On April 27, 2004 President George W. Bush opined: "(T)here's a lot of talk about productivity gains in our society, and that's because companies and industries have properly used information technology…. And yet the health care industry hasn't touched it, except for certain areas. And one area that has is the Veterans Administration [VA]." In our judgment, the continual advances occurring within the communications and technology fields will ultimately transform health care in an unprecedented fashion. Will our nation's behavioral and mental health care providers, and their training institutions, embrace the challenges and opportunities that are on the horizon?
Winifred Quinn, Director, Advocacy & Consumer Affairs, Center to Champion Nursing in America of the AARP Public Policy Institute: "Older adults with complex care needs want to independently live with dignity and limit stress on family caregivers. Telehealth interventions, such as remote patient monitoring, offer the potential to improve access to care and the quality of care, while reducing strain on family caregivers. For example, the Visiting Nurse Association of Nebraska is providing people with tablets and simple bio-metric devices that allow the consumers to record and transmit their vital signs to a remote team of nurses. This set of tools is also being used to educate people about their own health literacy. The combination of the technology and the remote clinical team is also helping to reduce unnecessary hospitalizations and to control costs – for the consumer and the overall system."
Hawaii Health Systems Corporation, East Hawaii Region: "Hilo Medical Center (HMC), a safety-net hospital on the Big Island of the State of Hawaii, delivers a full range of services and programs to the uninsured, underinsured, and vulnerable populations. To address the growing problem of Behavior Health patients in the Emergency Room awaiting a psychiatric evaluation before final disposition, the hospital initiated a telehealth program in the ER on May 15, 2018. HMC currently has only one psychiatrist who evaluates and admits acute Behavioral Health patients which is inadequate for the population on the island. The telehealth program has successfully evaluated 50+ patients since inception using qualified remote physicians. The technical set up is very minimal using a video cart. The remote physician documents on a separate screen, which the patient is not able to view, and once the document is completed it will electronically file directly into HMC's Electronic Health Record (EHR)" (Chris Takahashi).
Experiences from the Front Lines: The Department of Defense (DOD), with considerable support from the U.S. Congress, has been systematically developing a robust telehealth capacity, especially in the behavioral and mental health arena. This was a high personal priority for Ron Blanck while serving as Commander of the Walter Reed Army Medical Center and continued during his service as the U.S. Army's 39th Surgeon General – a futuristic vision which each of his successors have actively pursued. Ron is currently the Chair of the Board of Regents of the Uniformed Services University (USU) from which two of my psychiatric mental health colleagues recently retired as mental health program chairs.
"My experience with telepsychiatry health began in 2006 while I was Active Duty Army. I established the first policies and procedures for telepsychiatry for the Western Region Medical Command. Our mission was to provide telepsychiatric support and consultation to military installations that either did not have or had limited psychiatric resources. In 2011, I developed the first telepsychiatric capacity in Iraq. This allowed psychiatric providers to reach Service Members at multiple bases throughout Iraq and Kuwait, minimizing travel and risk to both patients and providers.
"Since retiring from the Army, I started a telepsychiatry consulting company and currently provide telepsychiatric services to two rural healthcare systems in Washington State, although I am located in Virginia. I am leveraging a collaborative care model that incorporates primary care providers and social workers into the care process. I provide consultation to primary care providers, psychiatric evaluation and medication management, continuing education to both providers and nursing staff, and inpatient consultation to attending providers and nursing staff. The success of this model has been predicated on incorporating behavioral health into the continuum of primary care. Having access to, and documenting in, the organization's EMR system has been another essential factor in the success of this model.
"Finally, improving access to care for those in underserved areas has been incredibly rewarding. Since starting telepsychiatry services with these facilities 18 months ago, mental health visits to the Emergency Department and Primary Care have significantly reduced and no-show rates are consistently below 10%, well below the national average of 20+% in community mental health.
"Telepsychiatry and more broadly telebehavioral health are here to stay and are invaluable resources to support underserved populations. Medicaid and Medicare now reimburse for services and it is only a matter of time before all payers cover these services. Synchronizing our efforts as behavioral health providers that include comprehensive services is a step in the right direction in improving access to care and a viable solution in beginning to address the mental health crisis in this country" (U.S. Army Lt. Col. (Ret.) Jess Calohan).
And from my other DNP colleague: "I have just recently started to use telehealth services with patients down here in South Eastern North Carolina (e.g., Blue Cross/Blue Shield, Medicare, and Tricare). I am currently in the first phase of use with select patients who are stable in care and/or have difficulty commuting to the practice (e.g., elderly, physically impaired, psychologically avoidant or frequent travelers).
"Best Practice Strategies: 1. My vision for practice requires that I physically see the patient (at least) quarterly and we can employ the telehealth option in between physical appointments. 2. Have the patient bring technology (e.g., laptop or tablet) to our session to ensure it works before going live in future sessions. 3. Use a reputable video conferencing software package (e.g., Cisco's WebEx) which incorporates administrative and technical safeguards that meet HIPAA requirements. 4. Specify in my clinical documentation that the session is a telehealth encounter for insurance purposes. 5. Establish an alternate medium (commonly telephone) as a failsafe option in the event technology breaks down on either end of the connection. 6. Be mindful of a crisis intervention plan in the event you encounter an imminent safety issue during the telehealth encounter. 7. Obtain formal training (e.g., https://telehealth.org/telebehavioral-health-certificate/) to learn legal and practical nuances associated with telehealth. 8. Not all pharmacies support electronic submission of Schedule 2 medications (e.g., psychoactive stimulants and benzodiazepines) so it is important to work that problem before starting the telehealth option because without a solution the patient will have to come into the practice anyway to pick up a physical script. The irony in my area is that the only pharmacy that does not accept an e-script for schedule 2 medications is Naval Medical Center Camp Lejeune. 9. If the mental health provider takes the time to structure up the process and provide real time oversight, the administrative and education based aspects of telehealth implementation can be championed by a medical assistant. Finally, 10. We also have a patient portal (patient to provider secure email) that provides additional structure and support to the telehealth option. I no longer allow patients to call the front desk of the practice for questions. They are all directed to the patient portal. This way I can 'cut and paste' the patient's concerns directly into the EMR.
"General Observations: 1. Millennials tend to adapt to the medium quicker than older generations. 2. Geriatric patients tend to be more easily frustrated with the telehealth option and require more than one education session to adapt to the medium. 3. Telehealth is markedly easier (not impossible) to navigate for traditional medication management as compared to psychotherapy. 4. While initial evaluations are commonly done via the telehealth option all across the country, I have not done this yet. While I appreciate that it is the 'least worst option' when you think about providing the service to geographically isolated patients, I personally think something is lost in translation when you conduct an evaluation via telehealth when it comes to rapport development and diagnostic fidelity. 5. There are certain populations who generally don't respond well to the telehealth option. In my experience people with poorly managed paranoia, delusions, hallucinations, substance use disorder, and cognitive impairment don't take to it well. For these patients telehealth can be an option once you achieve some degree of crude target symptom stabilization. 6. Getting fellow mental health providers on the (telehealth) train has been a challenge. I commonly find that healthcare providers are more resistant to the telehealth option than the actual patient. Telehealth is a strategic solution to several national problems that exist within our current healthcare delivery system. Either we are on the train or under it. Academia is already moving toward distance education. The healthcare delivery system needs to follow that lead. 7. There is a lot of misinformation out there as it relates to the 'rules of the road' for safe – effective – legal telehealth. I would recommend that before a practice embarks on this journey that they consult a specialist that understands the technologies, legalities, and established standards of care" (U.S. Navy Commander (Ret.) Sean Convoy).
An Educated View: During his nearly 15 year tenure directing the APA Ethics Office, Steve Behnke saw the ethics of telehealth evolve. "Telehealth gives us a wonderful example of ethics from a developmental perspective, with the VA and DOD leading the way. Reflecting upon my work with colleagues in both agencies, I consistently found that these folk were – and remain – on the cutting edge of the technology. Competence is the cornerstone of ethics and these colleagues have the competence both in the technological aspects of delivering telehealth interventions and in the clinical understanding of which populations may benefit most from these services. I am pleased that the APA Ethics Office partnered with the Association of State and Provincial Psychology Boards (ASPPB) to enhance competent and ethical practice in all areas of psychology, including telehealth. VA and DOD psychologists have an advantage because their unique circumstances allow them to deal with jurisdictional challenges that may be obstacles for other psychologists, but ASPPB has been working diligently to allow greater flexibility in crossing jurisdictional lines. I am personally excited about the future of telehealth and look forward to a day when financial resources, physical distance, and other impediments to meeting with a mental health professional are diminished or non-existent factors in receiving services."
Reflections: Over the past several years, we have been extraordinarily impressed by the pioneering efforts of Marlene Maheu and her colleague Ken Drude to utilize the APA annual convention platform in their efforts to educate psychology as to the nuances of telehealth. We expect that they will continue to do so and accordingly, we would urge those interested in the future to participate in their ongoing continuing education workshops. (Associate Justice Ruth B. Ginsburg, 2009). Aloha. Pat DeLeon, former APA President – Division 42 – July, 2018
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