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APA's Committee on Telemedical Services released a new resource document last month to guide psychiatrists in the clinical, research, and administrative applications of videoconferencing. Committee Chair Ellen Rothchild, M.D., told Psychiatric News, "As a specialty organization, we needed to establish guidelines for the evolving practice of telepsychiatry to keep pace with the technology and wider applications."
The comprehensive document also addresses licensing and reimbursement issues and equipment, and provides a glossary of useful terms. The Board of Trustees approved the document at its July meeting.
The principles outlined in the document are derived largely from an unpublished paper by Frank Brown, M.D., immediate past chair of APA's Committee on Tele-medical Services and an associate professor of psychiatry at Emory University in Atlanta.
"The number of psychiatrists interested in telepsychiatry has grown significantly in the last decade from about four physicians to about 80," he said in an interview. "The change has been prompted by greater availability of and familiarity with communications technology such as e-mail and the Internet."
Another factor is that the cost of buying videoconferencing equipment has decreased substantially from between $20,000 and $100,000 in the 1980s to between $500 and $3,500 now, said Brown.
He noted that videoconferencing has been used historically for educational and administrative purposes. However, "the goal is to be able to provide an array of clinical services to patients at a distance."
Brown added that progress in telemedicine for patient care has been slowed by a lack of Medicare reimbursement. Nonetheless, he recommended that physicians planning to use video-conferencing for patient care contact third-party payers and present a business plan showing the cost-effectiveness of this method.
Telepsychiatry has diagnostic and therapeutic applications including prehospital-ization assessment and posthospital follow-up care, medication management, and consultation, according to APA's resource document. Psychotherapy, including supportive, cognitive-behavioral, brief interpersonal, and psychodynamically oriented modalities, is also feasible.
However, little information is available on the impact of telepsychiatry on interactional and dynamic issues such as transference and countertransference, according to the resource document. "Anecdotal information suggests that given good technical quality, people tend to accommodate to communication via television equipment 'as if I were in the same room as the doctor.' "
Moreover, physicians have reported that video consultations tend to be more focused and briefer than those conducted face to face because less time is devoted to the usual opening and closing social rituals, the document states.
Videoconferencing also allows multiple providers to collaborate on a case regardless of distance. Clinical treatment plans can be developed with input by experts and recorded and shared with other clinicians regardless of distance.
Forensic applications of telepsychiatry include assessing patients for involuntary commitment and conducting commitment hearings. The physician should determine whether a state's commitment laws allow a telepsychiatric evaluation for involuntary commitment and whether a license is required in the state in which the involuntary commitment will occur, states the resource document.
Brown noted that many states have begun wrestling with the issue of interstate licensing to practice telemedicine but some may not have formal policies. He recommended that physicians using video-conferencing for patient care or consultations check with the licensing board in the patient's state and obtain a written statement regarding its policies "because anyone can sue."
Research appears to be another promising venue for applying telepsychiatry. It enables multisite gathering of information for large clinical databases; however, validation studies are needed to address the use of telepsychiatry in specific populations, according to the resource document.
Because the technology facilitates multiple case management and the presence of family members during patient interviews or treatment, physicians should inform patients about individuals who are not on camera but are watching the consultation, states the document.
Telepsychiatric interviews may occasionally be audiotaped or videotaped. Informed consent for taping should be obtained verbally or in writing from the patient, next of kin, or guardian, according to the APA document. If a consent form is used, it should reflect that privacy is not guaranteed.
Brown noted that decisions to keep part or all of a videotape or audiotape as part of a patient's medical record should be made by the appropriate clinicians at each site in compliance with institutional rules. Moreover, telepsychiatric interventions should be clearly documented in the patient's medical record.
A progress note should also mention a transmission with poor quality, particularly if it prevented adequate diagnosis or treatment, the location of the clinician providing the service, the location of the patient, types of equipment used, and a list of those present during the office visit and their role.
Who owns the medical record and where the original record will be kept should be communicated to the patient and relevant individuals. A copy of the medical record should be sent to the treating clinician in case of emergencies.
A psychiatrist should also check whether his or her malpractice carrier covers interstate use of telepsychiatry.
For the full text of the APA Resource Document on Telepsychiatry via Videoconferencing, including acknowledgments, go to APA's Web site.