[Show abstract][Hide abstract] ABSTRACT: We have reached a critical convergence in psychiatry between the changing systems of health care structure and funding, our evolution into a technology-based society, and growth in the science and delivery of psychiatric treatments. Fostered by this convergence is the maturation over the past two decades of telepsychiatry, in the form of live interactive video conferencing, as a critical tool to improve access, increase quality and reduce costs of psychiatric treatment. This article reviews the history and evolution of telepsychiatry including implications for the field in order to provide individual psychiatrists and psychiatric organizations guidance on how to formulate current and strategic directions. This article begins with a broad overview of the history of medicine providing contextualization of the development of the field of telepsychiatry. It concludes with projected trends and recommendations.
No preview · Article · Sep 2015 · International Review of Psychiatry
[Show abstract][Hide abstract] ABSTRACT: The purpose of this brief report is to make clinical and research recommendations to advance current knowledge and practices related to the assessment of antipsychotic drug-induced movement disorders (DIMDs) via live interactive videoconferencing.
The authors provide an overview of the frequent neurological side effects of antipsychotic drugs and review relevant telemedicine research. DIMD prevention is critical, but these disorders remain underdetected and under-reported. Although there are not yet formal recommendations for specific screening tools or screening frequency, baseline and annual assessments are generally agreed-upon minimums. As DIMD awareness increases and more specific guidelines are developed to steer assessments, telemental health may aid practitioners in efficiently and regularly monitoring onset and severity. Research shows that videoconferencing can be used for effective psychiatric treatments and assessment, with at least one study validating the use of videoconference assessment for a subset of movement disorders.
Clinical recommendations include developing practice-level protocols and procedures that include regular DIMD assessment (either in-person or via telemedicine) for the full spectrum of possible movement disorders for all patients taking antipsychotic medications. Research and evaluation recommendations include replicating and expanding upon the existing study using videoconferencing to assess movement disorder symptoms, using asynchronous telemental health assessments of DIMDs, and pilot-testing facial and movement recognition software to allow for clinical comparison of patients' movement patterns over time.
No preview · Article · Jun 2015 · Telemedicine and e-Health
[Show abstract][Hide abstract] ABSTRACT: Many Native veterans-including American Indian/Alaska Native (AIAN) and Native Hawaiian/Pacific Islanders (NHPI)-have served in the United States Armed Forces. Most of these veterans are eligible for medical care from the Department of Veterans Affairs (VA), but research examining the determinants of their service use is needed to inform policy and allocate appropriate resources for these unique groups. In a retrospective cohort study, we examined the impact of Native veterans' personal demographics on their outpatient utilization of VA-based primary care and mental health services. AIAN (n = 37,687) and NHPI (n = 46,582) veterans were compared with a non-Native reference (N = 262,212) using logistic and binomial regression. AIAN and NHPIs were more likely to be female, report military sexual trauma, and utilize the VA for posttraumatic stress disorder, traumatic brain injury, depression, addiction, anxiety, hypertension, and diabetes care. More AIAN and urban NHPI veterans served in Iraq and Afghanistan, and Native women reported more military sexual trauma than their non-Native counterparts. Primary care and mental health services were associated with race, number of diagnoses, and disability ratings. For mental health services, service era, military sexual trauma, and marital status were related to service utilization. Native veterans' medical need was elevated for primary and mental health care. Rural residence was associated with less mental health use. The findings underscore the need for additional specialized services in rural areas, more targeted outreach to Operation Enduring Freedom/Operation Iraqi Freedom Native veterans, and additional care directed toward Native women's health care needs. (PsycINFO Database Record
(c) 2015 APA, all rights reserved).
No preview · Article · May 2015 · Psychological Services
[Show abstract][Hide abstract] ABSTRACT: There is a national shortage of psychiatrists, and according to nationally available data, it is projected to get worse. Locum tenens psychiatry and telepsychiatry are two ways to fill the shortages of psychiatric providers that exist in many areas in the United States. Employment and salary data in these areas can be used to illuminate current trends and anticipate future solutions to the problem of increasing demand for, and decreasing supply of, psychiatrists in the United States.
A search was conducted of the literature and relevant Web sites, including PubMed, Google Scholar, and www.google.com , as well as information obtained from locum tenens and telepsychiatry organizations.
There is a dearth of data on the use of locum tenens in the field of psychiatry, with little available prior to 2000 and few published studies since then. The majority of the data available are survey data from commercial entities. These data show trends toward increasing demand for psychiatry along with increasing salaries and indicate the utilization of telepsychiatry and locum tenens telepsychiatry is increasing. The published academic data that are available show that although locum tenens psychiatry is slightly inferior to routine psychiatric care, telepsychiatry is generally equivalent to face-to-face care.
One can anticipate that as the national shortage of psychiatrists is expected to accelerate, use of both locum tenens and telepsychiatry may also continue to increase. Telepsychiatry offers several possible advantages, including lower cost, longer-term services, quality of care, and models that can extend psychiatric services. If current trends continue, systems that demand face-to-face psychiatry may find themselves paying higher fees for locum tenens psychiatrists, whereas others may employ psychiatrists more efficiently with telepsychiatry.
No preview · Article · Mar 2015 · Telemedicine and e-Health
[Show abstract][Hide abstract] ABSTRACT: Introduction:
The Centers for Medicare and Medicaid Services has incentivized electronic health records (EHRs) implementation through meaningful use (MU) to improve healthcare quality and efficacy. Telemedicine is a key tool that has shown its ability to facilitate MU through technological innovation with cost savings and has shown promise in the area of integrated behavioral healthcare. The purpose of this article is to propose a model of MU to frame the incentivized implementation of an integrated telemedicine (ITM)-specific model to effect system-level change.
Materials and methods:
We reviewed the background, principles, and a justification for the ITM Model including cost issues, the development and structure of MU in the context of EHRs, the benefits of integrated behavioral healthcare and telemedicine, and the case for their combined implementation in the form of ITM.
The model proposed, the ITM Incentive Program, parallels the current MU program and is composed of three stages. Stage 1 focuses on incentivizing current and new Medicaid providers to adapt, implement, and upgrade technology needed to conduct virtual meetings with patients and other healthcare professionals. Stage 2 is a tiered incentive system with process-focused and track metrics related to increasing the number of consultations with patients. In Stage 3, providers are encouraged to continue use of ITM by meeting thresholds for several objectives focused on clinical outcomes. Recommendations for implementing this model within a payment waiver system are discussed.
The ITM Model offers a needed union of integrated care and telemedicine through the combination of technology, business, and clinical processes. The success of MU as a tiered incentive program for EHRs, as well as the precedent of using waiver opportunities for incentive funding repayments, sets forth a strategic framework to successful implementation of ITM to address cost issues and improve quality and access to care in the healthcare system.
No preview · Article · Jan 2015 · Telemedicine and e-Health
[Show abstract][Hide abstract] ABSTRACT: Objectives:
We conducted an exploratory study to determine what organizational characteristics predict the provision of culturally competent services for American Indian and Alaska Native (AI/AN) veterans in Department of Veterans Affairs (VA) health facilities.
In 2011 to 2012, we adapted the Organizational Readiness to Change Assessment (ORCA) for a survey of 27 VA facilities in the Western Region to assess organizational readiness and capacity to adopt and implement native-specific services and to profile the availability of AI/AN veteran programs and interest in and resources for such programs.
Several ORCA subscales (Program Needs, Leader's Practices, and Communication) statistically significantly predicted whether VA staff perceived that their facilities were meeting the needs of AI/AN veterans. However, none predicted greater implementation of native-specific services.
Our findings may aid in developing strategies for adopting and implementing promising native-specific programs and services for AI/AN veterans, and may be generalizable for other veteran groups.
Preview · Article · Sep 2014 · American Journal of Public Health
[Show abstract][Hide abstract] ABSTRACT: Mental health problems pose challenges for military veterans, returning service members, and military family members including spouses and children. Challenges to meeting mental health needs include improving access to care and improving quality of care. Mobile Health, or "mHealth," can help meet these needs in the garrison and civilian environments. mHealth brings unique capabilities to health care provision through the use of mobile device technologies. This report identifies high-priority mHealth technology development considerations in two categories. First, priority considerations specific to mental health care provision include safety, privacy, evidence-based practice, efficacy studies, and temperament. Second, priority considerations broadly applicable to mHealth include security, outcomes, ease of use, carrier compliance, hardware, provider perspectives, data volume, population, regulation, command policy, and reimbursement. Strategic planning for the advancement of these priority considerations should be coordinated with stated Department of Defense capability needs to maximize likelihood of adoption. This report also summarizes three leading, military programs focused on mHealth projects in mental health, The Telemedicine and Advanced Technology Research Center, The Military Operational Medicine Research Program, United States Army Medical Research and Materiel Command, and The National Center for Telehealth and Technology.
[Show abstract][Hide abstract] ABSTRACT: Background:
This study examined predictors associated with readmission to detoxification in a sample of adult Alaska Native patients admitted to inpatient alcohol detoxification. Even though Alaska Native people diagnosed with alcoholism have been identified as frequent utilizers of the health care system and at elevated risk of death, little is known about factors associated with readmission to detoxification for this group.
We sought to predict readmission using a retrospective cohort study. The sample included 383 adult Alaska Native patients admitted to an inpatient detoxification unit and diagnosed with alcohol withdrawal during 2006 and 2007. Cox proportional hazard modeling was used to estimate unadjusted and adjusted associations with time to readmission within one year.
Forty-two percent of the patients were readmitted within one year. Global Assessment Functioning (GAF; Axis V in the multi-axial diagnostic system of the Diagnostic and Statistical Manual of Mental Disorders [DSM IV]) score measured at the time of intake was associated with readmission. A one point increase in the GAF score (HR=.96, 95% CL=.94, .99, P=.002) was associated with a four percent decrease in readmission. The results also indicated that the GAF mediated the relationship between readmission and: employment and housing status.
The GAF measures both illness severity and adaptive functioning, is part of standard behavioral health assessments, and is easy to score. Readmission rates potentially could be decreased by creating clinical protocols that account for differences in adaptive functioning and illness severity during detoxification treatment and aftercare.
No preview · Article · Apr 2014 · Drug and Alcohol Dependence
[Show abstract][Hide abstract] ABSTRACT: While many women choose to live in rural areas after retiring from active military duty, a paucity of studies examine rural women veterans' health care needs. This report is the first of its kind to describe the population demographics and health care utilization of rural female veteran patients enrolled in the Department of Veterans Affairs (VA).
Using the National Patient Care Datasets (n = 327,785), we ran adjusted regression analyses to examine service utilization between (1) urban and rural and (2) urban and highly rural women veterans.
Rural and highly rural women veterans were older and more likely to be married than their urban counterparts. Diagnostic rates were generally similar between groups for several mental health disorders, hypertension, and diabetes, with the exception of nonposttraumatic stress anxiety that was significantly lower for highly rural women veterans. Rural and highly rural women veterans were less likely to present to the VA for women's specific care than urban women veterans; highly rural women veterans were less likely to present for mental health care compared to urban women veterans. Among the users of primary care, mental health, women's specific, and all outpatient services, patients' annual utilization rates were similar.
Improved service options for women's specific care and mental health visits may help rural women veterans access care. Telehealth technologies and increased outreach, perhaps peer-based, should be considered. Other recommendations for VA policy and planning include increasing caregiver support options, providing consistency for mental health services, and revising medical encounter coding procedures.
No preview · Article · Apr 2014 · The Journal of Rural Health
[Show abstract][Hide abstract] ABSTRACT: American Indians and Alaska Natives serve at the highest rate of any US race or ethnic group, yet are the most underserved population of Veterans and do not take advantage of the Department of Veterans Affairs (VA) benefits and services. Barriers to seeking care include stigma, especially for mental health issues; distance to care; and lack of awareness of benefits and services they are entitled to receive. In response to this underutilization of the VA, an innovative program-the Tribal Veterans Representative (TVR) program-was developed within the VA to work with American Indians and Alaska Natives in rural and remote areas. The TVR goes through extensive training every year; is a volunteer, a Veteran and tribal community member who seeks out unenrolled Native Veterans, provides them with information on VA health care services and benefits, and assists them with enrollment paperwork. Being from the community they serve, these outreach workers are able to develop relationships and build rapport and trust with fellow Veterans. In place for over a decade in Montana, this program has enrolled a countless number of Veterans, benefiting not only the individual, but their family and the community as well. Also resulting from this program, are the implementation of Telemental Health Clinics treating Veterans with PTSD, a transportation program helping Veterans get to and from distant VA facilities, a Veteran Resource Center, and a Veteran Tribal Clinic. This program has successfully trained over 800 TVRs, expanded to other parts of the country and into remote areas of Alaska.
Preview · Article · Mar 2014 · Journal of Community Health
[Show abstract][Hide abstract] ABSTRACT: Background:
The purpose of this document is to provide initial recommendations to telemental health (TMH) professionals for the selection of assessment and outcome measures that best reflect the impacts of mental health treatments delivered via live interactive videoconferencing.
Materials and methods:
The guidance provided here was created through an expert consensus process and is in the form of a lexicon focused on identified key TMH outcomes.
Each lexical item is elucidated by a definition, recommendations for assessment/measurement, and additional commentary on important considerations. The lexicon is not intended as a current literature review of the field, but rather as a resource to foster increased dialogue, critical analysis, and the development of the science of TMH assessment and evaluation. The intent of this lexicon is to better unify the TMH field by providing a resource to researchers, program managers, funders, regulators and others for assessing outcomes.
This document provides overall context for the key aspects of the lexicon.
Full-text · Article · Jan 2014 · Telemedicine and e-Health
[Show abstract][Hide abstract] ABSTRACT: This study compared common deployment-related health issues and correlates of mental health service utilization among rural and urban veterans of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) living in Hawaii. Frequency of utilization of a broad range of mental health resources, including clergy/spiritual leaders, videoconference/online programs, and traditional/alternative healers, was also characterized. A random sample of 116 rural and 117 urban ethnoracially diverse veterans completed a mail survey. Rural veterans were more likely than urban veterans to meet screening criteria for posttraumatic stress disorder (PTSD), deployment-related concussion with persistent postconcussive symptoms, and alcohol use problems. Over one third of veterans who desired help for a mental health problem reported no current use of any services. Rural veterans were more likely than urban veterans to have accessed Veteran Readjustment Centers, but they did not differ with respect to utilization of other services. Correlates of mental health service utilization included higher education, PTSD, and lower mental-health-related quality of life. Results of this study underscore the need for dissemination efforts to enable OEF/OIF/OND veterans to access mental health resources. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
No preview · Article · Oct 2013 · Psychological Services
[Show abstract][Hide abstract] ABSTRACT: Table of Contents PREAMBLE SCOPE INTRODUCTION Internet-Based Telemental Health Models of Care Today CLINICAL GUIDELINES A. Professional and Patient Identity and Location 1. Provider and Patient Identity Verification 2. Provider and Patient Location Documentation 3. Contact Information Verification for Professional and Patient 4. Verification of Expectations Regarding Contact Between Sessions B. Patient Appropriateness for Videoconferencing-Based Telemental Health 1. Appropriateness of Videoconferencing in Settings Where Professional Staff Are Not Immediately Available C. Informed Consent D. Physical Environment E. Communication and Collaboration with the Patient's Treatment Team F. Emergency Management 1. Education and Training 2. Jurisdictional Mental Health Involuntary Hospitalization Laws 3. Patient Safety When Providing Services in a Setting with Immediately Available Professionals 4. Patient Safety When Providing Services in a Setting Without Immediately Available Professional Staff 5. Patient Support Person and Uncooperative Patients 6. Transportation 7. Local Emergency Personnel G. Medical Issues H. Referral Resources I. Community and Cultural Competency TECHNICAL GUIDELINES A. Videoconferencing Applications B. Device Characteristics C. Connectivity D. Privacy ADMINISTRATIVE GUIDELINES A. Qualification and Training of Professionals B. Documentation and Record Keeping C. Payment and Billing REFERENCES.
Full-text · Article · Aug 2013 · Telemedicine and e-Health
[Show abstract][Hide abstract] ABSTRACT: The Department of Veterans Affairs (VA) and the Indian Health Service (IHS) signed a Memo of Understanding in 2010 to strengthen their partnership in improving health care services for Native veterans, who are disproportionately rural. This paper describes the demographic and service use profile of rural Native veterans who access VA health care.
Data were abstracted from the 2008 Veteran Health Administration (VHA) medical dataset, and the characteristics of rural Native veterans were compared to rural non-Native veterans.
Rural Native veterans were more rural (41% vs 35%) and more highly rural (8% vs 2%) compared to non-Native veterans. Rural Native veterans were younger, more likely to be female, and earned about the same median income compared to rural non-Native veterans. Although rural Native veterans had fewer diagnoses on average, they were more likely to have served in combat areas and to have higher levels of service-connected disability compared to other rural veterans.
Demographic and service-related characteristics of rural Native veterans who accessed VA care differ from those of rural non-Native veterans. Identifying specific health care and service use characteristics will assist in the development of appropriate policy and programs to serve rural Native veterans.
No preview · Article · Jun 2013 · The Journal of Rural Health
[Show abstract][Hide abstract] ABSTRACT: Background
Physician health programmes (PHPs) are peer-assistance organizations that provide support to physicians struggling with addiction or with physical or mental health challenges. While the services they offer are setting new standards for recovery and care, they are not immune to public debate and criticism since some have concerns about those who are enrolled in, or have completed, such programmes and their subsequent ability to practice medicine safely.AimsTo examine whether medical malpractice claims were associated with monitoring by a PHP using a retrospective examination of administrative data.Methods
Data on PHP clients who were insured by the largest malpractice carrier in the state were examined. First, a business-model analysis of malpractice risk examined relative risk ratings between programme clients and a matched physician cohort. Second, Wilcoxon analysis examined differences in annual rates of pre- and post-monitoring claims for PHP clients only.ResultsData on 818 clients was available for analysis. After monitoring, those enrolled in the programme showed a 20% lower malpractice risk than the matched cohort. Furthermore physicians' annual rate of claims were significantly lower after programme monitoring among PHP clients (P < 0.01).Conclusions
This is the only study examining this issue to date. While there are a variety of reasons why physicians present to PHPs, this study demonstrates that treatment and monitoring is associated with a lowered risk of malpractice claims and suggests that patient care may be improved by PHP monitoring.
Preview · Article · Apr 2013 · Occupational Medicine
[Show abstract][Hide abstract] ABSTRACT: Abstract The purpose of this document is to provide an overview of a collaboration science process used to develop recommendations for the field of telemental health (TMH) in the selection of outcome measures that best reflect programmatic impacts. A common use of group development techniques in medicine is the development of clinical guidelines, which typically occurs using one of two methods: the nominal group or the Delphi method. Both processes have been faulted for limited transparency, reliability, and sustainability. Recommendations to improve the traditional process include making goals explicit, making disagreements transparent, and publicly displaying levels of agreement. A group of 26 TMH experts convened during the American Telemedicine Association's 2012 Fall Forum in New Orleans, LA to participate in a 1-day, interactive, consensus-building workshop to initiate the development of a shared lexicon of outcomes. The workshop method was designed to improve on traditional methods of guideline development by focusing on clarity of expectations, transparency, and timeliness of group development work. Results suggest that, compared with other traditional methods, the current process involved more people, occurred more rapidly, was more transparent, and resulted in a comparable deliverable. Recommendations for further process development, both within and external to TMH, as well as an initial overview of defined outcome measures are discussed.
No preview · Article · Apr 2013 · Telemedicine and e-Health
[Show abstract][Hide abstract] ABSTRACT: The provision of psychiatric treatment via live interactive videoconferencing, frequently termed telepsychiatry, is a viable option for psychiatrists to provide care to individual patients, populations, and communities faced with limited access and to move the point of care delivery into patients' living environments. Psychiatric providers new to videoconferencing should not be intimidated by the technology or its encompassing logistics, but they do need to develop an awareness of the salient regulatory, administrative, and clinical issues that arise in the practice of videoconferencing-based telepsychiatry. This article provides an overview of the current evidence base in telepsychiatry and reviews administrative and clinical issues in videoconferencing-based treatment. These points are then highlighted in a case example.
Preview · Article · Mar 2013 · American Journal of Psychiatry