Seven reasons why telepsychiatry is hot!

When, just after arriving at the recent Open Minds Technology and Informatics Conference in Baltimore, I asked at trusted provider organization leader, “what’s up?” , he answered in a single word:  “telehealth.”  But his expression said: “TELEHEALTH!”

I took comfort in his certainty, because, deep down, I believe that many who lead behavioral health organizations face a relatively common set of problems and may benefit from variations on a number of common solutions.  With that bit of direction, I dove in to the conference and learned some more.

1) Telehealth maximizes the impact of a shrinking pool of psychiatrists.  There’s a crisis in psychiatry, says Jonathan Evans, whose based organization, Safe Harbor Behavioral Health (Erie, Penn.) has struggled to match a long-term increase in consumer demand with a shrinking supply of local psychiatry talent.  Statistics say that the field is “aging out,” says Evans, citing the fact that many psychiatrists are already over age 55 and fewer young psychiatrists are entering the field.  Demand for community psychiatrists is also being stretched by the rising need for psychiatry in the prison system, and by the concern that the covered population will rise significantly with the onset of 2014 healthcare reforms.

When Evans faced the loss of a psychiatrist due to a family move to Ohio—one of just five or six at Safe Harbor—he asked her if she would consider offering her services via telehealth.  When she said yes, they adopted a relatively simple connection—essentially a Skype line and a quiet, home-based office—to get the job done. Now, the psychiatrist works from her home near Dayton, Ohio, serving many of the same consumers as before.  The only significant change:  Her compensation is “productivity” rather than salary based, says Evans, noting, in retrospect, that the psychiatrist’s productivity and effectiveness in the work is such that he needn’t have worried. “I need to remind her to take a break once in a while,” he said.

2) Telehealth is nearly “perfect” for behavioral health. “Visualization is at the root of clinical trust. Relative to a telephone conversation, “the visual interaction is much more powerful,” said Noel Obourne of American Well, a major telehealth provider that serves clients including the Veterans’ Health Administration.. “There’s a tremendous opportunity for telehealth services in behavioral health, since it’s the only medical specialty where you don’t have to lay hands on the patient.”

3) Telehealth is more and more widely accepted by payers.  Obourne said that 36 states recognize and pay for telehealth services in their Medicaid programs.  Some fourteen states reimburse for telehealth services as “on par” with office visits, and therefore pay equal reimbursements for them.  Just as significant, she said that half of employers are considering telehealth-based services for their employee assistance programs.  

There’s no better proof of the technology’s promise than its recent growth:  “There’s an enormous emergence of entrants in the telehealth/telemedicine space,” said Obourne.  She cited a recent count that included some 600 new entrants in the telehealth category. She and other observers predict a significant shakeout. 

4) Telehealth delivery is not technology limited, but provider limited.  Obourne added that telehealth technology is now so ubiquitous, so relatively easy to use, that growing demand for telehealth services is putting strain on people and processes. The key to further expansion, she noted, is that “we have to unlock supply and demand problems with the high-demand resources—the providers.”  She identified workflow problems as a primary sticking point.  One example:  Making traditional appointments is a job handled by staff with the expectation of a provider “schedule” at a fixed office.  But, when the technology frees the provider from the office, scheduling can be much less labor-intensive, and not necessarily reflective of normal “office” hours.  It might be as simple, in some cases, of a quick couple of e-mails between a psychiatrist and a consumer.  Making, and keeping an appointment, is no big deal, say proponents, who cite dramatic improvements in no-show rates when consumers and psychiatrists 

5) Care delivery to consumer devices. While telehealth approaches can offer significant freedom to providers, Obourne said that nothing is possible unless the treatment can get to the would-be consumer. “We’ve worked hard with all sorts of groups—VA, the indigent, and many in the public sector—to simplify and to deliver video in the easiest way,”  she noted, explaining that “Sometimes people don’t have a car, but they often do have a smartphone.  Tablets are also increasingly popular,” she added.  The relatively low cost, combined with the video capabilities of these devices make them a natural for bringing specialized resources (like psychiatrists) into specific and accessible locations—like the hands (or homes) of  would-be consumers.  

6) Help for schoolkids. Just as student needs brought social workers and counselors into the school environment long ago, telehealth is “bringing in” specialty providers, like psychiatrists, says Sherrie Williams, LCSW, of the Georgia Partnership for Telehealth (Waycross, Ga.). Telehealth’s impact must be understood not just with regard to the student, but to the parent.  Students, she explained, were limited in their ability to participate in specialty care by their parent’s work schedules, schedules that preclude days off to take a child to a distant specialist for fear of losing a job.

7) Impact on hospitals and local health care.  The value of bringing “virtual specialists” to schools was also recognized by local hospitals. With access to specialists provided by telehealth in the school setting, job-conscious parents made significantly less use of “off-hours” medical resources—notably emergency rooms, because their children were receiving appropriate medical and behavioral support at school--a place where a parent could visit on a lunch hour or short break to participate in a child's care.  Williams noted that as the grants to launch some of Georgia’s school-based telehealth programs ran out, local hospitals stepped in to help with funding because they too noticed the savings. 

A few other thoughts . . . Hearing all of these things, I couldn't help but wonder if one future for psychiatry isn't simply online. Imagine it: a flexible schedule of appointments, filled by provider referrals, patient requests, or on an "as needed" basis, that allow psychiatrists to serve the needs of multiple providers--and consumers--from the relative comfort of a well-wired home office, aided by a range of now-available consumer self-reporting tools and assessments, and by ready access to consumer health records via a remote or cloud-based EHR.  Think of it--such an approach opens up the possibility for a quick med-check on a lunch hour, for a brief, 15-minute crisis intervention to an on-call resource, or for a more detailed assessment without the difficulty and expense of a long drive. 

One other interesting point: There continues to be some controversy about the level of "security" required to conduct telehealth calls--some standards call for 128-bit encryption--but providers are making do with everything from high-end, highly secure teleconference lines to free Skype calls.  A word from the wise, though, if you're inclined to use a free resource like Skype:  Be sure that your psychiatrists and your consumers are informed of, and consent to, the potential risk of using a popular web resource like Skype. I've heard several experts worry aloud that although Skype traffic is encrypted, Skype's interface was not designed with user security in mind.  With an informed consent or release in mind, this liability concern can, apparently, be mitigated.