Top 5 barriers to telemental health

In a world where change is often reactionary rather than anticipatory, many forward-thinking professionals are dismayed that telehealth is taking so long to be accepted. After all, the evidence base supporting telehealth started building in 1959, and at this point, contains more than 4,000 primary source references establishing its effectiveness at reducing healthcare costs, improving outcomes and receiving high satisfaction ratings among patients.

Why then, do so many barriers still exist?

1. Regulations and restrictions by state boards

Most regulatory boards have decided that licensees in most healthcare disciplines can legally and ethically offer services across state and national borders, but typically must be licensed in the state and/or country of the patient at the time of the contact with the patient. That is, a resident of New York may fly to another state to care for an ailing parent, for example, but is not allowed to have his regular Thursday afternoon appointment with an established clinician in New York by telephone or video teleconferencing.

Also prohibitive is the administrative burden of fees, forms and processing delays when obtaining and maintaining licensure in multiple states. Such rules are considered antiquated by many, who point to today’s mobile society and patient expectations regarding access.

Another factor making it difficult for clinicians to understand state regulations regarding telehealth is lax terms directly referencing telehealth. A recent study found that no fewer than 27 terms are being used across state boards to refer to telehealth. The lack of agreement regarding nomenclature all too often leaves the practitioner wondering or assuming that telehealth is unregulated.

The fact is that telehealth is heavily regulated, and arguably, too regulated. A notable example of a behavioral state board that is setting the pace with regard to clarity is Georgia’s Composite Board, which enacted a ruling October 1, 2015, that requires all licensees and supervisors to take up to nine hours of continuing education for telemental health. Its definition of telehealth includes all clinical service that uses telephones, video, email, text messaging and apps for client/patient contact.

2. E-Prescribing

A number of states are imposing more restrictive laws in an effort to curb the irresponsible prescribing of controlled substances, much to the dismay of many telepsychiatrists. Federally, the Ryan Haight Act requires at least one in-person medical evaluation of a patient before prescribing any controlled substances remotely. While some states allow the  remote prescribing of controlled substances, the federal act pre-empts those laws. Although the act contains specific exceptions for telemedicine, those exceptions were drafted in 2008, before telehealth's recent refinements. Therefore, they do not cover the models most widely used in telemedicine, such as in telepsychiatry, where medical management of medications for patients has been shown both safe and effective.

3. Limited reimbursement

 To date, 29 states and the District of Columbia have enacted commercial payment requirements. Similar bills are proposed in several more states. Other factors previously preventing the widespread adoption of telehealth involve the very structure of payment systems in the United States. Until now, clinicians have been paid for delivering care in segments of time, regardless of the patient’s improvement.

Heavily influenced by recent healthcare reform, “risk” for patient outcomes is being shifted away from the payer to the provider. With clinicians being held more financially responsible for treatment outcomes, new capitated, shared-savings or hybrid alternative payment models are evolving. Telehealth is well suited to these newer payment models because it can help  providers keep in touch with the patient to better assess and manage the provider’s risk in shorter amounts of time, such as in 10 to 15 minute sessions. Providing increased communication, often of shorter duration and increased frequency, telehealth is now seen as key to improving outcomes. Legislative reform is reducing reimbursement barriers for telehealth along these lines, and much more is on the way.  

4. Practitioner adoption

Of all the barriers to the expansion of telehealth across disciplines, practitioner reluctance is considered to the most pervasive. In some ways, the introduction of difficult-to-use and complex Electronic Health Records (EHRs) have cast a shadow on practitioners’ enthusiasm for telehealth. Furthermore, fueled by a lack of exposure to and understanding of evidence-based models of telemental health, many traditional educators, practitioners and supervisors have looked askance at the burgeoning field. Having drawn conclusions from witnessing many “direct to patient” models that evolved from “online therapy” experiments between 1993 and 2014, traditional practitioners and their employers have been dissuaded by Internet therapists who are acting as if they were in the lawless “Wild West,” ignoring all existing legal and ethical requirements. However, thought leaders now realize that the evidence base for telemental health has more than 4,000 references supporting positive outcomes. Approximately 1,000 such links are available here.

5. Privacy and security

According to the Trend Watch report published in May 2015 by the American Hospital Association, security concerns are paramount in the minds of both clinicians and patients. Careless mistakes are made all the time, and not just by hospital systems that accidentally “lose” tens of thousands of records. Most behavioral professionals get worried with stories of the unwitting clinician whose laptop is stolen while abandoning the device for a minute, for example, to order a refill at the Starbuck’s counter, or the cell phone without password protection that gets lost at an outdoor rock concert. Similarly, managing the video-therapy patient who allows an angry spouse to interrupt a home-based therapy session requires proper protocols. Telemental health brings sensitive data into much greater vulnerability, requiring patients as well as practitioners and their employers to understand and comply with requirements.