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Telepsychiatry gains momentum at academic medical centers
Psychiatry continues to experience a provider shortage, particularly in child and adolescent psychiatry. There are 8,300 child and adolescent psychiatrists practicing in the United States, and 400 residents graduate each year.
“There is no way we can meet the societal need with the present care model,” said David Pruitt, MD, director of child and adolescent psychiatry at the University of Maryland.
Specifically, telepsychiatry can extend the reach of providers to help them serve clients in rural areas, in schools that do not have staff on site or in areas where integrated care is being used. Pruitt spoke about the potential of telepsychiatry at the recent American Telemedicine Association meeting in Baltimore.
Delivery of remote behavioral health services using technology is a key component in the University of Maryland’s approach to community engagement. “We teach residents how we in psychiatry can be relevant in the new medical/behavioral care environment,” said Pruitt.
Proof of concept
Michele Fallon Travers, MD, chief of telepsychiatry at University of Florida (UF) Health in Gainesville, launched a telepsychiatry program last year. “As of a year ago, I was surprised to learn that no one was doing telepsychiatry at UF. In fact, no one was doing telemedicine at all, so I volunteered to do it.”
She worked with UF information technology teams on the first proof of concept for telemedicine, and it served as a model for the entire university. The project focused on student mental health in the Counseling and Wellness Center.
The team chose to start there because the billing would be easier and because students were likely to embrace the technology, Travers said. “College students pay health fees as part of their tuition, so collecting revenue was not an issue.” Also, college students are comfortable using Skype, Facetime and mobile devices regularly. They are more comfortable using technology than the doctors are, she said. HIPAA-compliant videoconferencing was offered free for college students, initially on campus, then anywhere in Gainesville, and later anywhere in the state of Florida.
The new setup has other benefits. For example, the infirmary, where students receive primary care, is quite a distance from the counseling center. Previously, in an emergency situation, UF would have to activate the campus police department to transport a student to the psychiatry department for consultations, Travers said. Now the primary care doctor can hold an emergency consultation through the use of telemedicine, rather than moving the patient.
UF has begun several research projects to gauge its program, including studying student perceptions. “In our first study, the students rated the acceptability of telepsychiatry high compared to group therapy,” Travers said. “In fact, many preferred it to face-to-face meetings.”
As providers increasingly seek reimbursement for the virtual services, the Florida Legislature is examining the issues with a state telepsychiatry task force, which Travers has been asked to chair. “At UF, our focus has been on improving convenience factors. But now that we have our sea legs, we are starting to pursue fee-for- service and contract work,” she said. “We are in negotiation with several clinics and hospitals that have asked us to provide emergency and forensic services via contract.”
Collaborative care model
Patrick O’Neill, MD, director of telepsychiatry at Tulane University in New Orleans, said his institution has been working on telepsychiatry for several years. Six years ago, Tulane was approached by a region of the state that was underserved. “We developed a system that piggybacks on the state intranet,” O’Neill explained. “We have Polycom desktop sets and sell our faculty time in four-hour blocks.” Tulane has gradually built up to clinical services. “We average 180 hours a week, not including the VA and forensic work we do,” he said.
Among other programs, Tulane provides telepsychiatry services to the grant-funded Integrated Behavioral Health Program (IBHP) for federally qualified health centers in Louisiana. The program employs a collaborative care model, in which the primary care provider, behavioral health specialist, patient navigator and consulting psychiatrist work together to address a patient’s mental health issues within the primary care setting.
Robert Caudill, MD, associate professor of psychiatry at the University of Louisville, directs its telepsychiatry program. It has grown to offer 64 hours per week of clinical services to several rural community health agencies in underserved areas of the commonwealth.
“Kentucky has 120 counties with 14 community mental health centers. Each has its own internal politics and governance structures,” Caudill said. “We have active programs in two [centers], and will have a third up and running soon.”
Rather than seeking grant funding, the program has worked to develop institutional contracts to be self-supporting. “We can offer two hours a week to an isolated rural clinic,” he said. “We offer a fixed hourly rate with agreed-upon clinical parameters, such as how many patients per hour.”
Still under investigation for future offerings, he added, are emergency department coverage, medical-surgical hospital consultations, asynchronous services, home-based patients, nursing homes and day treatment programs.
Foster participation
Pruitt said at the University of Maryland, faculty teach a community-based liaison model of how to work with teams and how to integrate treatment. “There are 6.5 million children with attention deficit hyperactivity disorder (ADHD) diagnoses, and 3.5 million children take ADHD medications. Many will be seen by 54,000 practicing pediatricians,” Pruitt said. “How will the primary care provider, child psychiatrist, school clinician, and community provider participate and interact? What will be the role of tele-mental-health in fostering participation and interaction?”
UM’s focus is on the underserved, both rural and high-density urban. The Maryland Behavioral Health Integration in Pediatric Primary Care (B-HIPP) is a collaboration between the Maryland Department of Health and Mental Hygiene, the State Department of Education, Johns Hopkins Bloomberg School of Public Health, the University of Maryland School of Medicine and the Salisbury University Department of Social Work.
The core component is a phone consultation service to help the primary care provider to effectively deliver more mental health services. There is no cost to providers or patients, and no insurance required. It also offers referral services to link families to services in their community county by county and statewide and co-location of social workers with primary care providers. “Our telephone consultation is anonymous to the patient. It has become clear that the primary care provider at times needs more direct patient evaluation. We plan to develop this capacity immediately through telehealth,” Pruitt said.
B-HIPP is expanding sites into Maryland counties with few or no child psychiatrists. “There is a huge societal need for more mental healthcare for children and adolescents,” Pruitt said. “Seventy to 80 percent of children receive mental health services through schools. Psychiatry is the most needed service in school mental health. We provide telepsychiatry consultations in both rural and urban schools in Maryland. We are in 70 schools across the state, and 27 in Baltimore schools.”
Pruitt described plans to move to a school mental health model that is a hybrid, where a child psychiatrist does the initial evaluation face to face with telehealth follow-ups. “The philosophy is to have the right person in front of the patient at the right time with evidence-based treatment using the right technology.”
What is telemedicine?
Formally defined, telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status. Telemedicine includes a growing variety of applications and services using two-way video, email, smart phones, wireless tools and other forms of telecommunications technology.
While the term telehealth is sometimes used to refer to a broader definition of remote healthcare that does not always involve clinical services, ATA uses the terms in the same way one would refer to medicine or health in the common vernacular. Telemedicine is closely allied with the term health information technology (HIT). However, HIT more commonly refers to electronic medical records and related information systems while telemedicine refers to the actual delivery of remote clinical services using technology.
