Telepsychiatry:Promises and Pitfalls

Peter Della Bella, MDClinical Assistant Professor, NYU School of Medicine

Staff Psychiatrist, Acadia Hospital, Bangor, MaineTuesday, April 29, 2014

2014 YAI International ConferenceNew York Hilton Midtown, New York, NY

All slides are available atwww.dellabella.us

I have no conflicts of interest to report.

Outline

• 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 – 1/14/2014For the Mentally Ill, Finding Treatment Grows Harder

New health-care law may add to crunch for enough treatment

• Between 2005-2010, 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 1e-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 2telehealth

How many of you are providers who engage directly in telehealth services?

Survey Question 3telemental 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

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

2014 State Telemedicine Legislation Tracking (as of 4/25/2014)

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

• 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 ServiceStep 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 ServiceStep 3

❸Establish your management controls Site Champions Front and back office Informed consent/assent Workflow protocols for each site Prescriptions, Labs, Emergencies, Back-up plans Billing

Implementing A Telepsychiatry ServiceStep 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 ServiceStep 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?

• 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/professional-interests/underserved-communities/telepsychiatry-internet-resources

• 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