to rural facilities and
others.
Videoconferencing is the two-way transmission of digitized video images between multiple
locations.
WiFi is the name of wireless networking technology that uses radio waves to provide wireless highspeed Internet and network connections.
Implementing Telemental Health
Just as with EHR and HIE, in planning to adopt telemental health technology, it is important to apply
a process that includes: a readiness assessment of both the behavioral health facility and each person
to whom telemental health services are offered; optimal selection of equipment; proper
implementation; attention to workflow changes; and assurance of necessary documentation.
Readiness Assessment
An assessment of the organization’s standard operating procedures and protocols, professionals’
readiness to perform e-therapy effectively, and other assessments includes:
 Standard operating procedures and protocols. Practice Guidelines for VideoconferencingBased Telemental Health published by ATA suggest that there be an assessment of the
organization and provider that assures:
o Agreements are in place with respect to licensing, credentialing, training, and
authentication of patients and practitioners as appropriate according to local,
state, and national requirements.
o Billing and coding processes are in compliance with requirements and sharing
them with third party payers does not risk exposure of mental health patients’
protected health information.
o Privacy and security practices of the organization and providers address the
higher standard of rights afforded mental health patients and documentation
of services provided to them.
o Appropriate policies and procedures are in place for all administrative,
clinical, and technical components of telemental health services.
o A systematic quality improvement and performance management process
exists that complies with organizational, regulatory, or accrediting
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requirements. This process is used to evaluate the provision of telemental
health services and make any necessary programmatic and clinical changes.
o Consents for treatment are in place as needed. There are no special consents
needed to use telemental health, but there should be the ability to obtain and
appropriately share consents for any treatment that requires them.
 Assessment of the skills of behavioral health professionals have to effectively carry out
telemental health, perhaps including:
o Ability to determine which cases are suitable for telemental health services.
o Cultural competency in the population being served at a distance.
o Good listening skills (e.g., discovering details in patient conversation, interrupting
patient only if necessary)
o Effective interviewing techniques (e.g., asking open-ended questions, active listening,
motivating)
o Ability to detect emotional cues via the phone (e.g., crying, dyspnea, silence) that
may call for modifications or even discontinuation of telemental health service
 Availability of supporting documentation technology, such as EHR—to document telemental
health encounters in a timely, accurate, and complete and receive and use data feeds.
 Availability of supporting HIE technology, such as using the Direct protocol for secure email
and/or participating in an HIE organization (HIO).
Selection and Implementation Considerations
To select the right equipment, consider the following features (in addition to those relating to terms
defined above and to those described in Section 2.9 Requirements Analysis and Prioritization for
EHR and HIE:
 Vendor-related considerations
o Minimum number of units to acquire
o Monitoring service offered
o Equipment obsolescence
o Cloud-based storage
 Product-related considerations
o HL7 compliant
o Size/weight for portability
o Backup battery and/or operational batteries
o Video quality, if applicable
o Sound quality, if applicable
o Clinical peripherals, if any
 FDA approved
 Vendor flexibility
o Security controls meet HIPAA requirements
 Facility-side ease of implementation
o Integration with EHR
o Connectivity to HIE services used
o Special equipment (e.g., cameras, connectivity) setup
o Digital picture download
 Client-side ease of implementation
o “Plug and play” devices that fit standard computers (and telephones, especially
for mobile telemental health)
o Need for routers, (internal/external) modems, and other peripheral devices
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o Number of peripheral devices that can function at one time (i.e., how many
serial ports)
o Digital picture upload
 Facility-side ease of use
o Ability to transmit, retrieve, and store data
o Ability to generate clinical, productivity, and usage (e.g., telephone charges)
reports
o Programmability for unique patient needs
 Client-side ease of use
o Equipment reliability
o Sanitation and safety factors
Workflow Changes
There may be workflow changes that need to occur as telemental health services are performed. For
example:
 All persons present at both sites should be identified to all participants prior to the service
being performed.
 Sharing of clinical history, consents, and other information should occur prior to and/or
concurrent with the telemental health session.
 There should be a traceable record of the session at both the referring and consulting sites. It
is recommended that this be in the form of a consultation report that is generated through
standard dictation/transcription or via templates offered through an EHR. While audio and
video recordings may be retained, these do not serve as formal session documentation.
 If psychotherapy is performed, special considerations such as those provided through the
HIPAA Privacy Rule must be addressed.
 Expert pharmacotherapy workflow must be studied and codified in a procedure that is
precisely followed.
 Special considerations must be given to how medical emergencies occurring during a session
will be handled, how children and the elderly will be accommodated, additional requirements
of rural or underserved populations, and community resources available for substance abuse
assessment and treatment.
Copyright © 2014 Stratis Health.
Section 6 Optimize—Optimization Strategies for Telehealth and Home Monitoring - 7
Updated 01-01-14