The Psychiatrist Experience Shabana Khan, MD Assistant Professor of - - PowerPoint PPT Presentation

Shabana Khan, MD Assistant Professor of Psychiatry University of Pittsburgh School of Medicine Medical Director WPIC Telepsychiatry

Challenges and Innovations in Rural Psychiatry June 22, 2016

Telepsychiatry Applications in Rural Psychiatry: The Psychiatrist Experience

Shabana Khan, MD I have no relevant financial disclosures.

Disclosures

• Definitions
• Why we need telepsychiatry
• Services to rural areas
• Obstacles
• Evidence Base
• Overview of WPIC Telepsychiatry

Program (Dr. Jack Cahalane)

• Questions and discussion

Outline

What is Telepsychiatry?

Definitions

Telemedicine

Teleradiology Teledermatology Others Telepsychiatry Telemental Health

• Use of medical information exchanged from one

site to another via electronic communications to improve a patient’s clinical health status

• Includes a growing variety of applications and

services using two-way video, email, smart phones, wireless tools, and other forms of telecommunications technology

What is Telemedicine?

American Telemedicine Association

• National shortage of

psychiatrists

• Difficulty recruiting to

rural areas

• Limited services in

underserved areas

• Lost time and money

when traveling for care

• Opportunities for case

consultation

• Enhance existing

services and collaboration

Why do we need Telepsychiatry?

History of Telemental Health

York Retreat 1800s

Modern Era of Telemental Health 1960s

1970s and 1980s



1990s

2000s

Scope of Services

• Diagnostic

evaluations

• Therapeutic

modalities

• Forensic modalities
• Pre-hospitalization

assessment

• Post-hospital follow-

up care

• Case management
• Psychotherapy
• Scheduled and

urgent outpatient visits

• Medication

management

• Consultation
• Research
• Staff Training
• CME
• Disaster Planning

Synchronous versus Asynchronous

MGH TeleHealth Center

• Greater illness burden
• Fewer resources
• Limited access to care
• Different systems of care
• Cultural differences
• Firearms
• Suicide rates

Rural Psychiatry Challenges

Potential Barriers to Adoption of Telemental Health

• Licensing and Credentialing
• Privacy and Confidentiality
• Reimbursement
• Malpractice
• Disruption of Clinical Workflow
• Physician Resistance to Technology

Potential Barriers for Providers

Physician Resistance to Technology

Physician Resistance to Technology

• Significant evidence that

patients quickly adapt and establish rapport with TMH provider

• Must adapt existing rapport

building techniques to this modality

• Gaze angle, bandwidth,

resolution

Therapeutic Alliance and Establishing Rapport

Evidence Base in Telemental Health

• Satisfaction and Acceptance

are most consistently reported outcomes

• Less time off from work, less

travel time, shorter wait time for services

• Satisfaction – simple variable

to measure

• Risk of overemphasizing

patient satisfaction as being same as clinical effectiveness

• Would satisfaction still be

high if other services were available locally?

• Strong evidence for high

patient and moderate-high provider satisfaction

Patient Satisfaction in Telemental Health

Richardson et al. 2009

Jenkins-Guarnieri et al. (2015)

• Systematic review of 14 studies examining measures of

patient satisfaction and therapeutic alliance

• Studies with direct comparisons of VTC or phone-based

psychotherapeutic TMH treatments with in-person

• Comparable treatment satisfaction and similar ratings of

therapeutic alliance Patient Perceptions of Telemental Health

• Majority of TMH conducted in outpatient settings
• School-based programs increasing
• Limited evidence-based outcome data for geriatric patients

in nursing home settings

• Literature on VTC diagnostic assessments demonstrates

their acceptance, utility, and accuracy in clinical practice Evidence

ATA Evidence-Based Practice for TMH (2011)

• Ruskin et al. (2004) – RCT showed comparable
• utcomes for depressed veterans treated via

telepsychiatry vs. in-person (Hamilton Depression Rating Scale and Beck Depression Inventory scores improved over time); equally adherent to appointments and medication treatment

• Hyler et al. (2005) – meta-analysis of 14 studies with

500 patients; no difference in accuracy or satisfaction Telemental Health Evidence Base

• Fortney et al. (2007) – RCT telemedicine-based

collaborative care model 395 patients; superior treatment adherence and outcomes and higher satisfaction in telemedicine group vs. treatment as usual

• Morland et al. (2010) – RCT of 125 veterans with PTSD

and anger difficulties; group CBT with therapist in- person or via videoconferencing; both groups showed significant reductions in anger symptoms; no between group differences in attrition, adherence, or satisfaction

Telemental Health Evidence Base

• Rabinowitz et al. (2010) – 278 telepsychiatry

consultation encounters for 106 residents of rural nursing homes; reduced fuel costs, physician travel time, personnel costs

• Godleski et al. (2012) - clinical outcomes of 98,609

mental health patients before and after enrollment in telemental health services at the VA from 2006-2010; patients’ hospitalizations decreased by about 25%

Telemental Health Evidence Base

• Elford et al. (2000) – 23 children age 4-16, two psychiatric

assessments, in-person and via TMH; diagnoses made via TMH reliable; satisfaction high

• Nelson et al. (2003) – 28 children with MDD randomized

to 8 CBT sessions of TMH vs. TAU; equals in-person in reducing depression over 8 weeks and satisfaction high

• Yellowlees et al. (2008) – 41 children showed

improvements in Child Behavior Checklist ratings 3 months post single consultation with child psychiatrist

• ver VTC (referred by PCP)

Pediatric Telemental Health Evidence Base

• Xie et al. (2013) – 22 parents of children age 6-14

received group parent management training in-person of via videoconferencing at same clinic with comparable

• utcomes
• Reese et al. (2013) – 21 children with ASD or

developmental delay; no difference in ADOS observations and ratings for ADI-R parent report

• Meyers et al. (2015) – CATTS RCT 223 children referred

by 88 PCPs; both groups improved but TMH group had greater improvement for diagnostic criteria for inattention, hyperactivity, combined ADHD, ODD on caregiver and teacher scales

Pediatric Telemental Health Evidence Base

• Telepsychiatry is a feasible, acceptable, effective, and

efficient model of health service delivery

• Literature supports ability to develop a therapeutic alliance

via videoteleconferencing

• Strong evidence for high patient satisfaction and moderate-

high provider satisfaction

• Telemedicine is becoming a core component of routine

clinical care and residents and fellows benefit from training Take-Home Points

• American Telemedicine Association
• www.americantelemed.org
• ATA 50 State Telemedicine Gap Analysis
• American Psychiatric Association Telepsychiatry Toolkit
• AACAP Practice Parameter for Telepsychiatry
• ATA Practice Guidelines for Video-Based Online Mental

Health Services (May 2013)

• Center for Connected Health Policy
• cchpca.org
• University of Colorado’s Telemental Health Guide
• www.tmhguide.org

Resources

Special Thanks To:

• Jack Cahalane, PhD, MPH
• Joseph Pierri, MS, MD
• Manish Sapra, MD, MMM
• Kate Dempsey
• Ken Nash, MD, MMM
• Residents and Fellows (Drs.

Borue, Joseph, and Schreiber)

• WPIC Telepsychiatrists and

Clinical Sites

Shabana Khan, MD

khans@upmc.edu