Telehealth is at a tipping point and is gaining momentum. As medical directors with a health services company, we wish to help psychiatrists and other mental health clinicians make informed choices about how to add telehealth to their clinical work in a way that is safe and effective for patients, legally sound for providers, and sufficiently remunerative to their practices.
It is important to understand why telehealth for psychiatry is on the rise. Because of increased access to technology (eg, smart-phones, computers, applications [apps]), doctors, more than ever before, are just a quick click or tap away from patients who live in remote areas and who have limited options for care. Furthermore, there is an increased demand for clinical service that is attributable in part to the Patient Protection and Affordable Care Act, which added 11 million people to the ranks of the insured.
Telehealth technology has improved tremendously. For example, the Veterans Administration, a pioneer in telehealth, invested significantly in technology and human resources for telemedicine. Although initially the service was not cost- effective, now multiple apps allow for immediate connectivity at low or no cost to the patient, with increased accessibility and viability. This means that telehealth is an idea whose time has come, and whose strongest proponents have come of age. Having grown up with it, young adults are comfortable with all types of digital technology and demand expanded access and convenience, sometimes to the apparent detriment of real-time, face-to-face encounters.
Considerations for psychiatry
Telehealth is not a medical specialty in itself, but simply a newer modality to deliver health care. It is expected to increase access and decrease the cost of delivering care. Initially, practitioners felt that phone and video were impersonal means of communication that “altered” the quality of the physician-patient encounter. Eventually, many realized that psychiatry is one of the specialties best suited to video.1 Interactions with patients are mostly oral and visual: telehealth sessions provide information similar to that of an in-person examination and can thereby conform to the standards of care for psychiatry.
Physical examinations are frequently not necessary for routine outpatient care. In general, telehealth is feasible for patients who require routine outpatient visits (although it has been used in other settings, including prisons and emergency departments, with appropriate ancillary support).2 Psychiatrists may be able to provide virtual visits to primary care clinics, hospitals, or other health care providers on a consultative basis. Patients for whom tactile or olfactory input is necessary to the examination (eg, detecting odors or testing for cogwheel rigidity) or patients who are at severe risk for harm are generally not good candidates for telehealth services.
For telehealth, psychiatrists must be licensed in the state where the patient is at the time of contact. However, this area is in rapid flux. Psychiatrists are encouraged to contact the AMA and Federation of State Medical Boards for updates. State laws that regulate the practice of telemedicine may include limitations on the use of specific technologies and prescribing practices. State medical boards may place additional regulations.
Psychiatrists who are interested in providing telehealth services from their current offices (or homes) have 2 options. The first is to work with one of several companies that provide telemedicine services. Many can be found online by searching for “telepsychiatry networks.” These companies offer several advantages: they provide the technology platform, technical support, scheduling support and, perhaps most importantly, the patients, enabling psychiatrists to supplement their incomes and diversify their patient populations from existing home or office practice locations. Psychiatrists may therefore choose to augment their face-to-face practices with telehealth. For example, a child psychiatrist who sees children and adolescents in the afternoon may choose to collaborate with a telehealth company in the morning to see adults.
For those psychiatrists who wish to cut out the proverbial middle man, it is now easier than ever to establish one’s own telehealth practice. A phone is a prerequisite, as is a computer, ideally one with a built-in web camera (webcam), which most have nowadays. The patient also needs a computer or phone with a webcam. Webcams allow computer owners to see themselves. You can therefore check to see how you look to your patients, mannerisms they might notice, etc.
Drs Lopez and Lustig are Medical Directors at Cigna. (The Cigna name is a registered service mark of Cigna Intellectual Property, Inc, and is used to refer to operating subsidiaries of Cigna Corporation, including Cigna Behavioral Health, Inc, and Cigna Health and Life Insurance Company.) The authors report no conflicts of interest concerning the subject matter of this article.
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