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Telepsychiatry: Promises and Pitfalls

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Presentation on theme: "Telepsychiatry: Promises and Pitfalls"— Presentation transcript:

1 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

2 All slides are available at

3 I have no conflicts of interest to report.

4 Outline Definition and terms Survey Benefits, State mandates, outcomes
Mechanics Implementation Barriers & Pitfalls Resources

5 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

6 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 , US population grew by 4.7%, while the # of psychiatrists stayed the same at 38,000.

7 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

Centers for Medicare and Medicaid (CMS) ORIGINATING SITE DISTANT SITE New York State Dept. of Health SPOKE HUB

9 Survey Question 1 e-Health
How many of you work in or get services from an organization with: Telescheduling or tele-check-in services? Electronic health records? Real-time clinical telehealth services?

10 Survey Question 2 telehealth
How many of you are providers who engage directly in telehealth services?

11 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?)

12 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

13 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

14 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

National Conference of State Legislatures

16 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; S Medicaid reimbursement for capital costs related to telemedicine NJ no OTHER: S 1204 and AB Medicaid coverage and reimbursement of telemental health in FQHCs CT OTHER: HB Medicaid demo for FQHCs; HB Medicaid coverage of home telemonitoring American Telemedicine Association

17 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”

18 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):

19 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

20 Clinical Advantages? Novelty effect with the technology
Less overwhelming and threatening for many psychiatry patients Working in Teams

21 Clinical Limitations Fear of the technology Visual information
Other sensory information Motor data and vitals testing Off-screen activities & communications “Bonding”

22 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

23 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

Referrer is present (Maine ERs, Canada; NYCaT program; referrer handles Rxs) Not present (more common in US, good for ERs; Texas; disaster sites) ONGOING CARE MODELS Direct care by psychiatrist (rural US) Physician extender is present (Bangor; specialty services) Team presence (academic centers)

25 Implementing A Telepsychiatry Service Step 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

26 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

27 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

28 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)

29 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

30 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

31 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

32 Resources American Telemedicine Association:
American Psychiatric Association: links to telemedicine practice guidelines, reimbursement, program development Center for Telehealth and e-Health Law: American Association for Technology in Psychiatry: Telehealth Technical Assistance Manual, by the National Rural Health Association:

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