Telemental health seems to be emerging, even booming.  Also referred to as telebehaviorial health, e-counseling, e-therapy, online therapy, cybercounseling, or online counseling, for purposes of this post, I will define telemental health as the provision of remote mental health care services (usually via an audio/video secure platform) by psychiatrists, psychologists, social workers, counselors, and marriage and family therapists.  Most services involve assessment, therapy, and/or diagnosis.   Over the last few years, I have seen a wider variety of care models—from hospitals establishing telepsychiatric assessment programs in their emergency departments to virtual networks of mental health professionals providing telemental health services to underserved areas to remote substance abuse counseling being provided to inmates in state prisons.VA telehealth

Even the federal government is in on the act.  For example, in 2010, the Veterans Health Administration established a National Telemental Health Center. In 2013, the center provided almost 3,000 video encounters to 1,000 patients at 53 sites in 24 states.  The scope of the services the center provides includes all mental health conditions with a focus on post-traumatic stress disorder, depression, compensation and pension exams, bipolar disorder, behavioral pain and evidence-based psychotherapy.

There are many reasons for the recent boom.  First, telehealth is a good fit for providing mental health services because providers rarely have to lay hands on the patient in conventional face-to-face encounters.  Second, telemental health is accepted by a large number of payers as a legitimate use for telehealth—more so than other telehealth disciplines. As an example, most Medicaid programs and many private insurers cover and reimburse for telemental health services.  Finally, patients surveyed have consistently stated that they believe telemental health to be a credible and effective practice of medicine, and studies have found little or no difference in patient satisfaction as compared with face-to-face mental health consultations.

The Need for Telemental Health

In essence, we are stuck in a vortex of sorts with millions of Americans suffering from mental illness or substance abuse disorders combined with a shortage of qualified mental health providers to address these issues.  The numbers speak for themselves.

In addition to the high numbers described above, there is a critical mental health provider shortage creating significant access to care issues.  Here is a snapshot:

You get the idea.  And even with mental health parity laws, cost of care remains an issue—not to mention the social stigma and mistrust of mental health providers that exists in many communities.Mobile phone

Telemental health is bridging the gap.  Numerous studies have shown the effectiveness of telemental health services.  For example, a recent study showed that providing telemental health services to patients living in rural and underserved areas significantly reduced psychiatric hospitalization rates.  Another study concluded that the effects of telemental health on low-income homebound older adults were sustained significantly longer than those of in-person mental health services. Many other studies arrive at the same conclusion.  Note, however, obstacles remain, including how to properly assess non-verbal cues by video, technical difficulties, and the lack of proper training of many providers regarding telehealth.

Practice Guidance

There is also good news in that, unlike other telehealth subspecialties, there is a well-developed library of practice guidelines available regarding telemental health.  The American Psychiatric Association, American Psychological Association, National Association of Social Workers, Association of Social Work Boards, TeleMental Health Institute, for example, all have guidelines or statements related to telemental health.  The American Telemedicine Association has developed a series of practice guidelines over the years related to telemental health, including its latest regarding using real-time videoconferencing to provide online mental health services. There are also other resources such as the telehealth resource centers that provide guidance on telemental health.

Legal & Regulatory Issues

As with all things telehealth, however, there are a number of significant legal and regulatory issues implicated by the use of telemental health, including privacy and security, follow-up care, emergency care, treatment of minors, and reimbursement. While telemental health touches on some federal laws and regulations (e.g., HIPAA), most of the significant issues involve state law.  And as you might imagine, the result is an inconsistent patchwork of laws and regulations that vary widely by state.

We recently completed a 50-state survey of laws and regulations that may be implicated by the use of telemental health services to assess a variety of issues such as privacy, follow-up care, treatment of minors, and provider scope of practice.  Here are a few nuggets:

  • Psychiatrists, as practicing physicians, must comply with all the obligations that apply to physicians practicing telehealth generally. Very few states exempt mental health from physician requirements despite the fact that many psychiatrists never lay hands on patients. Ironically, Texas is one of the few states that explicitly carves out mental health services from other telehealth requirements.
  • In Delaware, an individual practicing “telepsychology” must conduct a risk benefit analysis and document findings specific to issues such as whether a patient’s presenting problems and Skype 4apparent condition are consistent with the use of telepsychology to the patient’s benefit; and whether the patient has sufficient knowledge and skills in the use of technology involved in rendering the service or can use a personal aid or assistive device to benefit from the service.
  • Kansas requires psychologists and social workers providing telemental health services to obtain the informed consent of the patient before services are provided.
  • In Maryland, physicians (psychiatrists) are required to develop a procedure to prevent access to data by unauthorized persons through password protection, encryption, or other means; and develop a policy on how soon an individual can expect a response from the physician to questions or other requests included in transmission.
  • Montana psychologists can initially establish a “defined professional relationship” electronically so long as the means of communication involves a two-way, real-time, interactive platform providing for both audio and visual interaction.
  • To regulate marriage and family therapy therapist, South Dakota relies on the American Association for Marriage and Family Therapy’s Code of Ethics which provides that therapists evaluate whether electronic therapy is appropriate for individuals and inform them of the potential risks and benefits associated with electronic therapy.

As I look over the telehealth landscape, I predict that telemental health will continue its significant growth.  Demand for mental health services will not recede, and coupled with the mental health provider shortage, telemental health will be viewed as a viable solution by more and more clinicians, payers, and policymakers.  There are, however, significant legal and regulatory considerations—especially at the state level— with which stakeholders must wrestle.

Christine Kearsley contributed to this article.

In Durham, North Carolina, the child psychiatrist comes to the classroom.  By telehealth. For the past eight years, Duke University Medical Center has teamed up with Durham Public Schools to export child psychiatry to where the kids are.  Duke fellows in child psychiatry travel to three elementary schools and one upper-school site to offer in-person mental health services to children with diagnosed mental health disorders.  To supervise the fellows, the attending physician conferences in.  As Dr. Richard D’Alli, the leader of the program, explains, supervising the fellows by telehealth has opened a world of possibility.

Why supervise by telehealth?

The major advantage of supervising by telehealth is clear; it lets the attending “be in three places at once.”  In this case, Durham community partners have set up self-contained therapeutic classrooms embedded in ordinary schools, which enable children with acute needs to continue their academic progress alongside their peers.  These classrooms bring together more than seventy students with special-ed qualified teachers, counselors, case managers, and family members.  The Duke psychiatry fellows visit once a week to offer evidence-based cognitive therapy, behavioral therapy, and on-site medication management.  Telehealth lets the attending psychiatrist be present to supervise and offer advice without having to travel to the multiple sites.  If problems arise in the middle of the week, it is as easy as a phone call to dial up the doctor.  Plus, the kids love it; “my doctor’s on TV!”  As Dr. D’Alli observes, psychiatry is all about the face-to-face encounter.  Telehealth makes that encounter possible, even at a distance.

The legal how

To move the telehealth project off the ground, Duke had to work through the legal how.  That legal how involved ensuring valid supervision, establishing contracts, and finding the proper technology.

For ensuring valid supervision, the basic rules are simple.  If a trainee is practicing off a medical campus, an attending supervisor must be present.  With sites at four schools, though, bringing in a busy attending would be no small task.  To overcome this hurdle, the Duke project leaders conferred with the Accreditation Council for Graduate Medical Education, the Duke risk management team, and other stakeholders.  Would telehealth supervision of fellows be equivalent to in-person supervision?  “To my surprise, shock, and delight,” Dr. D’Alli relates, the answer was “Yes!”

Contracts were another key piece of the legal picture.  First, the Duke Departments of Psychiatry and Pediatrics developed a training letter of agreement with Durham Public Schools, to establish the classrooms as their official training sites.  Second, Duke University Medical Center entered into a contract with Durham Public Schools for flat-rate, hourly compensation for services rendered, opting out of the more complicated billing arrangements that are sometimes common  in telehealth.  Third, Duke signed agreements with each child and family served, making the children official Duke patients that the fellows and attending physicians had the right to treat.

The final ingredient in the legal picture was the technology itself.  In medical consults, and particularly in mental health, the confidentiality of health information takes on greater significance.  To protect the information, the Duke telepsychiatry program uses encrypted teleconference technology, so that the students’ health information is secure in transmission.  Duke doctors do not record or otherwise store the video consults.  They keep the medical records in Duke’s electronic medical record system, rather than at the schools.  Through all these precautions, Duke can help keep the students’ medical information safe.  From supervision to the use of secure technology, Duke and the Durham Public Schools seem to have found a way to make the initiative work.

Looking Back, Looking Forward

Looking back on the project over the years, Dr. D’Alli’s advice for others is to embrace telehealth technology:  “As medicine evolves, we are being asked to serve more and more people with less and less, and telehealth is a fantastic example of efficient, effective delivery of medical care versus brick-and-mortar, traditional centers.”  Telehealth can improve “not just efficiency, but outreach.”

In fact, telepsychiatry has helped mental health professionals improve outreach since 1959, when the University of Nebraska School of Medicine wanted to connect patients a hundred miles away with psychiatric care.  At that point, the work involved a rudimentary, closed-circuit television interface.  Fortunately, technology has evolved over time.  Today, the interface is so good that a doctor can spot a subtle side effect of a psychotropic medication or a tic that might be caused by an ADHD medication.  Through this new technology, the Duke-Durham telepsychiatry project brings care to kids in their very own classrooms, where they can sit side-by-side with their teachers, parents, and the visiting fellows.  Telepsychiatry may be an old model, but the initiative in Durham is demonstrating new possibilities for it every day.