It is the beginning of a new day. A psychiatrist presses a switch and a dormant computer springs to life, humming its electronic rituals as it boots up. With a click of the mouse the video image of a patient appears on the screen. Physician and patient exchange morning pleasantries across hundreds of miles, and are now ready to begin treatment.
In more than two dozen programs throughout the United States, telepsychiatry is ushering in a new way of bringing mental health services to thousands of individuals who, in the past, may have gone without. More often than not, however, they are pilot projects or grant-supported endeavors, meaning that these prototypes of the psychiatrist's office of the future have yet to prove themselves in the medical marketplace. There is no question that the technology works, but the jury is still out on whether these electronic delivery systems will be able to succeed as financially viable alternatives to hands-on mental health care.
There are a host of obstacles to overcome. Technology standards are still being hammered out, while researchers attempt to determine whether treatment delivered over transmission wires matches the efficacy of in-person interactions. A patchwork of state laws renders statutes governing licensing, health care regulation and professional liability inconsistent and often conflicting. Meanwhile, payers and managed care organizations struggle with reimbursement issues.
Ace Allen, M.D., an oncologist, is the director of research at the University of Kansas Telemedicine Project in Kansas City and is the editor of Telemedicine Today (http://www.telemedtoday.com), the official publication of the Association of Telemedicine Service Providers. The magazine's last full survey found that in 1996 and the first quarter of 1997, there were 72 interactive video-mediated telemedicine programs in the United States, with about only a third of them providing mental health services. These facilities, according to the survey's tally, accounted for 3,460 mental health consults.
Although a new survey is currently underway, Allen predicts that the number of telepsychiatry programs may not have grown significantly since then. However, the number of consults in existing facilities most likely has doubled.
He downplays the impact of legal and reimbursement issues, focusing instead on the failure of today's physicians to overcome their near-phobic resistance to technology solutions to health care.
"In general, the argument that cross-state licensure is a serious impediment to telemedicine, or contributes to the failure of programs or inhibits their growth, is a straw man for the real issue. In any psychiatry venue, there are plenty of patients," Allen said. "The problems in telemedicine are very much organizational and administrative, and what I call medical/cultural problems."
Physicians, nurses and other health care workers are skeptical of the technology, Allen said, not because it doesn't work, but because they haven't been adequately trained or acculturated to its use. "It may be a generational thing," he said, but more rapid expansion of telemedicine may have to await the individuals currently in training who are less resistant to technology. "Physicians are trained to be skeptical and that's a good thing," Allen said, "but they have to overcome that skepticism in using this new technology."
Jill N. Afrin, M.D., a senior psychiatrist with the South Carolina Department of Mental Health (SCDMH), based in Charleston, overcame her skepticism after she decided to start a family in 1995. Fluent in American Sign Language, and an important resource for the state's deaf and hard-of-hearing population, Afrin collaborated with the SCDMH to develop a telepsychiatry program that would improve access, increase clinical time and simultaneously accommodate Afrin's changing lifestyle interests. Today, a computer-based televideo system in her home means she can provide more cost-effective care to deaf mentally ill patients who are sometimes hundreds of miles away.
With telemedicine offering a solution to so many seemingly divergent interests, it is surprising more health care delivery systems haven't evolved. In Afrin's case, the initial startup required only a moderate investment in technology- mostly computer hardware and software. The first four stations cost a total of $30,000 to purchase and install in 1995, but operate for only $50 to $100 per month.
During the first two years of Afrin's program, the state nearly recouped the entire investment by saving the $28,000 it would have spent on travel expenses. Before telemedicine, Afrin alone was using a third of her time-about 10 hours a week traveling to remote centers to treat patients. With the likelihood that the SCDMH could not have replaced Afrin with another psychiatrist fluent in signing had she left the department to pursue family interests, the SCDMH faced spending another $50 per session to cover the cost of an interpreter. Meanwhile, Medicaid agreed to reimburse Afrin's telepsychiatry services at the same rate as before, with additional financial gains coming from the fact that time previously spent on the road was now being spent with patients.
Meanwhile, the advent of video conferencing has not caused a deterioration in services. "I'm providing the same psychiatric services as I did when I went to the mental health center, and the same [services] I do in person at my local mental health center," Afrin said. During an average half-hour consult, "I talk to patients and find out how they're doing, assess their present status in terms of their symptoms and their mental health, and discuss their medications and compliance, side effects, treatment plans and medication options."
Although formal outcomes studies have not yet been completed, anecdotally Afrin hasn't observed any negative consequences, although one patient was unwilling to interact through the system.
The efforts have paid off. This year Afrin expects to conduct 250 contacts with patients using telemedicine technology, up from about 200 during 1997. Meanwhile, the SCDMH is planning on expanding the program to include hearing patients, and expanding the program to embrace all of South Carolina's 17 main community mental health centers. They will also use video conferencing to increase continuing education for staff members, who were often unable to attend training sessions because of travel restraints.
At the University of Kansas Telemedicine Program in Kansas City, Kan., Charles Zaylor, D.O., an adult psychiatrist and clinical assistant professor, runs what may be the nation's largest financially self-supporting telepsychiatry program. Under contract with a private, nonprofit mental health services program in a county several hundred miles from Kansas City, psychiatrists undertake over 1,200 patient interactions a year without any outside source of funding or support. The program, in place for over two years, offers a range of services for adults, adolescents, children and entire families.
The county mental health center and the university's telemedicine program each purchased their own video conferencing equipment, and reimbursement to the participating psychiatrists is consistent with the hourly rate paid for personal interactions.
"There really hasn't been any problem with patient acceptance and there haven't been any instances where we looked back and said "'I wish we were seeing them in person,'" Zaylor said. The patient population includes those suffering from schizophrenia (26%), substance-induced mood disorders (14%), bipolar illness (18%), and clinical depression (35%), with the remainder diagnosed with panic disorder, obsessive-compulsive disorder and other miscellaneous mental health problems.
Erasing Preconceived Notions
Zaylor acknowledges that his experience with telepsychiatry has been surprisingly effective and problem-free. As a result, he urges psychiatrists to remain open-minded to the new treatment opportunities offered by technology.
"There is an assumption that you have to be present with somebody in order to help them; that there needs to be this sense of physical presence. Just because we've always had that doesn't necessarily mean you have to have that," he said.
Currently, the University of Kansas program is expanding into other areas of practice, each of which is expected to be financially self-supporting. For instance, Zaylor said that they will be providing services to a prison population, a growing area of interest to telemedicine programs because it solves access problems caused by remote sites and security concerns during surface transportation.
David Ermer, M.D., a child psychiatrist, provides the services offered to young people and their families at the University of Kansas program. He agrees that teleconferencing has opened new vistas of practice opportunities, often enhancing, rather than undermining, service. For instance, mentally ill children and adolescents housed in facilities a long distance from their rural families can now "visit" via video links.
Despite the complexity of interactions required by a child and adolescent psychiatric practice, video conferencing has not been an impediment. "Child psychiatry is different from adult in that you're dealing with the whole family," Ermer said. "I have the parents there; occasionally I have the therapist and the schoolteacher, too. Not only do the kids have to accept the technology but so does everyone else."
The technology is still foreign to most clinicians, Ermer said, and that is what is keeping telepsychiatry from gaining acceptance, despite the fact that programs such as his prove they can be economically viable and medically sound. Nevertheless, he predicts that "down the road 20 to 30 years, this will be as simple as making a phone call for most people."