The Use of Telemental Health -...

The Use of Telemental

Health

Informatics 6623

Yufang Gu, FNP-C Karen Guess, PMHNP, ANP,

BC

“Computers are magnificent tools for the realization of our dreams, but no machine can replace the human spark of spirit,

compassion, love, and understanding.”----Louis Gerstner

Problem and Solution

Problem

Mental health service provision in rural areas or frontier areas is critical challenge

Smith & Allison, 1998

Solution

Telecommunication technology

PresenterPresentation NotesThe provision of mental health services for those who have limited access, such as in rural and frontier areas, those with mobility problems, those who are impoverished, and those who are incarcerated, remains a critical health service challenge.

Funding of public mental health is often based on population size, which limits the amount of money available for less populated areas.

Telemental health, the provision of services at a distance using telecommunication technologies, is increasingly helping to surmount that challenge.

Definitions

Telemedicine— “the delivery health care with the patient and health care professional at different locations, and is facilitated through the use of information and communication technologies” (Leonard , 2004, p.463)

Telehealth— “the use of electronic communications and information technology to provide and support health care when distance separates the provider from the patient” (Morland , Greene, Rosen, Mauldin, & Frueh, 2009, p. 514)

Telepsychiatry– is a branch of telemedicine that focuses on mental health applications (Leonard, 2004).

Telemental Health– refers to behavioral health services that are provided using communication technology (Morland , Greene, Rosen, Mauldin, & Frueh, 2009)

PresenterPresentation NotesThere are several terms used to describe this technology. Telemedicine and telehealth are broad terms, often used interchangeably, to describe the use of information and technology to deliver healthcare.

Telepsychiatry and telemental health are more specific terms, often used interchangeably as well, to describe the delivery of mental healthcare using communication technology.

What is This Technology?

• Delivered via remote videoconferencing technology:

• High powered videoconferencing equipment

• Desktop video equipment

• Videophones or personal video stations and bandwidth

Center for School Mental Health, 2009; Egede , Frueh, Richardson, Acierno, Mauldin, Knapp, et al., 2009

PresenterPresentation NotesSo what is this technology? Telemental health encompasses a variety of technologies to deliver care…….such as videoteleconferencing (VTC) , electronic email, online self help groups, websites, or electronic administration of psychological tests. However, for this presentation, we will specifically discuss VTC.

VTC essentially occurs when a pt or group of pts in one location and a clinician in a different location each look at a computer monitor or TV screen in order to see and hear each other in real time.

It involves the use of high-powered videoconferencing equipment, desktop video equipment, videophones, personal video stations, and bandwidth. Bandwidth refers to the information-carrying capacity of the telecommunication channel (the size of the pipeline that carries the video and audio signals). At higher bandwidths, the picture and sound are transmitted more quickly and with better quality. Lower bandwidth systems are more affordable but they create noticeable lags in video and audio transmission that may negatively impact the service application.

History of Telemedicine and Telemental health

1920—First documented use of telecommunications technology at Haukeland Hospital in Norway

1950s– Telemedicine used in field of mental health at the Nebraska Psychiatric Institute (NPI)

1956--an interactive audio link between NPI to seven hospitals in Nebraska, Iowa, and North/South Dakota


PresenterPresentation NotesFor the past 40 years, telementalhealth projects have increased access to needed services for consumers in rural and remote regions of this country.

The first documented use of telecommunication technology to provide healthcare at a distance occurred in 1920 at a hospital in Norway where radio links were established to provide healthcare support services to ships at sea.

It wasn’t until the 1950s, however, under the pioneering efforts of Dr. Cecil Wittson and his staff at the Nebraska Psychiatric Institute, that telemedicine was used in the field of MH.

In 1956, the National Institute of Mental Health funded an interactive audio link connecting Nebraska Psychiatric Institute to 7 hospitals in Nebraska, Iowa, North and South Dakota. The Institute broadcast its weekly visiting lecturer series to the rest of the network and participants could ask questions to the lecturer, allowing audience interaction with the site of origin for the first time.


1959– First use of audio-visual interactive system

1964-- Use of microwave technology to open link with Norfolk State Hospital

1960s-- Nebraska project linked Veteran’s Administration hospitals in Omaha, Lincoln, and Grand Island into existing network


PresenterPresentation NotesWith continued federal funding, the University of Nebraska program expanded throughout the late 1950s and 1960s.

Milestones included the first audio-visual interactive system in 1959 and the use of microwave technology to open a link in 1964 with Norfolk State Hospital, which was approximately 112 miles away.

In the late 1960s, the Nebraska project linked the Veterans Administration hospitals in Omaha, Lincoln, and Grand Island into the existing network.


1968--Developed a closed circuit link using two microwave relay stations between Department of Psychiatry at Dartmouth Medical School and a rural hospital in Claremont, New Hampshire

1968-- Expanded an existing telemedicine project at Massachusetts General Hospital to provide emergency psychiatric consults to staff at Boston Logan Airport Medical State


PresenterPresentation NotesIn 1968, the National Institute of Mental Health funded a project to develop a closed circuit link using 2 microwave relay stations between the psychiatric department at Dartmouth Medical School and a rural hospital in NH.

The technology allowed for timely MH consultation without moving the pt from his/her home environment.

Also in 1968, Dr. Thomas Dwyer expanded an existing telemedicine project at Massachusetts General Hospital to provide emergency psychiatric consults to staff at Logan Airport Medical Station in Boston. This project allowed the consulting psychiatrist at the hospital to zoom and focus the camera which enabled them to see emotional and physical nuances without invading an individual’s personal space.


1993- 1999– An increase from 9 telmedicine programs to 100

1998-1999– Over 61 programs in 35 states delivering telemental health services


PresenterPresentation NotesThe inauguration of telemedicine’s 3rd generation began in the late 1980s. Renewed federal funding, the rapid advancement of telecommunication and computer technologies, and the introduction of managed care created opportunities to further investigate potential applications of this technology.

Between 1993 and 1999, there was an increase from 9 to 100 telemedicine programs.

Between 1998 and 1999, there existed over 61 programs in 35 states delivering telemental health services.

Settings using Telemental Health Services

Rural primary care clinics

Hospital emergency rooms

Community mental health centers

Schools

Nursing homes

Homes

On board Navy ships

Jails

State and federal prisons


PresenterPresentation NotesTelemental health services are being delivered in a range of settings…..as you can see…..rural primary care clinics, hospital emergency rooms, community MH centers, schools, and nursing homes.

They are also being delivered directly into homes as well as on board Navy ships, in jails, and in state/federal prisons.

Applications of Telemental Health Services

Pre-admission and pre-discharge planning

Cognitive and mental status assessments

Case management

Medication management

Family visit/family consultations

Psychotherapy

Court commitment hearings

Family and consumer support groups

Frueh , Deitsch, Santos, Gold, Johnson, Meisler, et al., 2000; Smith & Allison, 1998

PresenterPresentation NotesTelemental Health technologies are being utilized to provide the full range of MH services, including pre-admission and dc planning, assessments & evaluations, case mgmt, med mgmt, family visits, psychotherapy, court commitment hearings, and support groups.

Applications of Telemental Health Services

Crisis response

Case conferences

Patient and clinician education

Staff training

Clinician supervision

Frueh, Deitsch, Santos, Gold, Johnson, Meisler, et al., 2000; Smith & Allison, 1998.

PresenterPresentation NotesThese technologies also provide a means for crisis response and a means to train MH providers for rural practice. In some states, the clinical internship of master’s level prepared social workers is supervised via telehealth technologies.

The use of these technologies for continuing education and in-service sessions is providing access to educational opportunities that have been limited in rural areas.

Benefits of Telemental Health Services

Increases access to mental health care

Extends scarce resources into geographic areas of service

Reduces cost for transportation

Eliminates or shortens patient waiting lists for appointments

Improves existing services

Center for School Mental Health, 2009; Frueh, Henderson, & Myrick, 2005; Smith & Allison, 1998; Morgan & Patrick, 2008

PresenterPresentation NotesTelemental Health obviously increases access to MH care.

It removes cost and travel barriers.

It can eliminate or shorten wait time for appointments, thus improving existing services.

Benefits of Telemental Health Services

Provides immediate availability of emergency mental health assessments

Improves continuity of care for rural consumers

Creates “virtual support groups”

Increases family and consumer involvement in treatment

Reduces lengths of stay and readmission rates to state psychiatric facilities

Promotes cost-effective mental health care

Center for School Mental Health, 2009; Frueh , Deitsch, Santos, Gold, Johnson, & Meisler, et al., 2000; Center for School of Mental Health, 2009; Smith & Allison, 1998.

PresenterPresentation NotesIt can provide emergency MH assessments bringing the psych ER to the consumer. A rural MH consumer in crisis can be examined by a distant psychiatrist over a telemental network.

It provides continuity of care for rural clients by allowing the community treatment team to monitor their progress in the hospital and to be involved in dc planning. Also, the same psychiatrist who treats the pt while hospitalized can more effectively monitor his/her medication in the community.

Virtual support groups can occur involving patients and families to support one another.

Telemental health increases family/consumer involvement in treatment. It has enabled family members to speak with and see their loved ones who are receiving treatment in distant locations and to participate in treatment planning.

Research has shown that telemental health can decrease the length of hospital stays as well as readmission rates to psychiatric facilities.

Telemental health programs can be less expensive for patients: reducing travel time, travel costs, and time off work. A key rationale for using VTC is that it is less costly to deliver than having a clinician travel to a remote location or flying pts to care.

Limitations and Weaknesses of Telemental Health Services

Costly equipment, maintenance and fees for videoconferences

Need of clinicians to be trained

Cost of technical personnel and other infrastructure

Technical malfunctions

Inability to manage crises such as suicidal thoughts/ aggressions

Monnier, Knapp, & Frueh, 2003. Morland, Greene, Rosen, Mauldin, & Frueh, et al., 2009

PresenterPresentation Notes

The equipment, maintenance, and fees for videoteleconferencing can be costly. The quality of the equipment can range widely…..with the lower cost equipment being somewhat unreliable.

Clinicians need to be properly trained so they can maximize the benefits of the technology and minimize technical malfunctions.

Technical malfunctions will inevitably occur, so it is recommended that the clinician have a backup technician available.

One of the biggest clinical challenges is that the clinician is not physically present to address crisis such as suicidal thoughts and aggression. Having a back-up clinician on site is recommended.


Inability of clinicians to identify patients’ nonverbal cues such as psychomotor agitation or poor hygiene

Inability of patients to perceive providers’ personability, warmth, and empathy

Decreased effectiveness of influencing patients’ use of substance abuse, medical and mental health services

Monnier, Knapp, & Frueh, 2003; Morland, Greene, Rosen, Mauldin, & Frueh, 2009

PresenterPresentation NotesIt may be challenging for clinicians to pick up on nonverbal cues such as psychomotor agitation or poor hygiene.

There is a risk that the pt will not pick up on nonverbal cues such as psychomotor agitation or poor hygiene.

There is a risk that the pt will not pick up on the clinician’s warmth and empathy and will perceive the interaction as impersonable.

Because telemental health is still relatively new, it has not been thoroughly or empirically validated, therefore its efficacy is still in question.


Lack of universal guidelines, standards or regulations regarding reimbursement, legal and ethical practice of telemedicine

Licensing issues relating to provision of care across state lines

Liability and malpractice issues

Privacy, confidentiality and consent issues

Leonard, 2004; Monnier, Knapp & Frueh, 2003

PresenterPresentation NotesEthical, clinical, and insurance-reimbursement guidelines are still in development. There were only a limited number of articles that discussed legal, regulatory, and ethical issues r/t delivery of MH services by electronic means.

There are concerns including licensing and regulation issues r/t providing care across state lines; liability and malpractice issues (lack of legal precedent to determine the provider’s liability when delivering services via telepsychiatry)

Some examples of legal and professional licensing/liability issues-----1) Deciding when a therapist-patient relationship has been established. 2) Determining when a telepsychiatry provider becomes liable for harm to the pt; 3) Determining whether the lack of clear standards for teleMH may increase the likelihood of providers being charged with malpractice because they don’t have accepted standards of care.

There are also privacy and consent issues, such as unclear guidelines as to whether or not separate informed consent is needed before care is delivered by telemedicine.

Project Management

Initiation

Planning

Execution Monitoring/Controlling

Closing

PresenterPresentation NotesUsing telemental health for clinical work requires much planning and preparation.

Project Management Framework Initiation Phase

Needs Identification

Needs assessment Target population Disease/disorder of interest Community to serve

Literature search (Lessons learned)

Potential problems/limitations

Boydell, Greenberg, & Volpe, 2004; Telemental Health Guide, Retrieved from http://www.tmhguide.org.

Initiation Phase

PresenterPresentation NotesIn the initiation phase of project management, you would want to conduct a needs assessment. Ascertain the health needs of the community through discussions with local organizations, medical professionals, and community members.

During the needs assessment, you want to identify the target population, the diseases/disorders of interest, and the community you will serve.

You want to understand the needs of the community. How many potential patients are in the community? How many potential pts are dealing with the treatment condition of interest? Does the community support treatment for this problem/condition?

You would want to perform a literature search to identify the lessons learned from similar endeavors.

You would want to identify potential problems/limitations you might encounter.

Project Management Framework Initiation Phase

Infrastructure Survey

Technological needs Speed of transmission Identification of local companies

for installation

Contextual Sensitivity Cultural considerations Geographical considerations Community considerations

Boydell, Greenberg, & Volpe, 2004; Telemental Health Guide, Retrieved from http://www.tmhguide.org.

Initiation Phase

PresenterPresentation NotesYou would want to conduct an infrastructure survey. Assess existing technological, organizational, and programmatic infrastructure.

Determine the technological needs of your services. Consider logistics such as preparation of the room and equipment. What is the necessary speed of transmission? You would need appropriate lighting to optimize the quality of video images.

Identify local companies that can help install or maintain system/equipment. How quickly can the service be obtained? What is the cost of services? Who do you contact in the event of technical difficulties?

Sensitivity to cultural and geographical contexts in the delivery of telemental health service is important. Community context included factors such as location, local availability of services and resources, language & culture, and the skill level of service providers.

It has been acknowledged that cultural sensitivity might vary according to the individual consultant psychiatrist overseeing a particular case, who might be more or less are of the challenges facing individuals living in isolated communities.

Program Management Framework Planning Phase

Education

Staff training Educational seminars

Structure Configuration

Preparation of room and equipment Technical and clinical backup support Optimizing video image

Written Protocol

Morland , Greene, Rosen, Mauldin, & Frueh, 2009

Planning Phase

PresenterPresentation NotesStaff training is vital to the success of VTC. Educational seminars can be conducted via TVC. It’s important to address barriers to attendance at these seminars.

The planning phase also consists of the structural configuration including preparing the room and equipment, providing technical/clinical back-up support and optimizing the video image.

The roles and responsibilities may be delineated via a written protocol. Potential topics for the protocol include: contact information for clinic staff & community resources, pt recruitment & qualifications, pt admission information, emergency procedures and contact information, instructions re: technical failures, list of FAQs pts may ask, and provider services such as referrals.

Program Management Framework Execution Phase

Pilot Implementation

Begin small scale trial Expect delays Extra time for troubleshooting Possible staffing issues

Assess patient and staff feedback Alter service based on feedback

Telemental Health Guide, Retrieved from http://www.tmhguide.org.

Execution Phase

PresenterPresentation NotesIn the execution phase, you would want to begin with a pilot implementation. Begin a small-scale trial of the project to ensure the process will operate smoothly and effectively and will allow you the opportunity to make changes without disrupting treatment.

Expect delays. New technologies often need extra time for trouble shooting and reconfiguring. Possible staffing issues will readily become apparent.

Assess pt and staff feedback. Be open to alter the service based on the feedback.

Program Management Framework Monitoring/Controlling Phase

Evaluating Contextual Sensitivity

Sensitivity to users’ local cultural/geographical situation? Recommendations reflect knowledge of community context?

Evaluating Access

Barriers to access? Services delivered in timely manner? Access to care improved?

Barker, 2003; Boydell, Greenberg, & Volpe, 2004

Monitoring/Controlling Phase

PresenterPresentation NotesIn the monitoring/controlling phase, you will essentially evaluate efficacy of the project and make changes when needed.

So we will start with evaluating contextual sensitivity. Do the users of the service feel that the program is sensitive to their local cultural and geographical situation? Do recommendations deriving from the consultation reflect knowledge of the community context?

In evaluating access, we want to identify what barriers and facilitators determine access to the telemental health program? Are the telemental health services delivered in a timely manner? Is access to care improved?


Evaluating Administration and Technology

Participant’s comfort level? Comfortable physical setting?

Consultation process explained adequately?

Ability to integrate system?

System upgradable?



PresenterPresentation NotesWhen evaluating administration and technology, determine how comfortable the participants are with the use of the technology. Is the physical setting comfortable? Do participants feel that the consultation process is adequately explained to them? Is the system able to be integrated and upgradable?


Evaluating Communication Voice heard/questions answered? Key elements of satisfying/successful consultation? Appropriate/feasible recommendations? Follow-up?

Evaluating Overall Satisfaction Access to mental health services? Travel time? Feelings of professional/personal isolation? System affordable?



PresenterPresentation NotesIt’s important to evaluate the communication. Do participants feel that their voices are heard and their questions are answered? What are the key elements of a satisfying and successful consultation?Are recommendations for treatment felt to be appropriate and feasible?How is follow up handled and by whom?

Next, you want to evaluate overall satisfaction. It is strongly suggested that all users, including family members, clinical staff, and other stakeholders, be surveyed for levels of satisfaction.What is the effect of the program on access to MH services? For pt and provider travel times? What is the effect of the program on feelings of professional and personal isolation?Is the system affordable?

Project Management Framework Closing Phase

Solidification

Open clinical services to wider population Lessons learned from pilot

Solicit feedback

Telemental Health Guide, Retrieved from http://www.tmhguide.org.

Closing Phase

PresenterPresentation NotesFinally, in the closing phase, you want to solidify the project. Open clinical services to a wider pt population.Consolidate lessons learned from the pilot into a fully functioning telehealth clinic.Solicit feedback about pt satisfaction and program/pt outcomes.

Potential Problems Related to Project Management

Lack of experience and inadequate staff training and support in use of new technologies

Psychological resistance to change

Fear of new technologies

Program sustainability

Privacy and confidentiality

Ethical and legal considerations

Frueh, Deitsch, Santos, Gold, Johnson, Meisler, et al., 2000; Leonard, 2004

PresenterPresentation NotesSome potential problems related to project management are lack of experience or inadequate staff training and support.There may be some initial resistance on the part of the staff.There may be fear of new technologies. Some staff may be anxious about being on “television”. Other staff may fear either increased workloads or staff reductions as a result of the new technology.

Can the program be sustained long-term? How will the program fare once research or grant funding expires?

Some pts will have justifiable concerns about their privacy or confidentiality of the consultations.

There are several instances where it is unclear if telemental health should be used ethically or legally, such as in a crisis intervention, involuntary commitments to psych facilities, and informed consent.

Financial aspects of Telemental Health Care

Datamonitor estimates that the annual spending on telehealth hardware, software, and other related services will increase from 2.4 billion in 2009 to 6.1 billion in 2012

High Powered Videoconferencing Equipment: approximately $4000-$10,000

Desktop Video Equipment: approximately $400-$500 for camera

Videophones or Personal Video Stations: approximately $300- $500

Baburajan, 2009; Center for School Mental Health, 2009

PresenterPresentation NotesIn regards to the financial aspects of telemental health care, Datamonitor, a provider of online database and analysis services, forecasts that annual spending on telehealth hardware, software, and related services will triple in 2012 to $6.1 billion from the rate in 2009 of 2.4 billion.

The videoconferencing equipment ranges from $4000 to 10,000. The desktop video equipment ranges from 400-500 dollars for camera.Videophones or personal video stations range from 300-500 dollars.

References

Baburajan, R.(2009). ATA Releases Guidelines for Delivery of Tele-Mental Health services. Retrieved March 3, 2010 from http://reseller.tmcnet.com/topics/unified-communications/articles/70030-ata-releases-guidelines-delivery-tele-mental-health-services.htm.

Barker, D.(2003). Tele-Mental Health: An Examination of Use In Military Geographically Separated Units. Retrieved March 2, 2010 from http://facaulty.ed.umuc.edu/~menkej/inss690/barker.pdf.

Boydell, K., Greenberg, N. & Volpe, T.(2004). Designing a framework for the evaluation of paediatric telepsychiatry: a participatory approach. Journal of Telemedicine and Telecare, 10, 165-169.

Center for School Mental Health (2009). Telemental health in schools. Retrieved March 2, 2010 from http://csmh.umaryland.edu/resources/CSMH/briefs/TelepsychIssueBrief.pdf.

Egede, L., Frueh, C., Richardson, L. , Acierno, R., Mauldin, P., Knapp, R., & Lejuez, C., (2009). Rationale and design: telepsychology service delivery for depressed elderly veterans. Trials, 10,22.

http://csmh.umaryland.edu/resources/CSMH/briefs/TelepsychIssueBrief.pdf�

References

Frueh, C., Deitsch, S., Santos, A., Gold, P., Johnson, M., Meisler, N., et al., (2000). Procedural and Methodological Issues in Telepsychiatry Research and Program Development. Psychiatric Services, 51 (12), 1522-1527.

Frueh, C., Henderson, S., & Myrick, H. (2005). Telehealth service delivery for persons with alcoholism. Journal of Telemedicine and Telecare, 11, 372-375.

Leonard, S. (2004). The development and evaluation of a telepsychiatry service for prisoners. Journal of Psychiatry and Mental Health Nursing, 11, 461-468.

Monnier, J., Knapp, R., & Frueh, C., (2003). Recent Advances in Telepsychiatry: An Updated Review. Psychiatric Services, 54 (12), 1604-1609

Morgan, R., & Patrick, A., (2008). Does the Use of Telemental Health Alter the Treatment Experience? Inmates’ Perceptions of Telemental Health Versus Face-to –Face Treatment Modalities. Journal of Consulting and Clinical Psychology, 76(1), 158-162.

References

Morland, L., Greene, C., Rosen, C., Mauldin, P., & Frueh, C., (2009). Issues in the design of randomized noninferiority clinical trial of telemental health psychotherapy for rural combat veterans with PTSD. Contemporary Clinical Trials, 30, 513-522.

Morland, L., Greene, C., Ruzek, J., & Godleski, L. (2009). PTSD and Telemental Health. Retrieved on March 3, 2010 from http://www.ptsd.va.gov/professional/pages/ptsd-telemental.asp.

Smith, H., & Allison, R., (1998). Telemental Health: Delivering Mental Health Care at a Distance- A Summary Report. Retrieved March 3, 2010 from www.hrsa.gov/telehealth/pubs/mental.htm.

The Telemental Health Guide. Retrieved on March 2, 2010, from http://www.tmhguide.org.

http://www.ptsd.va.gov/professional/pages/ptsd-telemental.asp�http://www.ptsd.va.gov/professional/pages/ptsd-telemental.asp�http://www.hrsa.gov/telehealth/pubs/mental.htm�

The Use of Telemental Health“Computers are magnificent tools for the realization of our dreams, but no machine can replace the human spark of spirit, compassion, love, and understanding.”----Louis GerstnerProblem and SolutionDefinitionsWhat is This Technology?History of Telemedicine and Telemental healthHistory of Telemedicine �and Telemental healthHistory of Telemedicine �and Telemental healthHistory of Telemedicine �and Telemental healthSettings using Telemental Health ServicesApplications of Telemental Health Services Applications of Telemental Health ServicesBenefits of Telemental �Health ServicesBenefits of Telemental �Health ServicesLimitations and Weaknesses of Telemental Health ServicesLimitations and Weaknesses of Telemental Health ServicesLimitations and Weaknesses of Telemental Health ServicesProject ManagementProject Management Framework�Initiation PhaseProject Management Framework�Initiation PhaseProgram Management Framework �Planning PhaseProgram Management Framework �Execution PhaseProgram Management Framework�Monitoring/Controlling PhaseProgram Management Framework �Monitoring/Controlling PhaseProgram Management Framework Monitoring/Controlling PhaseProject Management Framework�Closing PhasePotential Problems Related to Project ManagementFinancial aspects of �Telemental Health CareReferencesReferencesReferences

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