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 www.dellabella.us

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

8. More Terms PATIENT SITE PROVIDER SITE
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

15. STATE LAWS MANDATING TELEMEDICINE
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

24. Treatment Models CONSULTATION MODELS ONGOING CARE MODELS
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: www.atmeda.org
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: