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The Top 10 Barriers to Wider Adoption of Telepsychiatry

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Although telepsychiatry has received a lot of attention in the last few years, this modality has been around for more than 60 years.  As early as 1959, the Nebraska Psychiatric Institute was using early videoconferencing to provide group therapy, long-term therapy, consultation-liaison psychiatry, and medical student training at the Nebraska state hospital in Norfolk (APA).

Like innovators in other industries, early adopters of telepsychiatry operated without the benefit of clear legislation for many decades.  Providers have had to operate in murky waters and at the mercy of multiple jurisdictions such as local, federal and state government.  The widespread adoption of telepsychiatry has been hindered by fear and uncertainty around a variety of factors involved in seeing patients via this modality.  Here are the top ten barriers to a broader acceptance of telehealth:

  1. HIPAA (software encryption) – In today’s high-tech world, there is so much data exchanging hands that people’s privacy can sometimes be vulnerable.  This is especially important for healthcare, which involves managing sensitive patient data and personal health information.  Keeping information private and secure can be challenging, but remains an important aspect of a provider-patient relationship.

    Fortunately, most reputable telehealth platforms currently use a 256-bit encryption, which seems to be a reasonable bar.  As time goes on, data security will become increasingly complex, but no less important than it has always been.

  2. Special consent to use telepsychiatry – Telehealth is not a type of treatment like medication or surgery.  Instead, it is a modality of care.  Telehealth providers can still order medications and coordinate care.  Therefore, some consider it arbitrary to require consent from the patient for telehealth.  However, due to some subtle differences between virtual and onsite care, states have treated informed consent issues differently. Some states require a written consent delineating the risks and benefits of this service.  Others simply require verbal consent, or no consent at all.  This information can often be found on the state medical board websites.
  3. Hesitation or reluctance of the users – With a proven track record of success and more attention on innovative healthcare, hesitation to adopt telehealth not a significant problem these days.  Nevertheless, there are always laggards when it comes to adopting innovation.  Believe it or not, there are still some healthcare providers that are reluctant to utilize telepsychiatry for fear of rejection by patients. They may feel that patients will see the process as less personal or less effective.

    Certainly, patient willingness to engage in telepsychiatry is an important factor in evaluating whether it will be utilized, whether it will be effective, and whether patients will be satisfied. However, studies have shown that patients are much more adaptable than providers may initially believe.

    When alternative care is unavailable or difficult and expensive to obtain, patients who choose to undergo telepsychiatry report high levels of satisfaction and efficacy. Patients report increasing comfort and satisfaction with telepsychiatry once they use it. Truly, once patients try it, they like it.

  4. Establishing a patient-provider relationship via telehealth – Although all 50 states allow a physician to establish a relationship with a new patient via telemedicine, some states include caveats such as restricting the setting (e.g. to medical site), or narrow the modality that can be used (e.g. telephone vs videoconferencing technology) (AMA).  We feel that anticipate that one day all states will allow providers to establish a treating relationship with patients based on their own clinical discretion.
  5. Eligible Providers – Per CMS, only certain classifications are permitted to provide telehealth treatment.  These include physicians, nurse practitioners, clinical psychologists, clinical social workers, physician assistants, nurse midwives, clinical nurse specialists, certified registered nurse anesthetists, and registered dieticians or nutrition professionals.  It is our hope that CMS will one day also allow marriage and family therapists and other classifications of healthcare professionals to conduct visits remotely.
  6. Reimbursement Parity – In the last several years, individual states have passed party laws.  Some of them require that telehealth be reimbursed, but not all those laws require equal reimbursement.  Private payers are increasingly accepting telepsychiatry as a service worthy of reimbursement.  With time, our hope is that all states will pass legislation that requires insurance companies to reimburse telepsychiatry on the same level of onsite care.
  7. Eligible Services – Medicare reimburses only for specific services when they are delivered via live video. Store-and-forward delivered services are prohibited, except for CMS demonstration programs in Alaska and Hawaii (CCHP).  In recent years, more telehealth codes have been approved by the US Department of Health and Human Services.  However, it is our hope that almost any mental health service code will one day have a corresponding telehealth code.

    Unfortunately, CMS requires that originating sites (the location of the patient) are in rural or health professional shortage areas and within eligible facilities or offices.  Due to the public health emergency declaration in response to the COVID-19 pandemic, CMS has, for the most part, waived these requirements temporarily.  It is our wish that CMS considers eliminating these geographic requirements.  This will set the tone for a broader adoption of telehealth.

  8. Videoconferencing Fatigue – While the COVID-19 pandemic has shined a spotlight on telehealth, this is a double-edged sword.  Some providers miss being onsite in hospitals and colleagues.  Although many providers love spending each day doing virtual care, there are some that find it tiring and may be eager to return to onsite care.  Nevertheless, the benefits of virtual care are being demonstrated to the masses.  Hopefully, telehealth will remain a mainstay of how healthcare is offered, even when the pandemic resolves.
  9. Online prescribing/Controlled Substances – The Ryan Haight Online Pharmacy Consumer Protection Act of 2008 was originally intended to prevent “pill mills”- online pharmacies that dispense medication without a valid prescription.  Although the intent of Ryan Haight was noble, an unintended consequence was to make it much more difficult to prescribe controlled substances via telehealth.  Although there are 7 exceptions to the in-person rule, the exceptions are narrow and the DEA has not yet developed a Special Registration process for telemedicine as mandated by Congress.  Our hope is that the DEA will finally release the special registration process in the near future.
  10. Interstate Licensing Laws – Unlike a driver’s license, having a medical license does not allow you to practice in any state.  If you have a patient that you have been treating for a while but moved to another state, it makes no sense that simply due to the patient moving location, they are deprived of healthcare that has worked for them.  It unnecessarily disrupts the continuity of care and makes the healthcare system much less efficient. The Interstate Medical Licensure Compact and the FCVS have helped facilitate licensure, however, the better solution would be to have a national medical license.  Perhaps in the meantime, established patients should be allowed to keep their doctor, even if they travel across state lines.

The COVID-19 pandemic has forced regulatory bodies and healthcare organizations to rethink the role of telehealth in the overall healthcare system.  It is our hope that there will be a permanent lifting of many of the barriers to the practice of telehealth, while maintaining reasonable and appropriate rules and regulations to ensure the safety of patients alike.

Sources:

https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/history-of-telepsychiatry (APA)

https://www.cchpca.org/telehealth-policy/telehealth-and-medicare (CCHP)

https://www.ama-assn.org/system/files/2018-10/ama-chart-telemedicine-patient-physician-relationship.pdf (AMA)

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