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TELEPSYCHIATRY:
From Idea to Solution
Developing and Implementing a Telepsychiatry Program
Trilok Shah, M.D.
June 25, 2014
TOPICS
 Benefits
 Challenges
 Economics
 Technology & Logistics
 Developing your program
 Common Questions
 Discussion
WHAT IS IT?
Psychiatry services carried out using tele-video medium
 Focus on the service not the technology
 Has been around for long time
WHERE IS IT BEING DONE?
 Hospitals - ERs, Consults, Inpatient
 Clinics - Private practice, CMHC, FQHCs, RHCs
 Correctional facilities
 Nursing/residential homes
 Locum tenens coverage
 Schools
WHY IS IT BEING DONE?
 Increased Access to Providers
 Improved Quality of Care
 Cost Benefits and Improved Workflow
 Value Beyond Fee for Service
Increased Access to Providers
 A Congressional report earlier this year said 55% of the nation’s
counties have NO practicing psychiatrists, psychologists or
SWs
 Almost 90 million Americans live in federally-designated Mental
Health Professional Shortage Areas
 According to HHS, Illinois has a deficit of 169 Psychiatrists
 In rural AND urban areas
 Lengthy wait times
Improved Quality of Care
 Clinical decisions by experienced psychiatrist
 Would you want an internist to perform surgeries?
 PCPs recognize and diagnose less than half of mental
disorders

Pirl, W.F.; Beck, B.J.; Safren, S. A.; Kim, H. (2001). "A descriptive study of psychiatric consultations
in a community primary care center". Primary Care Companion Journal of Clinical Psychiatry, 3 (5):
190–194. doi:10.4088/PCC.v03n0501
 PCPs prescribe 50% of psychotropic meds- often out of
necessity
 ED docs report being overly cautious in commitment
decisions
Cost Benefits & Improved Workflow
 A study of almost 100,000 users of the VA telepsychiatry
program: Patients' hospitalization utilization decreased by an
average of 25% with the implementation of telepsychiatry.
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Linda Godleski, M.D.; Adam Darkins, M.D., M.P.H.; John Peters, M.S. (2012) Outcomes of 98,609 U.S.
Department of Veterans Affairs Patients Enrolled in Telemental Health Services study from 2006–2010.
 Psychiatric patients:
 Remain in the ED 3 times longer than non‐psych patients
 Psychiatric boarding in the ED prevents 2 bed turnovers
 Lack of bed turnover costs hospitals an average of $2264 per
patient
 Nicks and Manthey. “The Impact of Psychiatric Patient Boarding in Emergency Departments.”
Emergency Medical International. 2012.
Value Beyond Fee for Service
 Treat patients where they are
 Improve staff and referral source satisfaction
 Reduce burnout of primary care docs, and increase
confidence of the treatment team
 Reduce indirect costs
 Recruiting and retaining providers
 Decreased opportunity costs with increased throughput
 Risk reduction
CHALLENGES
 Reimbursement
 Licensing
 Credentialing
 Liability
 Security/privacy
Reimbursement
Medicare & IL Medicaid
 Geography
 Rural for Medicare- Telehealth Payment Eligibility Analyzer
 HPSA for Medicaid
 Facility- office, hospital, RHC, FQHC, SNF, CMHC
 Provider- must have completed a psychiatry residency
program
 CPT codes- most evaluation and follow up codes
 Reimbursement to the health professional is the same as
in-person amounts. Originating (patient) site is reimbursed
an additional $25 per telemedicine encounter
Reimbursement
Private payers
 Required to pay in some states
 In IL it is up to the individual companies to decide
whether or not to offer it as a covered service.
 Telehealth Act (SB0647) passed both
houses on May 30th
 Sets some guidelines for private payers with regards to
covering telehealth services- for example, it forbids
insurance from requiring that initial visits be in-person.
 Negotiate with your payers
CHALLENGES
 Licensing
 Currently need license in the state the patient lives in,
except for federal institutions (V.A.)
 Credentialing
 Proxy credentialing not commonly used
 Liability
 More insurers provide liability coverage for telemedicine
 Security/privacy
 Encryption, BAA, protocols
DEVELOPING YOUR
PROGRAM
 Convene Your Telemedicine Team
 Assess the need in the community & the current community
resources
 Develop your financial plan
 Select provider
 Select technology
 Develop protocols & do practice runs
 Set launch date & market
 Launch program
Convene Your Team
 Project Manager
 Medical Staff Representative
 Information Technology Representative
 Financial Officer
 Human Resources Representative
 Legal Representative
 Quality Improvement Representative
 Consumer Advocate –patient education programs and
information materials, consumer and community outreach
Assess the Need & Resources
 Talk to
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The primary care doctors at your facility and in the community
Potential referral sources
ED directors and docs
Patients
Support clinical staff
Current resources in the community
 Questions to ask
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How many patients are the current docs seeing with psych issues
Where are patients with psych issues currently going
What stress is the current setup putting on the providers
How long are the patients having to wait for psych services, and how
much are they having to travel
 What quality of care issues are there- stretching the PCP’s capacity to
care of complex patients, safety and risk issues
 What is the availability, capacity of the current resources
 Subspecialty needs- child, geriatric, addictions
Develop Your Financial Plan
 What will be the associated costs
 Provider
 Support staff
 Equipment and setup – a much smaller barrier now
 Cost savings
 Improved workflow for the ED, other providers
 Creates referral source for other on site providers- primary
care docs, neurologists & other specialists, therapists
 Creates revenue source for labs, imaging
 Cost savings and convenience for patients
 Reimbursement
 Who are the major insurers for your patients
 Negotiate with payers
Select Your Provider
 Fits your needs
 Availability
 Experience
 Subspecialty
 Willingness to work with the whole team
 Long term relationship with your facility and patients
 Less likely to utilize your organization as a stepping stone
Our Providers Are…
 Board certified/eligible psychiatrists
 Adult/child/geriatric specialists
 Experienced in implementing programs in ER, outpatient, and
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school settings
Local and interested in serving the patients here
Are thoroughly vetted, and have clean practice records
Go through extensive training process
Able to help with credentialing, billing, technology, staff training,
developing protocols, and with data collection for continuing
program evaluation
English proficient, and not requiring any visa sponsorship
Backed by $1mil/$3mil liability coverage
Select the Technology
 Work with your provider to ensure compatibility
 Engage your IT team, but do not let them be the sole
decision makers
 Security is not just about the technology- it is also about
how it is used
 Think about long term needs
 Need mobile unit?
 Technology costs are no longer prohibitive
Develop Protocols & Practice Runs
 Scheduling
 Medical records
 Sharing notes, storage of PHI
 Prescribing - Controlled medications
 Orders - Ordering and receiving results
 Consents
 Loss of signal or loss of power
 Emergency situations
Keys to Sustainability
 Expect to encounter some resistance
 Train those involved
 Expect to make adjustments
 Collect quality and satisfaction data
 Talk to patients, staff, referral sources to continue
improving
 Be proactive and inform everyone involved
early about the program to avoid negative
emotional reaction
Keys to Sustainability
 Keep the onsite team engaged
 Challenge team to focus on the positives
 Address fears about being replaced
 Support, not replace
 Keep the provider engaged
 Orient the provider to the different members of
your team
 Include them in your e-mail lists
 Familiarize them with the community’s culture and
resources
 Inform them of major changes in the organization
COMMON QUESTIONS
 Will patients like it?
 Does it work?
 Are there limitations to using this?
Will Patients Like It?
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A number of patients prefer this
Access
Convenience
Cost savings
Distance is perceived as protective by some
patients
 Control is maintained, can walk out easily
 Neutral place
 So many patients already use similar technology
to socialize/keep in touch with others
Will Patients Like It:
Patient Satisfaction Study
 A pilot study comparing satisfaction levels between
psychiatric patients seen face to face (FTF) and those
seen via videoconference (VC).
 Patients were randomly assigned to one of two
groups.
 One psychiatrist provided all the FTF and VC
assessment and follow-up visits. A total of 24 subjects
were recruited; 18 completed study.
 NO significant differences in patient satisfaction
Will Patients Like It:
Another Patient Satisfaction Study
 Evaluated client satisfaction and one-month mental health
outcomes for telepsychiatry (VC) clients compared with face-toface (FTF) consultation.
 Clients were asked to complete a health survey before the
consultation, a satisfaction survey after the consultation, and were
contacted for a one-month follow-up survey by telephone.
 VC clients demonstrated significantly more improvements on preand post mental health measures than the FTF group.
 VC clients felt that they could present the same information as in
person (93%), were satisfied with their session (96%), and were
comfortable in their ability to talk (85%); this was similar to the FTF
clients.
DOES IT WORK?
FQHC Based Depression Study
 From 2007 to 2009, patients at several federally qualified
health centers were screened for depression.
 364 patients who screened positive were enrolled and
followed for 18 months.
 About half the patients received care from an on-site PCP
and a nurse care manager.
 The other half received care from an on-site PCP and an offsite psychiatrist via videoconferencing.
 The primary clinical outcome measures were treatment
response, remission, and change in depression severity.
 The group receiving the care from the psychiatric team via
telemedicine did significantly better.
Depression Treatment- RCT
 The primary objective was to compare treatment outcomes of
patients with depressive disorders treated by telepsychiatry (VC)
to patients treated in person (FTF).
 Secondary objectives were to compare rates of adherence,
satisfaction with treatment, and costs of treatment.
 119 depressed veterans referred for outpatient treatment were
randomly assigned to VC or FTF. Treatment lasted 6 months.
 Hamilton Depression Rating Scale and Beck Depression Inventory
scores improved over the treatment period and did NOT differ
between groups.
 No differences in dropout rates, patients’ satisfaction with
treatment, adherence to appointments and medications.
Any Limitations?
 No hand shake
 Smell is absent: EtOH (need to rely on onsite staff)
 Some psychotic patients?
 Some evidence showing that even patients with paranoid
delusions involving TV or cameras were able to participate in
telepsychiatry sessions with no problems
 Some patients with propensity for violence?
 Would want to take precautions even if in-person. Also, would
want to have staff in room with patient.
 Patients with very significant cognitive impairments?
MORE COMMON QUESTIONS
 Where are the In Touch providers licensed?
 How are the providers credentialed at my organization?
 How does a typical telepsychiatry encounter go?
 Who takes medical ownership of the patient?
 Can the In Touch providers prescribe medications?
 How do In Touch providers document?
 Can the In Touch providers integrate with the healthcare team
at my organization?
 Can we supplement the In Touch telepsychiatry services with
our own psychiatrists?
RESOURCES
 In Touch Physicians Resource Center
 http://www.intouchphysicians.com/resource-center.html
 Practice Guidelines for Tele-Mental Health Services
 http://www.intouchphysicians.com/uploads/3/4/2/8/3428956/ata_telem
edicine_core_guidelines.pdf
 Practice Guidelines for Telemedicine Services
 http://www.intouchphysicians.com/uploads/3/4/2/8/3428956/ata_practi
ce-guidelines_videoconferencing.pdf
 American Telemedicine Association
 http://www.americantelemed.org
 Telepsychiatry in the 21st Century
 http://www.intouchphysicians.com/uploads/3/4/2/8/3428956/telepsychi
atry_in_the_21st_century.pdf
DISCUSSION
Trilok Shah, MD
President, CMO
773-916-7595
[email protected]
www.intouchphysicians.com