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The doctor will Skype you now: Online counseling goes high tech

Peter Jaret , special to AAMCNews
November 18, 2019

Telepsychiatry visits have increased access to mental health care, particularly in rural areas. Now, medical schools and teaching hospitals are including instruction in the nuances of conducting effective online visits.

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After several sessions with a patient in rural southwest Virginia who suffered from severe depression and anxiety, psychiatrist Larry Merkel, MD, was confident the patient was making progress. But it wasn’t until she gathered her kids in front of the camera to meet him that he understood how much their sessions meant to her. “She wanted them to meet the doctor she sees on TV,” says Merkel, associate professor of psychiatric medicine at the University of Virginia School of Medicine.

Merkel has never met his patient in person. His only contact is via a secure video link that allows them to talk and see each other on screens. The practice, called telepsychiatry, is part of the broader field of telemedicine — and one of its fastest growing applications.  

Advocates say psychiatric care delivered via video is an ideal way to expand access to mental health care, especially to populations in remote rural areas. Indeed, telepsychiatry visits have increased exponentially in the last few years. In a study published in 2017 in the journal Health Affairs, researchers analyzed Medicare fee-for-service claims among rural beneficiaries and found that the number of telemental health visits grew by more than 45% annually between 2004 and 2014. By 2014, there were almost 12 telepsychiatric visits per 100 rural beneficiaries with serious mental illness.

Other studies show that telepsychiatry has quickly outpaced other forms of telemedicine. Analyzing data from a large population of commercially insured patients, researchers found that more than half of all telemedicine visits (53%) were for mental health conditions. According to the findings, published in JAMA Network in 2018, telepsychiatry visits grew by 56% annually between 2005 and 2017.

“The technology is now so good that there’s really no difference between seeing a patient in person or on a video hook-up. You feel just as connected to a patient … the sense of empathy is just as strong. And some patients actually feel more comfortable interacting through telepsychiatry.”

Larry Merkel, MD, University of Virginia School of Medicine

Telepsychiatry does have some challenges. Doctors still have to be licensed in the state where patients reside. And not all public or private insurers pay for telepsychiatry visits. But as more payers reimburse for services, academic medical centers are expanding their telepsychiatry offerings, noting that video visits may offer distinct benefits over traditional in-person visits for some patients.

“The technology is now so good that there’s really no difference between seeing a patient in person or on a video hook-up,” says Merkel. “You feel just as connected to a patient. It’s true, you can’t shake hands. But the sense of empathy is just as strong. And some patients actually feel more comfortable interacting through telepsychiatry.”

From prisons to emergency rooms

Telepsychiatry is used most widely in states that have large rural populations, surveys show — Montana, North Dakota, Kentucky, and West Virginia among them.

“Here in Kentucky, which has really been a pioneer in this area, we’re helping patients we would otherwise simply not be able to reach,” says Robert L. Caudill, MD, director of the psychiatry resident training program and the telemedicine and information technology programs at the University of Louisville School of Medicine.

Jonathan P. Betlinski, MD, associate professor and director of telepsychiatry at Oregon Health & Science University School of Medicine, treats incarcerated patients via telepsychiatry, saving the time it would take to drive to a prison and go through the time-consuming security procedures.

Jay Shore, MD, director of telemedicine at the Helen and Arthur E. Johnson Depression Center at the University of Colorado (UC) Anschutz Medical Campus, sees native Alaskan patients via video links.

And the University of Rochester School of Medicine and Dentistry’s telepsychiatry program focuses on both rural patients and geriatric patients in skilled nursing homes. “With telepsychiatry, we can eliminate the need to transport older patients from a facility and in some cases even deliver care to people in their own homes,” says Michael J. Hasselberg, PhD, associate professor of psychiatry and director of the telepsychiatry program.

Video consultations are also increasingly being used in emergency medicine. “Most emergency departments are challenged to deal with psychiatric emergencies,” explains Shore, who is also professor of psychiatry at UC Denver and has helped the American Psychiatric Association develop practice guidelines and a toolkit for telepsychiatry. “Using telemedicine, emergency doctors can consult with psychiatrists who may have more experience diagnosing mental illness and prescribing psychiatric medications.”

Evidence-based benefits

The rise of telepsychiatry has been driven partly by technological advances that have improved reliability, security, and video image quality. But the practice is also supported by a growing evidence base that shows that video consultations can be just as effective as in-person visits.

In results published in the Canadian Journal of Rural Medicine in 2019, for example, researchers at the University of Ottawa surveyed 110 patients and 10 practitioners who had taken part in telepsychiatric care. Most patients said that, compared to an in-person appointment, telepsychiatry sessions were easier to attend, saved time, and allowed them to get mental health care sooner. All 10 providers reported being satisfied with telepsychiatry and agreed that they would use it again.

Indeed, in some cases, experts say, video consultations may be more effective than in-person sessions. “People with a history of trauma may be more comfortable with telepsychiatry, because they have a stronger sense of safety and control in a video session,” says Shore.  Children and teenagers — who have grown up with FaceTime, Skype, and other online platforms — are also often more comfortable interacting with a psychiatrist via video, according to Caudill.

“People with a history of trauma may be more comfortable with telepsychiatry, because they have a stronger sense of safety and control in a video session.”

Jay Shore, MD, University of Colorado Anschutz Medical Campus

Even elderly patients sometimes prefer telepsychiatric visits. “We often hear from patients that they feel more open, more willing to share, in a video consultation,” says Hasselberg.

Another advantage: telepsychiatry can remove any perceived stigma associated with going in for mental health care.  Rural patients, for example, are typically seen via telepsychiatry at primary care health clinics. “These patients don’t have to go to a psychiatrist’s office,” says Shore. “Telepsychiatry makes it possible to have a mental health professional embedded on a primary care team, as part of integrated care.”

Teaching the nuances of a new technology

As the use of video visits grows, more medical schools and residency programs are including instruction in telepsychiatry in their curricula. “Telemedicine is a central part of the culture here,” says Hasselberg of Rochester’s program. First- and second-year medical students rotate through and observe physicians and nurse practitioners conducting telepsychiatric consultations. Starting in their third year, medical students conduct their own telepsychiatry visits with geriatric patients in the community.

The fundamentals of psychiatric care remain the same whether a patient is seen in person or via video, experts say. But there are subtle differences and nuances in consulting that medical students and residents must master.

“If I’m seeing a patient here in Denver, I know that we’ve just had a big storm, or that something’s happened in the local news, so it’s easier to find ways to connect personally with a patient,” says Shore. “I also see patients remotely in Alaska. I know less about their environment, so I have to make a little more effort to connect with them and stay informed about what is going on in their community, to open up a broader range of conversation.”

Eye contact is another issue, says Caudill. “How eye contact is made or not made is a critical consideration in psychiatry, and there are special skills that you need to master conducting a video consultation. As anyone who’s used Skype knows, if you look at the person on the screen, you’re not looking into the camera, so you’re not really making eye contact. So we teach our students to look directly at the camera while they’re talking to a patient, and to look at the patient when he or she is talking.”  Video technologies allow psychiatrists to zoom in to look more closely at a patient or move the camera to see their surroundings.

Hurdles remain to the wider use of telepsychiatry

Most experts expect the use of telepsychiatry to continue to expand. Medicare recently announced that it will reimburse telemedicine visits at the same rate as in-person visits. And a growing number of states pay for telemedicine through their Medicaid programs. State regulations vary widely, however, according to the Center for Connected Health Policy’s latest nationwide survey. Some allow video visits with patients in their own homes, for example; others don’t.

And while telemedicine by its very nature breaks down geographic boundaries, federal law still requires that doctors be licensed in the state in which the patients they treat reside, a policy that limits the reach of telepsychiatry, since getting licensed and maintaining a license in additional states is costly and time-consuming.

Federal regulations also require doctors to conduct an in-person examination of a patient before prescribing controlled substances, placing constraints on teleprescribing. And while some malpractice policies cover telemedicine, others require additional coverage.

To help practitioners navigate the varied and changing landscape of law and regulations, the American Psychiatric Association has created an online toolkit with updated information.

“Health care will increasingly become digitally driven. We’ll engage with patients through apps on their smartphones. We’ll be able to deliver cognitive behavioral therapy, even prescribe, via apps. The fact is, telepsychiatry is really just the beginning.”

 Michael J. Hasselberg, PhD,  University of Rochester School of Medicine and Dentistry

Offering telepsychiatry also requires an investment in technology, typically on both ends of the encounter — for the psychiatrist conducting the session and the facility where the patient tunes in, often a local health care clinic. Some health care systems have been reticent to make the investment, especially where reimbursement for telepsychiatry has been uncertain. That’s changing, however, as increasingly more payers cover remote visits and as the cost for video connections decreases.

There will always be special considerations that must be addressed when a psychiatrist consults with a patient remotely. While a psychiatrist practicing on-site has ready access to support in case a patient experiences an emergency during a session, for example, providers working remotely have to be prepared to contact resources where the patient resides. “You have to know in advance what resources are available in the community, and how to contact them,” explains Betlinski. That’s especially challenging if patients are being seen via video in their own homes, rather than in local health care facilities.

But perhaps the biggest constraint on expanding the impact of telepsychiatry is the number of providers. Video technology has dramatically expanded access, but the need for mental health care still far exceeds the number of psychiatrists who can provide it. “We’re always being asked to expand our telemedicine program,” says Hasselberg. “What we need are more providers.”

Still, experts say technological advances continue to offer new ways to care for patients in need. “Health care will increasingly become digitally driven,” says Hasselberg. “We’ll engage with patients through apps on their smartphones. We’ll be able to deliver cognitive behavioral therapy, even prescribe, via apps. The fact is, telepsychiatry is really just the beginning.”

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