Using Telepsychiatry to Deliver Psychiatric Consultations & Treatment as Part of an Integrated Care Model

Report from a Workshop at the 2013 Academy of Psychosomatic Medicine

There are so many applications for telepsychiatry it is often hard to keep up with all of them!

A wonderful workshop was organized by Terry Rabinowitz, MD (Medical Director, Psychiatric Consultation Service Psychiatrist, Fletcher Allen, Clinical Director, Telemedicine, Fletcher Allen and Professor at the University of Vermont College of Medicine) for the 60th Annual Meeting of the Academy of Psychosomatic Medicine (November 13-16 Tucson, AZ http://www.apm.org/ann-mtg/2013/program.shtml).

The faculty were some of the key thought leaders in telemedicine (Drs. Terry Rabinowitz, Elizabeth Krupinski, Nina Antoniotti) and seasoned telemedicine/telemental health providers (Drs. Cornelia Cremens, Felissa Goldstein, Carol Larroque, Megan Olden, Thomas Sheeran, JoAnn Difede; Ms. Nanette Concotelli-Fisk).

Dr. Rabinowitz started out with a brief overview of the program and introductions, then Dr. Antoniotti gave a thorough nuts and bolts talk on “Licensing, Credentialing, HIPPA, Reimbursement, and Insurance, in Telemedicine”.

If anyone was unsure about what it takes to get started in telemedicine this talk provided an A to Z overview of practically everything you need!

A fascinating application was detailed by Dr. Larroque and Ms. Concotelli-Fisk – “A Cyber Support Group for Teens with Cystic Fibrosis”. They pointed out that more often than not there are teens with CF in very rural areas with no one else to talk to about CF and all of the complications it throws at them at such a young age.

Telemedicine to the rescue!

Since 2009 they have been running virtual support groups across 7 sites in NM with 11 adolescents participating since its inception. Surveys reveal that all participants really enjoy the group and it really helps them feel connected to each other, discussing such issues as death, leaving family behind, keeping up with school, and how to tell people they have CF.

The highlight was a very touching video of one of the long-term participants who in part through the group experience found the courage to attend college and hopes to extend her experience to other CF teens wanting to achieve more!

Drs. Difede and Olden provided an overview of their program on “Telepsychiatry in Psychosomatic Medicine: Post-Traumatic Stress Disorder”.

There is a lot of work in this area, but this experience is unique as the patient population consists primarily of police, fire and other first responders involved in the September 10, 2001 attack on the World Trade Centers in NYC.

They have an on-going study involving weekly sessions via Polycom or Skype for 12-14 weeks using a translational prolonged exposure (using D-Cycloserine or placebo) with psychoeducation, in vivo exposure homework, anxiety management, and cognitive restructuring. Key measures such as CAPS score, SCID-Depression ratings, STAXI-2 anger ratings) are improving significantly as a function of the intervention in patients with some very high baseline scores!

Another interesting population being treated via telemedicine was reported on by Dr. Sheeran – “Access to Mental Health Services for Depressed Nursing Home Residents”. These geriatric patients generally suffer from a variety of physical problems and depression often accompanies them, but access to care is often a major problem.

They use a system called “Talk to a Doctor Now” from NalariHealth to provide patient contact as well as professional consultation/supervision. The study has just started but clearly this is another unique application area where telepsychiatry is going to make a huge impact.

In yet another completely different application, Dr. Goldstein talked about “Using Telemedicine to Help Children with Developmental Disabilities” particularly those with autism spectrum disorders. In rural areas children are often diagnosed much later than those in urban areas so they do not receive interventions during key critical developmental years.

With telemedicine they can be diagnosed earlier, treated earlier, and the patient and family can get support and educational they would otherwise not have had. The Marcus Autism Center and GA Partnership for Telehealth collaboration started the program in 2009 and have had over 1700 encounters!

Through this experience they have learned a lot about working with this unique population especially with respect to human factors and running sessions – for example keeping distractions at a minimum and figuring out how to optimize eye contact!

Have you ever thought about trying to do telepsychiatry asynchronously? Many people probably have not, but in some circumstances it may be quite useful. Dr. Hilty provided an overview of their “Use of Telepsychiatry for First Episode Psychosis & Asynchronous Telepsychiatry Initiatives”.

It is especially useful in situations where the patient does not speak the same language as the telepsychiatrist. In this case the local health care provider can record all of the necessary information and even record an interview with the patient, then send the data to the telepsychiatrist with the necessary translation of the session.

The telepsychiatrist asynchronously evaluates the information and provides their advice and recommendations! They have found the process to be 70% reliable and valid – extending the reach of telepsychiatry to even more heights!

Finally, Dr. Krupinski brought the session full cycle by discussing “Human Factors in Behavioral Telehealth”. It was stressed that in setting up a tele-behavioral health program you need to consider more than just the technology – the technology, the user, and the entire support team represent an integrated system that must be assessed and optimized to effectively and efficiently provide services.

It’s not just bandwidth!

A list of some very useful surveys for use in assessing telehealth effectiveness was provided as well as a variety of key standards and guidelines for tele-mental health.

About the Author

Picture of  Elizabeth A. Krupinski, PhD

Elizabeth Krupinski, Ph.D. is a Professor at Emory University in the Department of Radiology & Imaging Sciences and is Vice-chair of Research. She is Associate Director of Evaluation for the Arizona Telemedicine Program and Director of the SWTRC. She has published extensively in these areas, and has presented at conferences nationally and internationally. She is Past Chair of the SPIE Medical Imaging Conference, Past President of the American Telemedicine Association, President of the Medical Image Perception Society, and Past Chair of the Society for Imaging Informatics in Medicine. She serves on a number of editorial boards for both radiology and telemedicine journals and is the Co-Editor of the Journal of Telemedicine & Telecare.