Telepsychiatry Applications in Rural Psychiatry: The Psychiatrist Experience Shabana Khan, MD Assistant Professor of Psychiatry University of Pittsburgh School of Medicine Medical Director WPIC Telepsychiatry Challenges and Innovations in Rural Psychiatry June 22, 2016
Disclosures Shabana Khan, MD I have no relevant financial disclosures.
Outline • Definitions • Why we need telepsychiatry • Services to rural areas • Obstacles • Evidence Base • Overview of WPIC Telepsychiatry Program (Dr. Jack Cahalane) • Questions and discussion
Definitions What is Telepsychiatry?
Telemedicine Others Telemental Health Teleradiology Telepsychiatry Teledermatology
What is Telemedicine? • Use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status • Includes a growing variety of applications and services using two-way video, email, smart phones, wireless tools, and other forms of telecommunications technology American Telemedicine Association
Why do we need Telepsychiatry? • • National shortage of Lost time and money psychiatrists when traveling for care • • Difficulty recruiting to Opportunities for case rural areas consultation • • Limited services in Enhance existing underserved areas services and collaboration
History of Telemental Health
York Retreat 1800s
Modern Era of Telemental Health 1960s
1970s and 1980s
1990s
2000 s
Scope of Services • Diagnostic Scheduled and evaluations urgent outpatient • Therapeutic visits modalities Medication • Forensic modalities management • Pre-hospitalization Consultation assessment Research • Post-hospital follow- Staff Training up care CME • Case management Disaster Planning • Psychotherapy
Synchronous versus Asynchronous MGH TeleHealth Center
Rural Psychiatry Challenges • Greater illness burden • Fewer resources • Limited access to care • Different systems of care • Cultural differences • Firearms • Suicide rates
Potential Barriers to Adoption of Telemental Health
Potential Barriers for Providers • Licensing and Credentialing • Privacy and Confidentiality • Reimbursement • Malpractice • Disruption of Clinical Workflow • Physician Resistance to Technology
Physician Resistance to Technology
Physician Resistance to Technology
Therapeutic Alliance and Establishing Rapport • Significant evidence that patients quickly adapt and establish rapport with TMH provider • Must adapt existing rapport building techniques to this modality • Gaze angle, bandwidth, resolution
Evidence Base in Telemental Health
Patient Satisfaction in Telemental Health • • Satisfaction and Acceptance Risk of overemphasizing are most consistently patient satisfaction as being reported outcomes same as clinical effectiveness • • Less time off from work, less Would satisfaction still be travel time, shorter wait time high if other services were for services available locally? • Satisfaction – simple variable • Strong evidence for high to measure patient and moderate-high provider satisfaction Richardson et al. 2009
Patient Perceptions of Telemental Health Jenkins-Guarnieri et al. (2015) • Systematic review of 14 studies examining measures of patient satisfaction and therapeutic alliance • Studies with direct comparisons of VTC or phone-based psychotherapeutic TMH treatments with in-person • Comparable treatment satisfaction and similar ratings of therapeutic alliance
Evidence • Majority of TMH conducted in outpatient settings • School-based programs increasing • Limited evidence-based outcome data for geriatric patients in nursing home settings • Literature on VTC diagnostic assessments demonstrates their acceptance, utility, and accuracy in clinical practice ATA Evidence-Based Practice for TMH (2011)
Telemental Health Evidence Base • Ruskin et al. (2004) – RCT showed comparable outcomes for depressed veterans treated via telepsychiatry vs. in-person (Hamilton Depression Rating Scale and Beck Depression Inventory scores improved over time); equally adherent to appointments and medication treatment • Hyler et al. (2005) – meta-analysis of 14 studies with 500 patients; no difference in accuracy or satisfaction
Telemental Health Evidence Base • Fortney et al. (2007) – RCT telemedicine-based collaborative care model 395 patients; superior treatment adherence and outcomes and higher satisfaction in telemedicine group vs. treatment as usual • Morland et al. (2010) – RCT of 125 veterans with PTSD and anger difficulties; group CBT with therapist in- person or via videoconferencing; both groups showed significant reductions in anger symptoms; no between group differences in attrition, adherence, or satisfaction
Telemental Health Evidence Base • Rabinowitz et al. (2010) – 278 telepsychiatry consultation encounters for 106 residents of rural nursing homes; reduced fuel costs, physician travel time, personnel costs • Godleski et al. (2012) - clinical outcomes of 98,609 mental health patients before and after enrollment in telemental health services at the VA from 2006-2010; patients’ hospitalizations decreased by about 25%
Pediatric Telemental Health Evidence Base • Elford et al. (2000) – 23 children age 4-16, two psychiatric assessments, in-person and via TMH; diagnoses made via TMH reliable; satisfaction high • Nelson et al. (2003) – 28 children with MDD randomized to 8 CBT sessions of TMH vs. TAU; equals in-person in reducing depression over 8 weeks and satisfaction high • Yellowlees et al. (2008) – 41 children showed improvements in Child Behavior Checklist ratings 3 months post single consultation with child psychiatrist over VTC (referred by PCP)
Pediatric Telemental Health Evidence Base • Xie et al. (2013) – 22 parents of children age 6-14 received group parent management training in-person of via videoconferencing at same clinic with comparable outcomes • Reese et al. (2013) – 21 children with ASD or developmental delay; no difference in ADOS observations and ratings for ADI-R parent report • Meyers et al. (2015) – CATTS RCT 223 children referred by 88 PCPs; both groups improved but TMH group had greater improvement for diagnostic criteria for inattention, hyperactivity, combined ADHD, ODD on caregiver and teacher scales
Take-Home Points • Telepsychiatry is a feasible, acceptable, effective, and efficient model of health service delivery • Literature supports ability to develop a therapeutic alliance via videoteleconferencing • Strong evidence for high patient satisfaction and moderate- high provider satisfaction • Telemedicine is becoming a core component of routine clinical care and residents and fellows benefit from training
Resources • American Telemedicine Association -www.americantelemed.org -ATA 50 State Telemedicine Gap Analysis • American Psychiatric Association Telepsychiatry Toolkit • AACAP Practice Parameter for Telepsychiatry • ATA Practice Guidelines for Video-Based Online Mental Health Services (May 2013) • Center for Connected Health Policy -cchpca.org • University of Colorado’s Telemental Health Guide -www.tmhguide.org
Special Thanks To: • Jack Cahalane, PhD, MPH • Joseph Pierri, MS, MD • Manish Sapra, MD, MMM • Kate Dempsey • Ken Nash, MD, MMM • Residents and Fellows (Drs. Borue, Joseph, and Schreiber) • Shabana Khan, MD WPIC Telepsychiatrists and Clinical Sites khans@upmc.edu
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