Why Telepsychiatry? Can t I just skype with my patients? Getting Started with Telepsychiatry! Steven E. Hyler, MD Professor Emeritus of Psychiatry Columbia University Medical Center New York, New York Convenience Efficiency Travel/Vacations Make Money Better Service Delivery International Applicability Like to Use Technology Language of Telepsychiatry Technology Videoconferencing Videoteleconferencing Teleconferencing Telepresence (Online therapy? Web therapy?) Hard Technology = equipment and transmission system vs Soft Technology = etiquette, scheduling, medical record, prescribing, tech support Host site vs Remote site(s) Important Issues 1) Efficacy/Effectiveness/Equivalence 1) Efficacy/Effectiveness/Equivalence? 2) Licensure 3) Reimbursement 4) Professional Liability Telepsychiatry vs In-Person The verdict is in YES! (with rare exceptions)
References References (continued) Chan S, et al. Telepsychiatry Today. Curr Psychiatry Rep. 2015;17(11):89. Telepsychiatry leads to high patient and provider satisfaction ratings, and outcomes equivalent to in-person care, while younger generations often prefer telepsychiatry over face-to-face encounters. Hilty D, et al. Telepsychiatry: Effective, Evidence-Based, and at a Tipping Point in Health Care Delivery? Psychiatr Clin North Am. 2015;38(3):559-592. Telepsychiatry or telemental health is effective, well accepted, and comparable to in-person care. Maieritsch KP, et al. Randomized controlled equivalence trial comparing videoconference and in person delivery of cognitive processing therapy for PTSD. J Telemed Telecare. 2015 Jul 30;[Epub ahead of print]. CPT over VTC may be equivalent to the treatment delivered in person CPT = cognitive processing therapy; VTC = video-teleconferencing. Myers K, et al. Effectiveness of a telehealth service delivery model for treating attention-deficit/hyperactivity disorder: a community-based randomized controlled trial. J Am Acad Child Adolesc Psychiatry. 2015;54(4):263-274. The CATTS trial demonstrated the effectiveness of a telehealth service model to treat ADHD in communities with limited access to specialty mental health services. Vahia IV, et al. Telepsychiatry for Neurocognitive Testing in Older Rural Latino Adults. Am J Geriatr Psychiatry. 2015;23(7):666-670. This study demonstrates feasibility and utility of neurocognitive testing in Spanish using TP among older rural Latinos. Munro Cullum C, et al. Teleneuropsychology: evidence for video teleconferencebased neuropsychological assessment. J Int Neuropsychol Soc. 2014;20(10):1028-1033. VTC-based neuropsychological testing is a valid and reliable alternative to traditional face-to-face assessment using selected measures. ADHD = attention-deficit/hyperactivity disorder; CATTS = Children s ADHD Telemental Health Treatment Study; TP = telepsychiatry. References (continued) References (continued) Hilty DM, et al. The effectiveness of telemental health: a 2013 review. Telemed J E Health. 2013;19(6):444-454. Telemental health is effective for diagnosis and assessment across many populations (adult, child, geriatric, and ethnic) and for disorders in many settings (emergency, home health) and appears to be comparable to inperson care. Diamond JM, et al. Telepsychiatry assessments of child or adolescent behavior disorders: a review of evidence and issues. Telemed J E Health. 2010;16(6):712-716. The studies tend to find acceptance [of telepsychiatry] and the diagnoses and recommendations are not seen as different from inperson assessments. Rabinowitz T, et al. Benefits of a telepsychiatry consultation service for rural nursing home residents. Telemed J E Health. 2010;16(1):34-40. The telepsychiatry approach was enthusiastically accepted by virtually all residents, family members, and nursing home personnel, and led to successful patient management. Providing psychiatric care to rural nursing home residents by videoconference is cost effective and appears to be a medically acceptable alternative to face-to-face care. Rowe N, et al. Ten-year experience of a private nonprofit telepsychiatry service. Telemed J E Health. 2008;14(10):1078-1086. satisfaction was generally very high, with telemedicine services provided over a period of up to 10 years perceived to be of similar (no worse) quality than inperson services. Hyler SE, et al. Can telepsychiatry replace in-person psychiatric assessments? A review and meta-analysis of comparison studies. CNS Spectr. 2005;10(5):403-413. the current meta-analysis concludes there is no difference in accuracy or satisfaction between the two modalities. 2) Licensure 3) Reimbursement You need to be licensed in the state where your patient resides Guidelines for telemedicine/telepsychiatry practice Varies by state: Check with licensing board Self pay Medicare: special requirements geographic, facility, procedure Medicaid: varies state by state Insurance companies: the big disconnect! In network? Out of network? Expect surprises. Be persistent CPT coding: GT modifier added
4) Professional Liability How much does the hardware cost? Make sure you are covered Get it in writing Don t rely on assurances of self insured Budget: PC (or tablet) based <$1000 Mid-range: dedicated codec ~$2000 to $5000 PTZ camera, remote control, auxiliary microphone eg, Lifesize, Polycom High-end: eg, Tandberg, Cisco, Avaya >$20,000 (better cameras, bigger monitors, better audio, sophisticated custom controls) PTZ = pan, tilt, zoom. How to connect? PTZ Camera Microphone codec Remote Control Hardwired: direct connection T1, multiple ISDN = expensive Internet-based: cable (modem), fiber optic, satellite Inexpensive, but secure? Encryption, HIPAA compliant? Wireless: Wi-Fi Office-based? Home-based? Public? Cell phone-based: 3G, 4G, (5G) The Cloud HIPAA = Health Insurance Portability and Accountability Act; ISDN = integrated services for digital network. Can t I just Skype with my patients? Microsoft/Skype Terms of Service (annotations) www.microsoft.com/en-us/servicesagreement/ Microsoft Privacy Statement: Microsoft collects and shares personal data about your communications with subsidiaries or affiliates eg, time and date, member or usernames partner(s) use data subject to it s own privacy policy Your content: you grant to Microsoft a worldwide license to use (and distribute) Your Content Microsoft/Skype Terms of Service (continued) Microsoft will comply with applicable law or respond to valid legal process, including from law enforcement or other government agencies Updates We may change the terms at any time Contracted entity, choice of law, jurisdiction Warranties: use of the services is at your own risk You bear the entire risk We do not guarantee the services will be uninterrupted, timely, secure or errorfree Limitation of liability: up to $10 if the Services are free.
Microsoft/Skype Terms of Service (continued) HIPAA Compliance? Terms specific for Skype: No access to Emergency Services May place limits on type, duration or volume of calls you are able to make Your use of Skype is for personal and non-commercial use Binding Arbitration and Class Action Waiver Privacy (PHI), Security Business Associates Agreement Conduit? (NEW: Skype for Business ) PHI = protected health information. Zur O. Reviewing the Debate on Skype & HIPAA Compliance and Introducing the Alternative Option. www.zurinstitute.com/skype_telehealth.html. Accessed April 13, 2016. If you want a salaried job doing telepsychiatry from your own office: Companies: Insight Telepsychiatry based in NJ / (Pennsylvania) JSA Health Telepsychiatry based in Texas and Florida, (California) Corizon Health Tennessee, correctional facilities, 27 states VA system Issues: Patient population, licensure, salary, benefits, liability, support, records, scheduling, etc Locum tenens companies If you want to do telepsychiatry from your hospital, clinic, or private office: Companies supplying tech solutions and services: Vsee Secure Telehealth CloudVisit Vidyo SecureVideo LiveTherapy WebEx (Cisco) Zoom 1DocWay Telepsychiatry IO Caveats HIPAA compliance: Business Associates Agreement but check the Terms of Service ( Privacy Statement ) Before you sign up: Hardware, software, compatibility? Costs: per month? Per visit? Free trial period Support: technical, scheduling, billing Professional liability?
New Telepsychiatry Businesses Additional Caveats (analogous to Internet dating) eg, Advanced Telemed, Breakthrough, WeCounsel, E-psychiatry, Iris Telehealth, InnovaTel Patients sign up Clinicians sign up Patients match to clinicians Connect in the Cloud Vetting the clinicians? Vetting the patients? (Vetting the company!) Third-party reimbursement? Again: Check Terms of Service and Privacy Statement Resources and Required Reading American Telemedicine Association (ATA) Practice Guidelines 2009, 2013 Journal of Telemedicine and Telecare American Telemedicine Association Practice Guidelines for Video-Based Online Mental Health Services, May 2013 Real-time videoconference services conducted via the Internet (Not refer to store/forward, e-mail, chat, social networking, online coaching ) ATA. www.americantelemed.org/resources/telemedicine-practice-guidelines/telemedicine-practiceguidelines#.vw6hznovar9. Accessed April 13, 2016. Clinical Issues Managing Emergencies Informed consent? Consultation vs Ongoing therapy Mandatory reporting The Setting: Institution vs Home Clinician availability Prescribing Termination of treatment **Managing emergencies Involuntary hospitalization Patient safety danger to self or others With available on-site professionals Without available on-site professionals The uncooperative patient Transportation Local emergency personnel
Patient Issues Logistics Specific patient population: child/adolescent, geriatric, developmentally disabled Diagnosis: eg, overt psychosis Cognitive functioning Medical/Neurological Structure and timing of services Record keeping Scheduling Technical failures Billing Coordination of care Physical Environment Privacy Seating Lighting Audio Camera placement Control of equipment remote control? PIP? Technical support Medical Issues Medication prescribing Medication side effects Comorbid medical conditions Medical emergencies Lab tests and results PIP = package management system (Pip Installs Packages). Cost Effectiveness Does Telepsychiatry cost more or less than in-person Psychiatry? It depends on: 1) The price of the equipment and the transmission costs 2) Whether the equipment is paid for exclusively by the telepsychiatry program or whether some costs are shared by other programs (eg, other medical specialties, administrative programs) 3) The cost of technical support 4) On how far the treating psychiatrist would have to travel in order to conduct in-person treatment and on the cost of the support staff at the remote end 5) The volume of cases treated 6) The reimbursement rate 7) And last, but not least, it depends upon the observer Telepsychiatry In the eye of the observer The Patient The Insurance Company The Health Care Provider Society
Funding Issues Research Applications Grant Funding of Pilot Studies Decreasing Costs of hardware and telecommunications lines Question of Medicare/Medicaid, Third- Party Insurance reimbursement? eg, Recent NY state legislation Efficient and consistent screening Standardization of assessments across multiple sites A broader population base Telepsychiatry Future Directions Is Telepsychiatry for you? Implications for Clinical Care Necessity vs Luxury Effect of Affordable Care Act A modest suggestion: Try it out on 1 patient in your existing practice Work out the kinks Expand Medical Legal Challenges for Telepsychiatry: Take-Home Points Make sure you are licensed in the state where the patient resides Make sure your malpractice carrier covers Telepsychiatry get it in writing Make sure the system that you use is HIPAA compliant Have a back-up plan if your videoconference connection breaks or is not available Have a plan for dealing with emergencies Caution your patients against using unencrypted connections, eg, public WiFi