With the dizzying pace of healthcare technology advancements, it can be difficult for healthcare leaders to parse which tools merely look good in news headlines and which truly drive patient outcomes.
Virtual care (i.e., a healthcare professional treating a patient without being physically present) could have earned its place in the latter category decades ago, but for many reasons, such as a lack of awareness, complex reimbursement, and outdated technology, it has often been overlooked or relegated to supporting a limited number of emergency rooms.
Fortunately, doctors and healthcare systems are adopting virtualized services across the continuum of care. The movement is especially picking up speed in psychiatry. The American Psychiatric Association (APA) deepened its endorsement of virtual care solutions through its release of the new 2018 textbook entitled “Best Practices in Videoconferencing-Based Telemental Health,” which complements the APA’s online toolkit. This resource underscores the inevitability of telepsychiatry becoming the norm, not the exception, within the next five to 10 years.
Three leading drivers of this recent growth in telepsychiatry can be identified.
1. The physician shortage is hitting behavioral health particularly hard, while demand for these services is growing exponentially.
In many cases, the physician shortages in psychiatry stem back to medical school – traditionally, it has been a less “glamorous” discipline than surgery or emergency medicine. Medical students have recently started to choose the specialty more frequently. Recruitment has improved with better marketing and exciting developments in the field, but the pipeline has been slow to recover. At the same time, the demand for behavioral health services has continued to increase.
More psychiatrists are needed. Affordable Care Act regulations have increased eligible beneficiaries for behavioral health care. Recognition of anxiety and depression diagnoses, particularly among teens, has increased the identification of those in need. Per a 2017 study published in Psychological Medicine, depression increased significantly among Americans from 2005 to 2015, and the rise was most rapid among those ages 12-17. Behavioral health needs in the midst of the opioid crisis have also driven demand.
In many areas, it can now take an average of two to three months for new patients to secure an appointment with an outpatient psychiatrist. Numerous hospitals struggle with the issue of “emergency room boarding.” Desperate patients go to high cost emergency rooms when they can’t get timely mental health attention elsewhere. This practice is expensive and inefficient for both the hospital and the patient, but it also results in a dangerous gap in care that leaves the patient and those around him or her at serious risk.
Telepsychiatry allows physicians to better match the limited supply with demand. It allows one psychiatrist to treat patients that are geographically separated or isolated. It can help primary care providers and pain clinics better manage their patients through consults that avoid referral to an outpatient visit in a mental health clinic. It also gives the opportunity to provide a more comprehensive approach to their treatment instead of simply prescribing medications.
In addition to expanding access and improving utilization of mental health services, telepsychiatry can also help with retention of providers. Rather than traveling to multiple different clinics and wasting time in traffic, the ability to work from a “home base” allows psychiatrists to better utilize their valuable time and maintain a better work-life balance.
2. New models of care allow telepsychiatry to integrate with more points in the patient care chain.
Many in the healthcare industry still have a limited view of what telepsychiatry entails, largely associating the technology with virtual video consultations between a psychiatrist and a patient in various practice settings. While this is certainly an important and growing service in telepsychiatry, there are many other opportunities for telepsychiatry to augment rather than replace links in the patient care chain.
The hybrid approach to telepsychiatry is growing in popularity and for good reason. It expands the options available to combine and coordinate virtual and in-person visits, enhancing the patient’s experience and quality of care. There are many examples of this, but one common scenario is when a patient comes into the office for an initial consultation and follow-up visits are then handled remotely. This method addresses many current objections (valid or not) to telepsychiatry. Skeptics of telepsychiatry believe that doctors won’t build the same rapport with their patients as they would in person, that they won’t have as many data points since certain tests are not available remotely, and that they won’t be able to spot potential risk factors (e.g., lack of self-care, weight changes, etc.) as well as they would in person. This fails to recognize potential disadvantages of a non-virtual visits. In-person visits, particularly for mental health patients with anxiety or psychosis, can cause a patient undue stress. Other barriers, such as travel time and desire for privacy, may result in missed appointments. A virtual follow-up option, however, can eliminate this.
Primary care partnerships
Another option some health systems are exploring is embedding mental health services into primary care visits, connecting a core patient team across a variety of disciplines remotely for the most holistic view of the patient possible. The value in this approach bears out in a variety of situations. For example, a psychiatrist may prescribe a patient a new medication. If that patient were subsequently to get sick, it’s likely they would pay a visit to their primary care provider. With telemedicine, all three parties could consult to determine whether the symptoms were a side effect from the new drug or an unrelated cause. The patient receives a higher level of specialty consultation, and both the psychiatrist and the primary care physician have additional insight that may shape their care moving forward. Finally, some disciplines are leveraging technology for a seamless “curbside consult” with psychiatrists. Historically, doctors have had to bump into a psychiatrist at the water cooler to gut check patient cases. New telemedicine solutions are emerging to connect doctors across disciplines and geographies to share notes and recommendations to better treat their patients without having to result in a formal consult.
Remote therapy as a “reverse triage” solution
While it’s admittedly an emerging space, some behavioral health practices have even started to deliver programs for cognitive behavioral therapy (CBT) completely online. CBT is a form of psychotherapy that has proven very effective for a wide variety of mental disorders. By allowing a patient to complete this first, a form of “reverse triage” results, whereby, based on the outcome of this initial therapy, patients and providers can better determine the best ongoing treatment options – be they remote or in-person.
3. Telepsychiatry can be safer for both doctors and patients.
In-person psychiatry consults can be dangerous. Psychiatrists have a significant risk of being assaulted by agitated or violent patients. For forensic psychiatrists who treat patients suspected or convicted of crimes, it can be even higher. A remote visit removes much of that risk. As an added benefit, this dynamic can enhance the therapeutic rapport – when physicians don’t feel they need to defend against a potential attack, they can focus more intently on the patient and their concerns. Anecdotally, many patients have also reported that remote visits allow patients to be more open with their psychiatrists. In a digital world, it can sometimes be easier to open up to a device than to a person. Virtual presence is often perceived as less threatening.
Telepsychiatry also presents a safe option to patients who may normally avoid seeking treatment due to unfortunate stigmas. Explaining the reason for meeting someone in a behavioral health waiting room can be embarrassing and anxiety provoking. It may seem counterintuitive, but popular public figures (business leaders, politicians, and celebrities) sometimes have the least functional access to resources due to the potential impact on their careers and reputations if others see or report them seeking treatment.
For these reasons and many more, private practices and health systems alike should expect to see telepsychiatry grow even more exponentially in the near future – for healthcare leaders, doctors, and patients, the potential benefits are too numerous to ignore.
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