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Cost issues with telepsychiatry in the United States

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Cost issues with telepsychiatry in the United States

Abstract

Videoconferencing has increased patient access to psychiatric care by linking specialists at academic or regional health centres with primary health care professionals in shortage areas (Hilty et al, 1999, 2002). Preliminary studies have demonstrated positive outcomes and user satisfaction (Hilty et al, 2002). Information is still being sought regarding costs because of a paucity of clinical outcome studies, cost data and randomised trials.
6
Bulletin of the Board of International Affairs of the Royal College of Psychiatrists
consumers. Some specialists who are particularly good
teachers will probably gradually migrate into the role of
world authority in certain areas. This is already happening
in commercial university programmes, where some indi-
vidual professors, mainly in areas such as business and
economics and from universities like Yale and Harvard,
have already become educational superstars. Students will
now enrol as much to hear their lectures as to take a
particular course, and teachers will increasingly be em-
ployed to headline particular teaching programmes, to
attract students. There is a parallel here with how sports
teams buy individuals with special talents to ensure success
both on the field and financially. There is absolutely no
reason why future university programmes will not head in
the same direction as our current sports teams, and this
will be supported by the eHealth environments of the
future, which will allow such superstar teachers, many of
whom will come from the health world, to be fitted easily
into prearranged courses and programmes, anytime, any-
where. Health education programmes will become more
flexible and will be available ubiquitously.
A future distributed eHealth care
environment
All of this will require a focus on distributed or enterprise
systems of information and communications technology,
and countries around the world are now beginning to
address the variety of technical issues involved.
The health system has to meet the challenges con-
tained in the recent crucially important report from the
Committee on Quality Healthcare in America, published
by the Institute of Medicine (Ross et al, 2001). This
influential report notes that information technology must
play a central role in the redesign of the healthcare system
and suggests that the United States needs a renewed
national commitment to build an information infrastructure
to support health care delivery, and that commitment
should lead to the elimination of most handwritten clinical
data by the end of the decade. For that to happen, the
health system has to think seriously about its basic infra-
structure requirements, and in the next century these will
increasingly involve close collaboration with telecommuni-
cations providers.
References
Ferguson, T. (1994) From industrial age medicine to information
age health care. In The Millennium Whole Earth Catalog (ed.
H. Rheingold). San Francisco, CA: Harper.
Murray, C. J. & Lopez, A. (1999) On the comparable quanti-
fication of health risks: lessons from the Global Burden of
Disease Study. Epidemiology, 1010
1010
10, 594605.
Ross, M. D., Twombly, I. A., Bruyns, C., et al (2001) Crossing
the Quality Chasm. A New Health System for the Twenty-First
Century. Albuquerque, NM: Institute of Medicine, University of
New Mexico Health Sciences Center.
Smith, R. (1997) The future of healthcare systems. British
Medical Journal, 314314
314314
314, 14951497.
Treister, N. W. (1997) Marketing and the medical specialist in the
managed care environment. Physician Executive, 2323
2323
23(6), 14
19.
Yack, D. (2000) Chronic disease and disability of the under-
privileged: tackling challenges. Business Briefing: Global Health
Care, October, 4549.
Yellowlees, P. (1997) Successful development of telemedicine
systems seven core principles.
Journal of Telemedicine and
Telecare, 33
33
3, 215222.
Yellowlees, P. (2001) Your Guide to eHealth Third Millennium
Medicine on the Internet. Brisbane: University of Queensland
Press.
THEMATHEMA
THEMATHEMA
THEMATIC PTIC P
TIC PTIC P
TIC PAPER TELEPSYAPER TELEPSY
APER TELEPSYAPER TELEPSY
APER TELEPSYCHIACHIA
CHIACHIA
CHIATRYTRY
TRYTRY
TRY
Cost issues with telepsychiatryCost issues with telepsychiatry
Cost issues with telepsychiatryCost issues with telepsychiatry
Cost issues with telepsychiatry
in the United Statesin the United States
in the United Statesin the United States
in the United States
Donald M. Hilty1, James A. Bourgeois2, Thomas S. Nesbitt3
and Robert E. Hales4
1Associate Professor of Clinical Psychiatry and Behavioral Sciences, Director of Telepsychiatry, University of
California Davis Medical Center, 2230 Stockton Boulevard, Sacramento, CA 95817, USA,
email dmhilty@ucdavis.edu
2Associate Professor of Clinical Psychiatry and Behavioral Sciences, Chief, ConsultationLiaison Division,
University of California Davis Medical Center, Sacramento, California, USA
3Associate Professor of Family and Community Medicine, Associate Dean, Regional Outreach and Telehealth,
University of California Davis Medical Center, Sacramento, California, USA
4Joe P. Tupin Professor and Chair of Psychiatry and Behavioral Sciences, University of California Davis Medical
Center, Sacramento, California, USA
VV
VV
Videoconferencing has increased patient accessideoconferencing has increased patient access
ideoconferencing has increased patient accessideoconferencing has increased patient access
ideoconferencing has increased patient access
to psychiatric care by linking specialists atto psychiatric care by linking specialists at
to psychiatric care by linking specialists atto psychiatric care by linking specialists at
to psychiatric care by linking specialists at
academic or regional health centres with primaryacademic or regional health centres with primary
academic or regional health centres with primaryacademic or regional health centres with primary
academic or regional health centres with primary
health care professionals in shortage areas (Hiltyhealth care professionals in shortage areas (Hilty
health care professionals in shortage areas (Hiltyhealth care professionals in shortage areas (Hilty
health care professionals in shortage areas (Hilty
et alet al
et alet al
et al, 1999, 2002). Preliminary studies have, 1999, 2002). Preliminary studies have
, 1999, 2002). Preliminary studies have, 1999, 2002). Preliminary studies have
, 1999, 2002). Preliminary studies have
demonstrated positive outcomes and userdemonstrated positive outcomes and user
demonstrated positive outcomes and userdemonstrated positive outcomes and user
demonstrated positive outcomes and user
satisfaction (Hilty satisfaction (Hilty
satisfaction (Hilty satisfaction (Hilty
satisfaction (Hilty et alet al
et alet al
et al, 2002)., 2002).
, 2002)., 2002).
, 2002).
Information is stillInformation is still
Information is stillInformation is still
Information is still
being sought regarding costs because of a paucitybeing sought regarding costs because of a paucity
being sought regarding costs because of a paucitybeing sought regarding costs because of a paucity
being sought regarding costs because of a paucity
of clinical outcome studies, cost data and ran-of clinical outcome studies, cost data and ran-
of clinical outcome studies, cost data and ran-of clinical outcome studies, cost data and ran-
of clinical outcome studies, cost data and ran-
domised trials.domised trials.
domised trials.domised trials.
domised trials.
There is absolutely
no reason why
future university
programmes will
not head in the
same direction as
our current sports
teams, and this
will be supported
by the eHealth
environments of
the future, which
will allow such
superstar
teachers to be
fitted easily into
prearranged
courses and
programmes,
anytime,
anywhere.
7
Issue 3, January 2004
The overall effectiveness of telepsychiatry has recently
been evaluated (Hilty et al, 2004a). Ideally, effectiveness
should be considered in terms of the patient, the provider
of services, the programme receiving services, the
community receiving services and society at large. Tele-
psychiatry appears effective with regard to access to care,
quality of care (in terms of outcomes, reliability, satisfaction
and comparison with in-person care), education and the
empowerment of rural communities. It may be premature
to claim it is cost-effective because of a lack of data. This
article reviews the cost data, discusses issues that affect
costs and makes recommendations to reduce costs.
Methods
A comprehensive review of the telepsychiatric literature
was conducted in the Medline, PubMed, PsychInfo,
EMBASE, Science Citation Index, Social Sciences Citation
Index and Telemedicine Information Exchange databases
(1965 to July 2003). Key words included telepsychiatry,
telemedicine, videoconferencing and costs. Article titles
and abstracts were reviewed by the first author and refer-
ences were reviewed for additional potential articles.
Results
Currently, there are over 50 telepsychiatry programmes in
the USA and another 14 in Canada (Hilty et al, 2004b).
Nearly all telepsychiatry services use dial-up integrated
service digital network (ISDN) or T1 lines, and transmit
at 128512 kbit/s (there is typically a 0.3 s audio and video
delay at the lower end of this range). Satellite transmission
is eight times as costly and almost always involves a 0.5
1.0 s delay in communication between parties.
Telepsychiatry works well in a number of regards. Most
studies have shown it to be diagnostically reliable compared
with in-person care for a wide range of diagnoses for
adults, children and geriatric populations (Hilty et al,
2004b). It appears to be generally acceptable to patients.
Telepsychiatry appears to allow the building of relationships,
with clear advantages over telephone consultation and few
disadvantages compared with in-person care. It may
improve outcomes; for example, in a study by Nesbitt et
al of specialty consultation to primary care providers,
including telepsychiatry, specialists changed the diagnosis in
91% of cases and recommended medication changes in
57%. Subsequently, 56% of patients showed clinical im-
provement (further details available from TSN on request).
Formal studies of cost-effectiveness are limited be-
cause:
the scope of data collection is often limited
cross-sectional rather than longitudinal measurement is
done
data have not been collected in a systematic, con-
trolled, prospective fashion.
One meta-analysis found that only 38 of 551 articles
contained any quantifiable cost data (Whitten et al, 2000).
Ideally, direct and indirect costs should be collected for
patients, clinics, providers and society at large. Many detailed
guidelines have been published with recommendations for
the assessment of cost-effectiveness measures in health
provider systems (Weinstein et al, 1996; Hailey &
Crowe, 2000; Hilty et al, 2004b).
Costs of telepsychiatry services
Direct costs include equipment, installation of lines and
other supplies. Fixed costs include the rental cost of lines,
salaries and wages, as well as administrative expenses. Vari-
able costs include data transmission costs, fees for service,
and maintenance and upgrades of equipment. Costs are
dependent on utilisation; for example, a break-even cost
analysis is used in Alberta, Canada (Hilty et al, 2004b). In
addition, the cost of telepsychiatry may seem high com-
pared with that of usual care in remote rural communities,
where usual care is often no care at all.
Telepsychiatry is in general less expensive for patients
than a conventional consultation, largely because it reduces
both travel and time away from work. Studies have been
inconsistent in their estimation of whether telepsychiatry
services are less expensive, as expensive or more
expensive than outreach services that involve personal
contact with the patient. Telepsychiatry, though, appears to
be cost-effective in terms of reducing the numbers of
patient transfers (e.g. Alessi, 1999) and hospital use (e.g.
Lyketsos et al, 2001). Communities have been able to
treat their patients locally and they have therefore retained
money that would otherwise have been lost to suburban
centres upon referral (Dimand et al, 2004).
The ongoing costs of maintaining telepsychiatry ser-
vices have been a major problem throughout the United
States. Start-up grants generally pay for technology, but not
for staff coordination and long-term psychiatric (physician)
service. Insurance or third-party payers have agreed to
fund physician time in most regards, although they often
require preliminary educational and administrative inter-
ventions. County mental health systems often deny tele-
psychiatry claims, partly in order to keep costs low but also
because the services are provided outside of their system,
in the medical sector. This is a problem because patients
receive 60% of their mental health services from the
medical sector, which they generally prefer because it
generates less stigma and gives patients the ability to main-
tain their relationship with the primary care provider, and
because of what is widely perceived to be inadequate care
in the mental health sector.
Federal programmes have been established with high
specialist reimbursement for some rural patients, but
telepsychiatry services do not qualify. This is because
telepsychiatry consultations are viewed as being provided
outside the designated clinics.
When rural agencies have funds available, contracts
with academic consultationliaison services have proved
successful in terms of patient outcomes. The use of
residents with faculty supervision appears to reduce costs
and provides them with a meaningful learning experience.
Consultationliaison services benefit from an expansion in
the scope of their work to the out-patient sector and
improved reimbursement (e.g. salary and benefits, as
reimbursement for an in-patient medical centre con-
sultation is limited) (Bourgeois et al, 2003).
Telepsychiatry
appears effective
with regard to
access to care,
quality of care,
education and the
empowerment of
rural communities.
It may be
premature to
claim it is cost-
effective because
of a lack of data.
The ongoing costs
of maintaining
telepsychiatry
services have been
a major problem
throughout the
United States.
Start-up grants
generally pay for
technology, but
not for staff
coordination and
long-term
psychiatric service.
8
Bulletin of the Board of International Affairs of the Royal College of Psychiatrists
Discussion
Little information is available about the cost-effectiveness
and costbenefit of telepsychiatry programmes; and data
need to be collected in a standard, prospective, preferably
longitudinal fashion. However, cost-effectiveness could be
improved by use of a consultationliaison model, whereby
the telepsychiatrist evaluates the patient and makes recom-
mendations for management by the primary care provider,
who thereby gains skills that could benefit patients and the
community setting. This educational role of telepsychiatry
is especially important for the primary care providers of
rural communities, in which 20% of the US population
lives.
References
Alessi, N. (1999) Cost-effectiveness analysis in forensic tele-
psychiatry: prisoner involuntary treatment evaluations.
Telemedicine Journal and E-Health, 55
55
5, 17.
Bourgeois, J. A., Hilty, D. M., Klein, S. C., et al (2003) Expansion
of the consultationliaison psychiatry paradigm at a university
medical center: integration of diversified clinical and funding
models. General Hospital Psychiatry, 2525
2525
25, 262268.
Dimand, R. J., Marcin, J. P., Struve, S., et al (2004) Financial
benefits of a pediatric care unit based telemedicine program
to a rural adult intensive care unit: impact of keeping acutely
ill and injured children in their local community. Telemedicine
Journal and E-Health (in press).
Hailey, D. M. & Crowe, B. L. (2000) Assessing the economic
impact of telemedicine. Disease Management and Health
Outcomes, 77
77
7, 187192.
Hilty, D. M., Servis, M. E., Nesbitt, T. S., et al (1999) The use
of telemedicine to provide consultationliaison service to the
primary care setting. Psychiatric Annals, 2929
2929
29, 421427.
Hilty, D., Luo, J. S., Morache, C., et al (2002) Telepsychiatry:
what is it and what are its advantages and disadvantages? CNS
Drugs, 1616
1616
16, 527548.
Hilty, D. M., Liu, W., Marks, S., et al (2004a) The effectiveness
of telepsychiatry: a brief review. Canadian Psychiatric
Association Bulletin (in press).
Hilty, D. M., Marks, S., Urness, D., et al (2004b) Clinical and
educational applications of telepsychiatry: a review. Canadian
Journal of Psychiatry (in press).
Lyketsos, C., Roques, C., Hovanec, L., et al (2001) Telemedicine
use and reduction of psychiatric admissions from a long-term
care facility. Journal of Geriatric Psychiatry and Neurology, 1414
1414
14,
7679.
Weinstein, M. C., Siegel, J. E., Gold, M. R., et al (1996)
Recommendations of the Panel on Cost-effectiveness in Health
and Medicine. Journal of the American Medical Association,
276276
276276
276, 12531258.
Whitten, P., Kingsley, C. & Grigsby, J. (2000) Results of a meta-
analysis of costbenefit research: is this a question worth asking?
Journal of Telemedicine and Telecare, 6 6
6 6
6 (suppl. 1), 46.
THEMATIC PAPER TELEPSYCHIATRYTHEMATIC PAPER TELEPSYCHIATRY
THEMATIC PAPER TELEPSYCHIATRYTHEMATIC PAPER TELEPSYCHIATRY
THEMATIC PAPER TELEPSYCHIATRY
TT
TT
Telepsychiatry in Europeelepsychiatry in Europe
elepsychiatry in Europeelepsychiatry in Europe
elepsychiatry in Europe
Paul McLaren
Consultant Psychiatrist, South London and Maudsley NHS Trust, Speedwell Mental Health Centre, 62 Speedwell
Street, Deptford, London SE8 4AT, UK; The Priory Ticehurst House, Ticehurst, Wadhurst, East Sussex TN5 7 HU,
UK, email PMcl639251@aol.com
TT
TT
Telepsychiatryelepsychiatry
elepsychiatryelepsychiatry
elepsychiatry, the use of videoconferencing in, the use of videoconferencing in
, the use of videoconferencing in, the use of videoconferencing in
, the use of videoconferencing in
mental health care, has been piloted in Euromental health care, has been piloted in Euro
mental health care, has been piloted in Euromental health care, has been piloted in Euro
mental health care, has been piloted in Euro--
--
-
pean settings as diverse as northern Norway andpean settings as diverse as northern Norway and
pean settings as diverse as northern Norway andpean settings as diverse as northern Norway and
pean settings as diverse as northern Norway and
inner London. These studies have been initiatedinner London. These studies have been initiated
inner London. These studies have been initiatedinner London. These studies have been initiated
inner London. These studies have been initiated
to improve access to services and have been limitedto improve access to services and have been limited
to improve access to services and have been limitedto improve access to services and have been limited
to improve access to services and have been limited
in scale. Nevertheless, some common themes havein scale. Nevertheless, some common themes have
in scale. Nevertheless, some common themes havein scale. Nevertheless, some common themes have
in scale. Nevertheless, some common themes have
emerged.emerged.
emerged.emerged.
emerged.
Telepsychiatry in Norway
Gammon et al (1996) surveyed the use of videocon-
ferencing in mental health services in northern Norway
in
1995. Over six months, 1028 persons participated in
140 videoconferencing sessions from 35 institutions. The
uses of videoconferencing included meetings (50%),
supervision, training and teaching (31%), clinical consul-
tations (14%) and tests or demonstrations (5%). The
forms of contact that videoconferencing replaced included
travel (59%), no contact (25%), telephone (14%) and
mail or fax (2%). No problems were reported in 55% of
the sessions. The majority of users reported that they
were satisfied or very satisfied with the facility. The low rate
of clinical videoconferencing reflects a reluctance of key
professionals to offer services this way. This network has
continued to grow.
Gammon et al (1998) also reported the use of video-
conferencing for psychotherapy supervision, over 384
kbit/s integrated service digital network (ISDN) connec-
tions. Trainees had five face-to-face sessions, alternating
weekly with videoconferencing. The quality of supervision
could be satisfactorily maintained by videoconferencing,
for up to half of the 70 hours required for training. A pre-
condition for this estimate was that the supervision dyad
should meet face to face and establish a relationship
characterised by mutual trust and respect. Major concerns
reported by the participants were the loss of non-verbal
cues and the effects this had on spontaneity, the expres-
sion of personal emotional material, and the experience
of social and emotional presence.
Telepsychiatry in Finland
Mielonen et al (1998) reported on the use of video-
conferencing in Oulu, where videoconferencing at 384
kbit/s was used for family therapy, occupational counselling,
clinical consultation and teaching. In 1996, video-
The uses of video-
conferencing
included meetings
(50%), super-
vision, training
and teaching
(31%), clinical
consultations
(14%) and tests or
demonstrations
(5%). The low
rate of clinical
videoconferencing
reflects a reluc-
tance of key
professionals to
offer services this
way.
Little information
is available about
the cost-
effectiveness and
costbenefit of
telepsychiatry
programmes.
... In addition, the start-up costs of telepsychiatry can be a barrier to smaller community-based clinics that must purchase up to date equipment and compatible software and provide training to medical staff on the use of this technology. 12 HIPPA requirements can also increase barriers to establish telepsychiatry at various medical practices. In addition, Raveesh et al. 13 discussed the possibility that providers intentionally or unintentionally coerce patients into using telepsychiatry over traditional in-person visits, assuming it is more convenient or profitable for the provider to treat patients virtually. ...
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Telemedicine and telehealth both describe the use of medical information exchanged from one site to another by means of electronic communications. This process is described in the American Telemedicine Association’s Practice Guidelines for Video-Conferencing for TeleMental Health as “electronic communication between multiple users at two or more sites which facilitates voice, video, and/or data transmission systems, and the audio, graphics, computer, and video systems required to do so” [1]. Emergency telepsychiatry involves the delivery of direct patient care or physician consultation to emergency departments (EDs) by a qualified psychiatrist over audio–visual communication systems. The discipline of emergency psychiatry dates back to the period from the mid 1950s to early 1960s; a time in which psychiatric patients were being discharged from largely rural state psychiatrist hospitals due to the availability of the first antipsychotic medication, chlorpromazine [2]. Many mental health patients gravitated toward urban environments, often without sufficient community-based care, resulting in frequent presentation to medical emergency rooms or jails in acute crisis.
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Consultation-liaison (CL) psychiatry is psychiatry for the medically ill. This review describes the evolution of CL psychiatry from its origins in early 20th century general hospitals to the present era. The differences between CL psychiatry and general psychiatry are emphasized. The CL psychiatrist works in a multi-specialty and interdisciplinary environment whereas the general psychiatrist may not. Because of the CL psychiatrist’s experience with comorbid psychiatric and physical illness, he/she is skilled in the management of psychiatric comorbidity in the medically ill. Healthcare systems now require integrated models of service delivery in resource-sensitive environments. The CL psychiatrist is qualified to advise fellow physicians and other healthcare practitioners in how to manage psychiatric illness. CL psychiatrists have clinical, educational, administrative and research roles that are valuable in the delivery of comprehensive medical care in integrated, outcome-oriented systems.
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Nowhere is information technology potentially more critical in the redesign of the health-care delivery system than in rural and frontier areas (Institute of Medicine, 2004), where it has the potential to dramatically change the way caregiving occurs. We are moving from health-care systems aimed at providing episodic institutional care for the treatment of illnesses to information-based systems seeking to promote increased consumer and caregiver involvement in the prevention of illness across the life span. Rural and frontier providers and caregivers are often faced with the need to provide a broad scope of practice with regard to medical condition, age, socioeconomic level, culture, and gender (Rosenthal & Fox, 2000). This occurs in an environment with far fewer specialty consultants and ancillary resources, and where a higher threshold for referral to larger centers may exist because of distance and economics (Rosenblatt & Hart, 1999).
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Objective. —To develop consensus-based recommendations for the conduct of cost-effectiveness analysis (CEA). This article, the second in a 3-part series, describes the basis for recommendations constituting the reference case analysis, the set of practices developed to guide CEAs that inform societal resource allocation decisions, and the content of these recommendations.Participants. —The Panel on Cost-Effectiveness in Health and Medicine, a nonfederal panel with expertise in CEA, clinical medicine, ethics, and health outcomes measurement, was convened by the US Public Health Service (PHS).Evidence. —The panel reviewed the theoretical foundations of CEA, current practices, and alternative methods used in analyses. Recommendations were developed on the basis of theory where possible, but tempered by ethical and pragmatic considerations, as well as the needs of users.Consensus Process. —The panel developed recommendations through 21/2 years of discussions. Comments on preliminary drafts prepared by panel working groups were solicited from federal government methodologists, health agency officials, and academic methodologists.Conclusions. —The panel's methodological recommendations address (1) components belonging in the numerator and denominator of a cost-effectiveness (C/E) ratio; (2) measuring resource use in the numerator of a C/E ratio; (3) valuing health consequences in the denominator of a C/E ratio; (4) estimating effectiveness of interventions; (5) incorporating time preference and discounting; and (6) handling uncertainty. Recommendations are subject to the "rule of reason," balancing the burden engendered by a practice with its importance to a study. If researchers follow a standard set of methods in CEA, the quality and comparability of studies, and their ultimate utility, can be much improved.
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Telepsychiatry, in the form of videoconferencing and other modalities, brings enormous opportunities for clinical care, education, research and administration to the field of medicine. A comprehensive review of the literature related to telepsychiatry — specifically videoconferencing — was conducted using the MEDLINE, Embase, Science Citation Index, Social Sciences Citation Index and Telemedicine Information Exchange databases (1965 to June 2001). The keywords used were telepsychiatry, telemedicine, videoconferencing, Internet, primary care, education, personal digital assistant and handheld computers. Studies were selected for review if they discussed videoconferencing for patient care, satisfaction, outcomes, education and costs, and provided models of facilitating clinical service delivery. Literature on other technologies was also assessed and compared with telepsychiatry to provide an idea of future applications of technology. Published data indicate that telepsychiatry is successfully used for a variety of clinical services and educational initiatives. Telepsychiatry is generally feasible, offers a number of models of care and consultation, in general satisfies patients and providers, and has positive and negative effects on interpersonal behaviour. More quantitative and qualitative research is warranted with regard to the use of telepsychiatry in clinical and educational programmes and interventions.
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Telemedicine is one strategy to improve the accessibility of mental health care in the primary care setting, including primary care clinics linked to academic medical centers. Successful applications of telemedicine will be facilitated by an awareness of consultation models, as well as of patient, physician, and system factors that affect psychiatric consultation-liaison service to the primary care setting. In preliminary studies, patient satisfaction with telepsychiatric care is comparable to patient satisfaction with in-person psychiatric care and other specialty care via telemedicine. Controlled trials are needed to further assess patient and provider satisfaction, as well as variables that affect satisfaction.
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The objective of this research was to examine the fiscal impact of telemedicine consultations for acutely ill and injured children in a rural setting using pediatric intensive care unit (ICU) telemedicine. One hundred seventy-nine acutely ill and injured infants and children were cared for in the Mercy Redding ICU from April 2000 to April 2002. Data were gathered from these patients, including 47 patients who received 70 pediatric ICU telemedicine consultations during the same time period. Transport and hospital costs avoided were calculated for patients who received telemedicine consultations (Group 1) and for those not transferred due to the availability telemedicine consultations (Group 2), estimated to be one-half of the 179 patients (Group 2). The revenue generated in the rural ICU based on the ability to keep these patients was also determined. An estimated annual cost savings of $172,000 and $300,000 for transport and inpatient care was demonstrated for Group 1 and Group 2, respectively. Additionally, this program resulted in generating $186,000 and $279,000 of inpatient revenue annually for the two groups at the rural hospital. The cost of this program was approximately $120,000 per year. Given the substantial financial savings, support for underserved rural programs, and significant funds kept in the rural community, this may serve as a viable model for providing care to acutely ill and injured infants and children.
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Telemedicine is a communications technology that can be expected to influence investment in equipment, the delivery and organisation of health services and outcomes of healthcare. Analysis of the economic impact of telemedicine has so far been limited and has focused on cost studies for individual applications. Telemedicine initiatives should be compared with conventional alternatives. A search of recent literature revealed 20 such studies that included, usually limited, economic analyses. It is important to note, however, that such assessments apply to localised situations and may not be generalisable. Overall, the potential impact of telemedicine on healthcare systems remains unclear. The challenges that lie ahead for telemedicine, and its economic assessment, include technological change, sustainability of applications, availability of outcomes and other data, and generalisability of evaluation results.
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We attempted a meta-analysis of telemedicine research studies of the costs associated with telemedicine. First, we performed a search of six well known databases with a variety of relevant keywords. After discarding non-English publications, books and duplicate publications resulting from the same study, we were left with 551 articles for analysis. Our second step was to separate the articles into two groups: those with and those without quantitative cost data. Only 38 articles contained any type of real data. Because many of these 38 studies proved to be inadequately designed or conducted, we were unable to perform a traditional meta-analysis. Furthermore, there were a number of disturbing features common to these studies, including the omission of the number of consultations or patients, almost non-existent longitudinal data collection and lack of uniformity in cost analyses. We conclude that it is premature for any statements to be made, either positive or negative, regarding the cost-effectiveness of telemedicine in general.
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Copper Ridge is a long-term care facility that provides care for persons with dementia and their families from early diagnosis to end of life. A low-cost videoconferencing system was employed in the development of a comprehensive, integrated continuum of care for Copper Ridge residents by bridging long-term care with inpatient psychiatric care at Johns Hopkins Hospital. In this article, we discuss the Copper Ridge/Johns Hopkins telemedicine project and how its operation appears to have brought about a reduction in psychiatric admissions. Telemedicine projects using inexpensive technology over standard telephone lines can be successfully used in long-term care settings.
Article
Telepsychiatry, in the form of videoconferencing and other modalities, brings enormous opportunities for clinical care, education, research and administration to the field of medicine. A comprehensive review of the literature related to telepsychiatry - specifically videoconferencing - was conducted using the MEDLINE, Embase, Science Citation Index, Social Sciences Citation Index and Telemedicine Information Exchange databases (1965 to June 2001). The keywords used were telepsychiatry, telemedicine, videoconferencing, Internet, primary care, education, personal digital assistant and handheld computers. Studies were selected for review if they discussed videoconferencing for patient care, satisfaction, outcomes, education and costs, and provided models of facilitating clinical service delivery. Literature on other technologies was also assessed and compared with telepsychiatry to provide an idea of future applications of technology. Published data indicate that telepsychiatry is successfully used for a variety of clinical services and educational initiatives. Telepsychiatry is generally feasible, offers a number of models of care and consultation, in general satisfies patients and providers, and has positive and negative effects on interpersonal behaviour. More quantitative and qualitative research is warranted with regard to the use of telepsychiatry in clinical and educational programmes and interventions.
Article
The perspective of the contemporary Consultation-Liason Service (CLS) psychiatrist is increasingly one of consultant to medical and surgical colleagues in models other than inpatient medical and surgical units. Simultaneously, the need for a clinically and educationally robust inpatient CLS persists despite funding pressures. The University of California, Davis Medical Center Department of Psychiatry has made use of creative organizational and financial models to accomplish the inpatient CLS clinical and educational missions in a fiscally responsible manner. In addition, the department has in recent years expanded the delivery of psychiatry consultation-liaison clinical and educational services to other models of care delivery, broadening the role and influence of the CLS. Several of the initiatives described in this paper parallel an overall evolution of the practice of consultation-liaison psychiatry in response to managed care influences and other systems pressures. This consultation-liaison paradigm expansion with diversified sources of funding support facilitates the development of consultation-liaison psychiatry along additional clinical, administrative, research, and educational dimensions. Other university medical centers may consider adaptation of some of the initiatives described here to their institutions.