What Does Telepsychiatry Mean?
Before the Covid-19 pandemic began, few were familiar with terms such as telehealth, telemedicine and telepsychiatry. The objective or even requirement to limit face-to-face interactions forced many to forego in-person interactions and substitute alternative means of interaction using technology. This alternate means of interaction became particularly important in health care, particularly interactions between patients and doctors. At the same time, telehealth is much more than just seeing your doctor on a computer screen.
Let’s take an example of two individuals in different locations who are working on a project together. Were this to happen 50 years ago, their contacts could be divided into “meetings” and “collaborative work.” Meetings occurred when the two had live contact with each other in real time – either face-to-face or over the telephone. However their collaboration was not limited only to real-time interactions. The two would exchange information via regular mail (and later email), fax machines, or voicemail messages. The two were still working collaboratively on the same project, but at different times and in different places.
Fast forward to our times, and apply the same idea to a different project: working on the health of an individual. Most broadly speaking, telehealth is the provision of health services delivered exclusively through technology. That technology may include video or telephone sessions with healthcare providers, communicating with providers via confidential messaging systems, receiving test results or educational materials on your computer or cell phone, having your X-rays, CT or MRI scans read by a radiologist far away, or even having the health data from your smartphone or watch automatically transmitted to your providers to monitor you.
Receiving telehealth services does not preclude meeting together with healthcare providers face-to-face. For example, one may see his/her provider in person but rather than filling out paper forms in the office or receiving printed health materials, forms are filled out online and patient educational material is delivered through email. Therefore there is a wide range of activities that falls under “Telehealth.”
Telehealth, Telemedicine and Telepsychiatry
Telehealth is the broadest term and it applies to the use of technologies to promote health in general. Telemedicine is a subset, albeit a very large subset, of Telehealth. In short, telemedicine is to telehealth what medicine is to health. Health goes far beyond the medical field and encompasses a very broad range of topics such as your diet, level of exercise, meditation, vitamins, water purity, air quality – essentially anything in our world that impacts one’s health. Medicine however is a learned profession composed of hospitals, clinics, pharmacies, doctors, nurses and other allied professionals. It is the field that treats illnesses. And thus, telemedicine is the provision of medical services through the use of technology. Telepsychiatry is yet a further subset of telemedicine. It is the provision of psychiatric services that utilizes technology.
The questions, “What is telehealth?” and “What is telemedicine?” and “What is telepsychiatry?” can be illustrated in the figure below:
Pros and Cons of Telemedicine
Advantages of Telemedicine:
Access to specialists when one is not local, or remote radiology services for immediate assessments
Ability to get an assessment and treatment from home when you are too physically ill or weak to travel to the doctor, or on off-hours
Access to one’s own medical records and to information regarding your illness and/or treatment
Monitoring mechanisms for early identification: home monitoring devices, for example vital signs, blood sugar levels, that send data to your doctor in order to identify a problem very early before it worsens and progresses, avoiding hospitalizations and more serious illness
Access to doctors for individuals who live in rural areas where doctors are either scarce or at a great distance
Disadvantages of Telemedicine:
Technology is not perfect and can break down, or internet service can go down.
Extraordinary precautions must be taken to protect your privacy so that confidential information about you is protected both during transmissions over the internet and when stored. Unfortunately personal information is susceptible to hacking.
Certain assessments and treatments simply cannot be done remotely. It is not possible to do a thorough physical exam over the Internet. You would also not want an obstetrician to be guiding a childbirth over video on the internet. Some things simply must be done in person.
Much of telemedicine is contracted through telemedicine companies. Patients have little to no choice about their doctors when using a telemedicine service.
What is Telepsychiatry?
Most common questions about telepsychiatry
- Can a telepsychiatrist prescribe? Yes, although there may be some restrictions depending on what state you are located. Prescriptions are sent electronically to your pharmacy.
- Can a telepsychiatrist do talk therapy? Yes. Some psychiatrists do only medication management but many do both talk therapy and medication management when relevant.
- Does a telepsychiatrist take insurance? Some psychiatrists accept insurance but some to many do not.
- Does health insurance pay for telepsychiatry? Currently during the pandemic, nearly all insurance companies pay for telepsychiatry. However once the pandemic ends, it will vary from state to state and company to company. Medicare and Medicaid have their own rules.
- What types of disorders do telepsychiatrists treat? Psychiatrists are trained to treat all types of psychiatric conditions however each psychiatrist may choose to prefer treating some conditions and choose to not treat others. Malpractice insurance companies also dictate the type of conditions a telepsychiatrist may and may not treat. Generally, the malpractice policies prohibit telepsychiatrists from treating “higher risk conditions” such as suicidal patients, frequently hospitalized individuals and substance abusers. More importantly, certain conditions should not be treated via telepsychiatry because these conditions are best treated either in person, or in groups, or at facilities where there is a team of providers including social workers, case managers, occupational therapists, etc.
- Can a telepsychiatrist treat everyone? Yes. Depending on the specialty training and/or preferences of the psychiatrist, all age groups (children, adolescents, adults, the elderly) can be treated via telepsychiatry. In addition, telepsychiatrists can offer couples and group therapy treatment.
What is synchronous and asynchronous telepsychiatry?
One may come across the terms synchronous versus asynchronous telepsychiatry. The best way to illustrate these two types of telepsychiatry is an analogy between a live telephone calls versus a series of voicemail messages that two individuals leave for one another. When the psychiatrist and patient are interacting in real time via video and/or audio, this type of telepsychiatry is called synchronous telepsychiatry. However there are other ways in which the two interact at different times. Asynchronous telepsychiatry allows the patient and psychiatrist to each interact in his/her own timeline. For example, there are certain settings in which the doctor is not present but the patient is video-recorded answering questions posed by a nurse or assistant. At a later time, the psychiatrist reviews the video recording and makes an assessment and/or implements treatment, Another simpler example of asynchronous telepsychiatry is the use of confidential messaging/email systems. The patient writes to the psychiatrist who reviews the message and responds. This type of interaction can be quite helpful for patients who experience symptoms only at certain times, such as in the middle of the night, and not necessarily when meeting with the psychiatrist. The patient is thus able to convey the symptoms in writing as they are happening to provide the psychiatrist with a much more in-depth picture of the patient’s experience.
Pros and Cons of Telepsychiatry
Advantages of Telepsychiatry:
Doctor-Patient Relationship: The “fit” or “chemistry” between doctor and patient is perhaps never as important as in psychiatry. With traditional office visits, one is limited to psychiatrists who are local. However with telepsychiatry, the choice of psychiatrists is vast offering the patient many options to find the psychiatrist with whom the patient feels most comfortable. At times, a patient may have a preference for a psychiatrist of a particular gender, race, orientation or approach. Again, the patient has many more options among telepsychiatrists in comparison to the psychiatrists who are geographically local.
Telepsychiatry Session: Perhaps more than any other field in medicine, psychiatry is most suited for telemedicine because there is usually no necessity for a physical examination or testing. (At times blood tests are indicated but these can be done easily at a nearby laboratory facility.).
Telepsychiatry “House-Call” : The ability of the telepsychiatrist to see the patient in his/her own environment is invaluable. In this sense, telepsychiatry is like the old-fashioned “house-call.”
Telepsychiatrist Availability: For many, there may be either no psychiatrist, no psychiatrist within a reasonable distance, or such a limited number of psychiatrists that the waiting list is months-long. Telepsychiatry eliminates the problem of access to a psychiatrist.
Convenience: It is obviously more convenient for individuals to be able to see a telepsychiatrist from his/her home, eliminating travel time and perhaps self-consciousness about entering a psychiatrist’s office. The convenience factor is particularly important for individuals who at certain times need to be seen frequently.
Telepsychiatry monitoring: Because telepsychiatry does not depend solely on appointments but rather utilizes other methods of communication, psychiatrists can monitor their patients more closely and more frequently, improving the quality of their care.
Disadvantages of Telepsychiatry:
There simply is no replacement for a face-to-face encounter; the quiet, safety and protected nature of the psychiatrist’s office.
It may be difficult at times for the patient to find a sufficiently private place to conduct the session, or to separate oneself from what is going on at home or work during the session.
As mentioned above, there are certain conditions for which telepsychiatry should not be used, such as with “high-risk conditions” or conditions proven to respond only to multi-disciplinary team approaches.
Prescribing limitations – Prescribing regulations for telemedicine vary from state to state. For example, in New Jersey (under usual, non-Covid conditions), patients must be seen in-person, face-to-face, once every three months if they are receiving controlled substances. There are additional telemedicine regulations by insurance companies and the FDA that may limit the telepsychiatrist’s prescribing options.
Insurance coverage: After Covid, it is not clear how and which insurance companies, including Medicare and Medicaid, will cover telepsychiatry services.
If you are considering treatment via telepsychiatry, here is a quick checklist that may be helpful to you in finding a telepsychiatrist who is right for you:
- In finding a telepsychiatrist, use listing sites such as WebMD or PsychologyToday. Both provide a filtering mechanism to specifically seek out a telepsychiatrist. These sites also have doctor reviews to help you choose a telepsychiatrist.
You can inquire if the telepsychiatrist provides a free initial, brief phone consultation before committing to a first appointment.
There are many telepsychiatry and telemedicine companies, many of which promise that you will be seen within minutes, or that they accept all insurance plans. First and foremost, be aware that you will have no choice of the psychiatrist you will see. Second, insist on the opportunity to do all the verification’s and necessary consents listed below before beginning a session. Third, make sure you have a written guarantee that they accept your insurance before you provide co-payments lest you receive a large bill from them later stating that your insurance was “Denied.”
Verify that the psychiatrist holds a valid physician’s license in your state. (Every state has a “Physician License Verification” website.). If the physician is not licensed in your state, he/she may not provide telepsychiatry services to you.
Confirm that the telepsychiatrist is board certified at https://www.certificationmatters.org
If your telepsychiatrist prescribes a controlled substance to you, the psychiatrist must possess a DEA certificate specific to your state. Some states also require what is called a CDS or CSR which is a separate state-specific license for controlled substances. CDS/CSRs can be verified online.
In addition to providing you with a copy of their privacy policies, telepsychiatrists must provide you with a separate, special “Telemedicine” consent.
If you’re planning on using your health insurance, phone your insurance company first to inquire if they cover telepsychiatry visits.