Telemental Health

416 Pages·2013·5.076 MB·English

1
Introduction1
Carolyn L. Turveya,b,(cid:1) and Kathleen Myersc
aDepartmentofPsychiatry,UniversityofIowaCarverCollegeofMedicine,
IowaCity,IA,bComprehensiveAccessandDeliveryResearchand
Evaluation(CADRE)Center,IowaCityVAHealthcareSystem,IowaCity,IA,
cDepartmentofPsychiatryandBehavioralSciences,Universityof
WashingtonSchoolofMedicine,TelementalHealthService,Seattle
Children’sHospital,Seattle,WA
Introduction
The Telemental Health Imperative
Telemental health (TMH) has the potential to deliver needed care to millions of
peoplestrugglingwithmentaldisorders. Achild sufferingfromautismwholivesin
a rural community of 500 can receive a teleconsultation at the local primary school
and benefit from timely expert diagnosis and treatment. Timely diagnosis can help
the child to remain in school and optimize both learning and socialization. An
elderly woman in a nursing home, who was secluded because of disruptive beha-
viors, receives a videoconsultation and treatment recommendations from a psychia-
trist located over 200 miles away. She is now able to control her temper, her mood
is bright, and she interacts positively with other residents and staff. In response to
Hurricane Katrina and the devastating earthquake in Haiti, the international com-
munity is coming together to develop strategies to provide mental health care even
inconditionsinwhichthetechnicalinfrastructureisdevastated.
These success stories bring human faces to the statistics regarding mental health
needs across the world and particularly for the disadvantaged. A study conducted
by the World Health Organization ranked mental illness as a leading cause of
disability in the United States, Canada, and Western Europe, more disabling than
heart disease and cancer (Demyttenaere et al., 2004; World Health Organization,
2001). Mental illness accounts for 25% of all disability across major industrialized
countries and the direct cost to the US economy is $79 billion annually
1Theviewsexpressedinthischapterarethoseoftheauthorsanddonotnecessarilyreflecttheposition
orpolicyoftheDepartmentofVeteransAffairsortheUSgovernment.
(cid:1)Corresponding author: Carolyn L. Turvey, Department of Psychiatry, University of Iowa Carver
CollegeofMedicine,IowaCity,IA52242.Tel.:[phone],Fax:[phone], E-mail:
[email protected]
TelementalHealth.DOI:http://dx.doi.org/10.1016/B978-0-12-416048-4.00001-4
©2013ElsevierInc.Allrightsreserved.
4 TelementalHealth
(United States Public Health Service Office of the Surgeon General, 1999).
Suicide, a tragic outcome closely tied to inadequately treated mental illness, is
responsible for more deaths worldwide than homicide or war (Demyttenaere et al.,
2004; World Health Organization, 2001). Nonetheless, the World Health
Organization found that even in developed countries, 35(cid:3)55% of people suffering
serious mental illness did not receive care in the past 12 months (Demyttenaere
et al., 2004). Many who do receive treatment receive inadequate care that does not
comply with professional guidelines or evidence-based practice (Kessler, Berglund
et al., 2001; Kessler, Demler et al., 2005). Unfortunately, the underserved are often
children, the elderly, or disabled who must overcome considerable additional bar-
rierstoreceiveadequatementalhealthtreatment.
Though there are many different barriers to mental health care, the most signifi-
cant includes the shortage of mental health practitioners, poor access to specialty
care, and financial barriers to care. TMH offers a way around each of these bar-
riers. For example, currentlythere is a nationwide shortage of child psychiatrists. It
is estimated that current practitioners can meet only 10(cid:3)45% of the need in child
mental health care (Thomas & Holzer, 2006). Most of this shortage occurs in rural
communities. Programs like Connected Kansas Kids, a state-funded initiative,
address this need by providing mental health services at rural primary schools
through mental health providers located at the University of Kansas (Nelson,
Barnard,&Cain,2003).Thiscollaborationallowschildrentoreceivementalhealth
assessment and interventions in the naturalistic setting of their school and the men-
tal health providers do not have to travel long distances at considerable disadvan-
tagetotheirotherclinical responsibilitiesandfamilies.Bothsitesmaybenefitfrom
lowerfinancialcostsassociatedwithvideoconferencing.
Current Trends Supporting the Broader Adoption of Telemental Health
TheviewthatTMHcanaddressmanyofthecurrentwoesfacingtheprovisionofmen-
tal health care is not new. TMH, the most commonly utilized aspect of telemedicine,
has been practiced in some form or another since 1957 (Lewis, Martin, Over, &
Tucker, 1957). Since this initial use, successive cohorts of clinicians and researchers
have touted the benefits of TMH and predicted its certain widespread adoption.
ThoughTMHhascontinuedtogrowslowlybutsteadilyovertheyears,itremainsout-
side the realm of mainstream clinical care. This pattern of expansive optimism about
potential coupled with slow and, at times, disappointing adoption has drawn cynical
comment that TMH has been “just around the corner for about 50 years.” Thus con-
fronted,wearefacedwiththechallengeofarguingthatthecurrentwaveofenthusiasm
issomehowdifferentfromthatofpriorcohortsandthatweare,infact,onthebrinkof
anexcitingwidespreadexpansionoftheuseofTMHintomainstreamhealthcare.
There are five critical developments in health care that just might make current
conditionstrulyconducive tothe broader adoption of TMH: (1) agrowingshortage
of mental health providers particularly for special populations such as children or
the elderly; (2) advances in the quality and availability of desktop videoconferenc-
ing technologies; (3) improved reimbursement from Medicare combined with
Introduction 5
mandates in some states for private insurers to reimburse telemedicine equal to
same-room care; (4) an increasingly large and sophisticated evidence base includ-
ing randomized controlled trials demonstrating the effectiveness of TMH in the
treatment of mental disorders; and finally (5) national-level mandates for health
care reform. Throughout the chapters in this book, these issues are discussed with
the aim of educating the reader about best practices in TMH and the research evi-
dencesupportingthesepractices.
The first critical development in health care that is influencing the adoption of
TMH is a growing shortage of mental health providers. Chapter 2 provides data
from the fields of both psychiatry and psychology to support the need for innova-
tive solutions to the workforce shortage in mental health care. Using data from
organizations that monitor supply and demand of professional services, this chapter
demonstrates both the current and anticipated severe shortage of mental health pro-
fessionals.ItalsodiscusseshowTMHcanaddressmany,butnotall,aspectsofthis
crisis.
The shortage of mental health resources in socioeconomically disadvantaged
areassuchasinner-citiesandcorrectionalfacilitiesislessrecognized.Videoconfer-
encingnowallowshospital-basedspecialiststoprovideconsultationstourbannurs-
ing homes, prisons, primary care offices, schools, and even day care centers that
have difficulty obtaining needed on-site care. TMH allows for the sharing of this
scarce valuable resource across geographic and socioeconomic boundaries. In par-
ticular, TMHhasbeen used successfullytoprovide neededservicestochildren,the
elderly, rural veterans, and correctional populations and holds promise for reaching
the larger population that relies on primary care for their mental health treatment
(see Section IV). Cultural and community aspects of care are a crucial component
of developing services for these populations. TMH allows patients to be treated
within theirowncommunities,whetherinnercityorruralreservation,accompanied
by their families and other supports, if desired. Several chapters provide insights
and advice gleaned from clinical practice on how the cultural context must be con-
sidered in TMH, particularly when making decisions about how to use TMH tech-
nologytoprovideculturallycompetentcare(inparticularseeChapter4).
The second of the critical developments listed above, advances in the quality
and availability of desktop and internet videoconferencing solutions, has greatly
increased the feasibility of conducting TMH in multiple, diverse settings. These
technological options and their relevance for practice are covered in Section III.
The advent of videoconferencing technology that can be conducted on desktop
computers and the use of secure Internet transmission of videoconferencing data
obviates the need for a separate space dedicated to videoconferencing and large,
high-definition and costly units. A desktop, computer-based, system allows the
clinicians to alternate between usual same-room and TMH care within the standard
workflow of clinical practice. In addition, the widespread increase in the recrea-
tional use of desktop videoconferencing, such as SKYPE and Google Talk, has
familiarizedclinicianswithvideoconferencingwhichmayreducetheirresistanceto
usingTMH.Theeaseofdesktopvideoconferencinghasalsopromotedtheadoption
of TMH from private practitioners’ offices, or even their homes—which allows a
6 TelementalHealth
unique option when balancing the demands of family and career. This is one of the
first developments in TMH that has improved access and opportunities for the pro-
vider, rather than the patient. As provider acceptance is necessary for widespread
adoption,thisisnosmallbenefit.
The relevance of these newer desktop videoconferencing systems, of course, is
their ability to provide care comparable to that provided through traditional, more
expensive, high-definition systems—and to same-room care. In Section II, clinical
technique, therapeutic alliance, and efficient workflow are addressed to help poten-
tial TMH providers glean the relevant issues in selecting equipment. This section
also addresses the ethical, privacy, and regulatory requirements of clinical practice
thatmustbeconsideredinchoosingtechnologyandestablishingapractice.
The third critical area influencing the adoption of TMH is reimbursement.
Medicare reimbursement for TMH has made great strides since the year 2000 and
now includes coverage for psychiatric diagnostic interviews, pharmacologic
management, and individual psychotherapy (Centers for Medicare and Medicaid
Services, 2009). Further, reimbursement is the same as the current fee schedule
for same-room care, and the facility where the patient is treated can also submit
a “facility fee” (approximately $30(cid:3)35 per visit). As Medicare guidelines
in these areas are dynamic and influence regulations by private payers, potential
TMH providers should consult the web site for the Centers for Medicare
and Medicaid for further and up-to-date information (www.cms.gov/Manuals/
downloads/bp102c15.pdf).
As of 2011, 39 states have some form of reimbursement for telemedicine within
their Medicaid population (Center for Telehealth and eHealth Law, 2011). In addi-
tion, state governments faced with large mental health provider shortages and
geographic access issues are now passing legislation requiring private insurers
within their states to reimburse for telemedicine, including TMH (American
Psychological Association Practice Central, 2012). Reimbursement by private
insurers opens many opportunities for private practitioners who typically are not
eligible for Medicare or Medicaid payments. Further information can be obtained
athttp://www.apapracticecentral.org/update/2011/03-31/reimbursement.aspx.
Issues related to the fourth critical development, the establishment of an evi-
dence base, is addressed in Chapter 19 (see Section VI). This candid look at the
strengths and weaknesses of the current research allows potential providers to
assess the quality of psychiatric assessment, psychiatric follow-up, and psychother-
apy provided through TMH. In the past 10 years, well-designed randomized con-
trolled trials have not only demonstrated that TMH is comparable to same-room
care, it has also demonstrated that TMH is effective in treating mental illness.
However, the importance of an evidence base underlies all of the chapters in this
text, particularly the chapters addressing the treatment of special populations (see
SectionIV)andthoseaddressingspecificinterventions(seeSectionV).
Finally, the fifth critical development, a national mandate for health reform, is
evidenced by the active debate within the United States on the need for and nature
of health care reform. On March 23, 2010, President Obama signed the Affordable
Care Act enacting comprehensive health insurance reforms to expand the provision
Introduction 7
of health care to uninsured and underinsured Americans. At the time that this book
goes to press, the constitutionality of this act will be determined by the US
Supreme Court making some skeptical about whether the reform will actually
occur. The decision of the Supreme Court is unknown, as is its impact. However,
the open national debate has led to widespread acknowledgment that health care
reform, in some version, is imperative given the inequities and spiraling costs of
health care in the United States. In April 2012, the Centers for Medicare and
Medicaid Services issued a report stating that the Affordable Care Act will save
over $200 billion for taxpayers through 2016 (Centers for Medicare and Medicaid
Services, 2012). This suggests that even if the Affordable Care Act is struck down,
the imperative for health care reform lies within the larger federal structures
responsible for providing health care for millions of Americans and is not tied
solelytoasinglepresidentialadministration.
Organization of This Book
This book was inspired by the converging evidence that the time for TMH has
come. The book seeks to stimulate conversation and action among health providers
and those interested in health innovation. Though innovations in TMH span video-
conferencing, online therapy, eHealth, mobile technology, and health information
technology,thisbook,withsomeexceptions,isprimarilyconcernedwiththeprovi-
sion of mental health care through real-time videoconferencing. This platform is
most consistent with current approaches to mental health care, has the strongest
evidence base supporting its feasibility, acceptability, and effectiveness, and is
increasingly being accepted and reimbursed by both public and private payers.
Other exciting platforms for providing TMH care have the potential to augment
videoconferencing as well as to eventually stand on their own as service delivery
models.Hopefully,theirapplicationswillsoonbeexploredinothertexts.
Eachchapterpresentsnewapproachesforunderstandingandsolvingthedispari-
ties in mental health care by providing hands-on guidance on how to start and
maintain a TMH practice including clinical, administrative, ethical, and financial
guidance.Theevidencebaseforthisguidanceisprovidedthroughoutthebook.
The aims for this text are ambitious and comprehensive. There are six sections.
Section I provides the context for the remaining sections by describing major
demographic and professional changes that underlie the problem TMH seeks to
remedy that of poor access to mental health services. Though Chapter 2 focuses on
the declining psychiatry workforce, data on the declining psychology workforce
andurban/ruraldifferencesinaccesstoanyformofmentalhealthcarearealsodis-
cussed. The other sections describe potential solutions to this problem. Section II
providesguidanceonhowtoconductclinicalsessionsthroughTMHwhileoptimiz-
ingethicalandculturallycompetentcareandminimizingrisk.Cliniciansandinves-
tigators with many years of experience in the use of videoconferencing to provide
TMHservicesofferinsightsandadvicetooptimizeTMHpractice.
Section III follows with some “nuts-and-bolts” discussion of both the business
and technical infrastructure needed to provide TMH. These chapters include
8 TelementalHealth
discussions of the newer business models that are emerging in TMH care.
Together, Sections II and III provide a tutorial on how to develop a TMH practice
thatmeetsalloftheclinical andregulatoryrequirementsfoundinsame-roomcare.
TMH has arisen in response to provider shortages, most often in populations
faced with multiple barriers to care, and TMH has the goal of redistributing the
provider workforce. Section IV describes the research supporting TMH and offers
guidelines for clinical practice with special populations. Children, the elderly,
incarcerated, and geographically remote patients all suffer poor access to care so it
is not surprising that the early development of TMH has focused on these popula-
tions. Section V complements Section IV with discussions of assessment and treat-
mentprovidedthroughTMH.
Section VI focuses on future applications of TMH. There is growing excitement
about the potential of TMH to address much needed mental health care in disaster
relief. Chapter 17 discusses the challenges of such care as well as the cause for
growingoptimism. Italsosetstheagendaforwhatneedstobeaccomplishedsothe
potential of TMH in this context can be realized. Like disaster relief, the potential
of social networking in TMH care is just starting to be realized. Chapter 18 dis-
cusses the few case studies of how videoconferencing has entered the sphere of
mental health care. The chapter also provides hands-on guidance for clinicians to
consider before “friending” their professional relationships. As already stated, the
aim of this text is to provide the evidence base for the topic addressed in each
chapter. Therefore, Chapter 19 serves as an editorial review of the strengths and
weaknesses of the current evidence base and indicates directions for future work. It
also addresses the newer developments in TMH such as mobile applications and
eHealth.
Telemedicine has been “just around the corner” for decades. How do we know
that its time has truly come? The chapters in this book illustrate again and again
that the convergence of unmet mental health need, technologic advances, changes
in health care structure, a growing evidence base and clinical practice history make
the time now. This book aims to facilitate the process by convincing readers inter-
ested in health innovation that a powerful solution is at our fingertips, and con-
certedeffortstopromoteTMHwillbenefitall.
References
American Psychological Association Practice Central (2012). Reimbursement for telehealth
services. Legal and Regulatory Affairs Staff. ,http://www.apapracticecentral.org/
update/2011/03-31/reimbursement.aspx.Accessed25.05.12.
Center for Telehealth and eHealth Law (2011). Medicaid reimbursement. ,http://ctel.org/
expertise/reimbursement/medicaid-reimbursement/.Accessed25.05.12.
Centers for Medicare and Medicaid Services. (2009). The Medicare benefit policy manual
(Chapter 15). ,http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/
downloads/bp102c15.pdf.Accessed25.05.12.
Introduction 9
CentersforMedicareandMedicaidServices(2012).Theaffordablecareact:Loweringmedicare
costs by improving care. ,http://www.cms.gov/apps/files/ACA-savings-report-2012.pdf.
Accessed25.05.12.
Demyttenaere, K., Bruffaerts, R., Posada-Villa, J., Gasquet, I., Kovess, V., & Lepine, J. P.,
etal.(2004).Prevalence, severity, and unmet needfor treatment ofmental disorders in
the World Health Organization world mental health surveys. Journal of the American
MedicalAssociation,291,2581(cid:3)2590.
Kessler, R. C., Berglund, P. A., Bruce, M. L., Koch, J. R., Laska, E. M., Leaf, P. J., et al.
(2001). The prevalence and correlates of untreated serious mental illness. Health
ServicesResearch,36,987(cid:3)1007.
Kessler, R. C., Demler, O., Frank, R. G., Olfson, M., Pincus, H. A., Walters, E. E., et al.
(2005). Prevalence and treatment of mental disorders 1990 to 2003. New England
JournalofMedicine,352,2515(cid:3)2523.
Lewis, R. B., Martin, G. L., Over, C. H., & Tucker, H. (1957). Television therapy:
Effectiveness of closed-circuit television as a medium for therapy in treatment of the
mentallyill.A.M.A.ArchivesofNeurologyandPsychiatry,77,57(cid:3)69.
Nelson,E.L.,Barnard,M.,&Cain,S.(2003).Treatingchildhooddepressionovervideocon-
ferencing.TelemedicineJournalandE-health,9,49(cid:3)55.
Thomas,C.R.,&Holzer,C.E.,III(2006).Thecontinuingshortageofchildandadolescent
psychiatrists.JournaloftheAmericanAcademyofChildandAdolescentPsychiatry,45,
1023(cid:3)1031.
United States Public Health Service Office of the Surgeon General (1999). Mental health:
A report of the surgeon general, United States Public Health Service Office of the
SurgeonGeneral,Rockville,MD.
World Health Organization (2001). The world health report 2001—Mental health: New
understanding, new hope. Geneva, Switzerland: World Health Organization Press.
,http://www.who.int/whr/2001/en/.Accessed29.05.12.
2
Telemental Health as a Solution
to the Widening Gap Between
Supply and Demand for
Mental Health Services
Michael Flaum(cid:1)
DepartmentofPsychiatry,UniversityofIowaCarverCollegeofMedicine,
IowaCity,IA
Workforce Shortages in Mental Health: The Example
of Psychiatry
What Is the Current Supply of Psychiatrists in the United States?
As of 2010, there were just under 50,000 psychiatrists practicing in the United
States. (Note: source of all data in Figures 2.1(cid:3)2.5 is from American Medical
Association (2010).) This makes psychiatry the sixth most common specialty in
medicine (behind internal medicine, pediatrics, family practice, obstetrics/gynecol-
ogy, and anesthesia). Figure 2.1 shows how psychiatrists are distributed in terms of
specialty and practice setting. Approximately 18% of US psychiatrists are certified
in Child and Adolescent Psychiatry. More than 11% of all psychiatrists are
currently in residency or fellowship training. About three-quarters (78%) are pri-
marilyinoffice-basedoutpatientsettings.
In order to put these numbers into a meaningful context, it is necessary to look
at trends over time, how these trends compare to the numbers of other physicians,
and most importantly, how the trends over time correspond with trends in utiliza-
tionofservices.
Rate of Growth in Psychiatrists and All Physicians Over Time
Figure 2.2 shows the numbers of general and child psychiatrists over the past 40
years and Figure 2.3 shows the number of all physicians in the United States over
(cid:1) Correspondingauthor:MichaelFlaum,DepartmentofPsychiatry,UniversityofIowaCarverCollege
of Medicine, 1-400 Medical Education Building, Iowa City, IA 52242. Tel.: [phone], Fax:
11-319-353-3003,E-mail:[email protected]
TelementalHealth.DOI:http://dx.doi.org/10.1016/B978-0-12-416048-4.00002-6
©2013ElsevierInc.Allrightsreserved.
12 TelementalHealth
Teaching Other,
Administration 695 Research 328
1562 967
Child
Psychiatrists
7358
Hospital Based
7505
Residents and Office Based
Fellows 5404 31,801
Adult
Psychiatrists
40,904
Total Psychiatrists = 48,262
Figure2.1 SpecialtyandTreatmentSettingforPsychiatristsintheUnitedStates,2010.
50,000
45,000 Psychiatry (General)
40,000 Child Psychiatry
35,000
30,000
25,000
20,000
15,000
10,000
5,000
0
1970 1980 1990 2000 2010
Figure2.2 NumberofGeneralandChildPsychiatristsintheUnitedStates,1970(cid:3)2010.
10,00,000
9,00,000
8,00,000
7,00,000
6,00,000
5,00,000
4,00,000
3,00,000
2,00,000
1,00,000
0
1970 1980 1990 2000 2010
Figure2.3 TotalNumberofPhysiciansintheUnitedStates,1970(cid:3)2010.
TelementalHealthasaSolutiontotheWideningGap 13
300.0%
All Physicians Adult Psychiatrists
250.0%
All Psychiatrists Child Psychiatrists
200.0%
150.0%
100.0%
50.0%
0.0%
% increase % increase % increase % increase
2010 vs 2010 vs 2010 vs 2010 vs
2000 1990 1980 1970
Figure2.4 PercentIncreaseinGeneralandChildPsychiatristsandAllPhysiciansoverthe
PastfourDecades(2010versus2000,1990,1980,and1970).
8.00%
7.00%
6.00%
5.00%
4.00%
3.00%
1970 1980 1990 2000 2010
1970 1980 1990 2000 2010
Figure2.5 PercentofPsychiatristsofallUSPhysicians,1970(cid:3)2010.
the same time period. Several points are worth noting. First, while the increase in
all physicians has been relatively constant over this time, the increase in numbers
of psychiatrists has flattened out over the past two decades. Second, the rate of
growth is substantially lower for psychiatrists than for all physicians (Figure 2.4).
Forexample,whilethere has been anearly 20%increaseinthenumberofUSphy-
sicians in the past decade, there has been less than a 6% increase in the number of
psychiatrists during the same period. Third, growth in child psychiatry has substan-
tially outpaced that of general psychiatry. Specifically, there has been a 20.2% and
69.4% increase in the numbers of child psychiatrists over the past 10 and 20 years,
respectively, versus 3.6% and 16.3% for general psychiatrists over those two dec-
ades. Finally, as the increase in the numbers of psychiatrists has not kept pace with
that of the increase in the numbers of physicians, the percentage of psychiatrists
amongphysicianscontinuestofall(Figure2.5).