From Linda M. Rio, M.A., Marriage and Family Therapist and PWN contributor: Various terms seem to be used today but most frequently, “telehealth” or “telemedicine”, are used to describe live, real-time visits with a medical, mental health, or other licensed professional providers. The use of electronic devices to connect with a licensed healthcare professional, regardless of the term used, is considered a modality for treatment but not a separate kind of care. Specific to mental health the term “telebehavioral health” has been adopted by the US Federal Office of Health and Human Services (HHS) to refer to the telehealth services delivered to the combination of substance use and mental health clients and patients. According to the Telebehavioral Institute (2018), this new term is an attempt to de-pathologize and de-stigmatize health care for people struggling with any one of these disorders. These terms will sometimes be used interchangeably in this article where we hope to shed some light on this novel way to obtain professional services. The American Telemedicine Association uses telemedicine and telehealth interchangeably and explains that telemedicine is the natural evolution of healthcare in the digital world. (American Telemedicine Association website, 2018).
The World Health Organization (WHO) established the Global Observatory for eHealth (GOe) to review the benefits that Information and communication technologies (ICTs) can bring to health care and patients’ well-being. The Observatory is charged with determining the status of eHealth solutions, including telemedicine, at the national, regional, and global level, and providing WHO’s member States with reliable information and guidance on best practices, policies, and standards in eHealth (WHO, 2010).
The increasing use of telehealth has spawned the start of many organizations to provide oversight to help assure quality standard adherence. Most professional organizations by now have incorporated into their ethical standards some statements and guiding principles regarding proper delivery of telemedicine. For example, The Joint Commission states, “Standards are developed with input from health care professionals, providers, subject matter experts, consumers, and government agencies (including the Centers for Medicare & Medicaid Services). They are informed by scientific literature and expert consensus. New standards are added only if they relate to patient safety or quality of care, have a positive impact on health outcomes, meet or surpass law and regulation, and can be accurately and readily measured.” (2018)
Until quite recently Telehealth services have been poorly understood not only by patients, but providers, as well as insurers, have suffered from an inadequate understanding of telehealth technology, provisions, and possibilities. Virtual care services will be critical to decreasing healthcare spending over the next decade. Medicare and Medicaid spending is projected to increase rapidly between now and 2026, the result of an aging population. In less than ten years, healthcare spending will account for almost 20% of the country’s GDP.
Since telemedicine is likely to become offered more in the future Pituitary World News wants to provide patients and providers with a summary of what telemedicine is and what it is not, how to understand the basic terminology, and most importantly how to decide if this may be safe, effective, and beneficial for you.
Assuring quality, as well as safety and security, are critical areas of concern for any method of care. Concerns over these and more have prevented creative and forward movement. But in 2018 the American Medical Association (AMA) introduced policies for physicians by providing guidelines to help ensure quality when using virtual care. The AMA also recently revealed their updated billing codes which will take effect in 2019 and reflect increased codes for the delivery of services through telemedicine. These codes make it possible for physicians and other providers to bill insurance and payors for services rendered. These codes for telemedicine and new technologies will be charged through a new set of virtual care codes.
Measures such as these will make it easier for patients to get high-quality care without the hassles and costs of driving, parking, and time in an office. Also, for some the physical effort to get to a physical location is exhausting or even painful. For others, telemedicine appointments can provide anonymity that showing up at a physical location doesn’t allow and this may be important to some for whom privacy is highly valued.
But the advent of services delivered via computer or other electronic devices remains new to many and a mystery to most. According to Joey Truscelli, the Office of the Inspector General for the Department of Health and Human Services (HHS) found that 31% of claims made by providers did not meet the Medicare requirements for telehealth services. Following the HHS findings, hospitals and healthcare providers could expect to have their claims subject to further review to ensure patients were eligible (2018). If services cannot be paid for, and with relative ease and efficiency, doctors and others won’t be willing to venture into this new realm.
Some of the obstacles to physical and mental healthcare delivered electronically are the regulations in place on the state level. Every state has regulatory boards that provide oversight to the delivery of professional services and require all clinicians working in a particular State to know and follow relevant laws in that state. Boards in each State often have different rules and regulations that differ from one another. Such differences make it difficult for a clinician to abide by such laws. Additionally, often states want control (and money) to govern their territories, with the stated intention of protecting its citizens. Therefore, for most providers, it may be impossible or at least challenging to provide treatment services across state lines. Currently, the physical location of the “patient” determines which state oversees rules and regulations which the provider must follow. For example, a medical or mental health professional licensed in California can treat a patient who travels from New York but once that person returns home cannot receive telehealth services from that provider because they no longer are physically located within California. The actual location of the patient at the time of the service is what is governed even if a follow-up with that provider would be the most efficient, medically sound, and financially reasonable.
There is also another problem. The lack of funded purview for boards to pole/educate themselves and their licensees is the crack that has allowed many Internet start-up companies to proliferate unfettered in their attempts to recruit licensees who are unaware of the many ways in which they violate their state laws when working online for large, well-funded money-making operations (Glueckauf, Maheu, Drude, Wells, Wang, Gustafson, Nelson, 2018).
In the brave new world of telemedicine, there are bound to be unscrupulous folks who do not have the quality of service at heart. So, buyer beware is an essential consideration in today’s world for any patient or provider who may be considering using telehealth as a means of getting or giving treatment.
Telemedicine in Mental Health:
Telemedicine in the delivery of mental health services has some unique challenges as well as opportunities. And, there is a note about the use of terms. Typically, when speaking about Western Medicine, the term “patient” is used. However, in most mental health (psychiatry is the exception since psychiatrists are medical doctors) the term used is “client.” This reflects a different philosophical view, too long for this article. For the sake of simplicity, we will use the term “patient”.
First the positives of telehealth and mental health. Rural locations often do not have mental health clinicians, and certainly not ones with specialty training. Treatment for many mental health issues typically requires regular, weekly or bi-weekly appointments. Being able to use a computer to have access on a regular basis without the need to travel long distances may avail more and more folks to the proper education and services regarding mental, emotional, and relationship issues without the burden of long-distance travel. There is also a potential to impact many more people about substance abuse treatment, parenting and couple relationships, domestic violence and so much more. Even in a modern world, many people are hesitant to seek services for such debilitating mental health issues as depression, anxiety, sexual dysfunction, suicidal thoughts and self-harming behaviors, mood fluctuations, impairments in thinking and memory, eating disorders, posttraumatic stress disorder (PTSD) and much more. Even problems in relationships that almost everyone has at some time dealt with could be handled more efficiently and quickly with the aid of a professional. But, the stigma remains about seeking help for mental, emotional, or relationship concerns. Some people may, however, be more willing to seek help if they had the opportunity to talk to someone without going in-person to an office. Some even fear being seen in a therapist’s office but telehealth could help immensely with this. There are also situations where someone may have physical limitations due to health or disability that could make getting to a physical location nearly impossible so being able to avail the services of a mental health therapist in the comfort of the home could provide much-needed services to those who otherwise go without help.
There are potential negatives too, of course. The first and most important ones lie in the possible breach of privacy/confidentiality due to improper or inadequate technology employed. Anyone who is in a lot of physical and/or emotional pain is also highly vulnerable, and telemedicine may not be the best mode of treatment delivery because they could be subjected to unscrupulous advertisement or claims that could lead to disaster. Anyone who is in a state of emotional crisis is likely not appropriate for telehealth. Even if a sound telemedicine platform is available and desired by a patient, a mental health therapist will often want to meet the person(s) in person initially to determine if telehealth services are appropriate and to discuss all aspects of treatment. Especially in mental health, it is essential to make sure that the chosen setting be safe, secure, and the most effective for that person(s).
If it is determined that the mental health services are deemed appropriate and desired via telehealth, then there are a few considerations to discuss between the therapist and patient. An important issue concerns the potential of a failure of technology (it happens) and developing a backup plan should the specific telehealth program, or the internet fail. This might include having a written policy in place that may resort to a telephone session, delaying the session until services are restored, brief communication via email or text, or rescheduling for an in-person appointment. Another consideration addresses the issue of protecting privacy/confidentiality. Therapists may recommend that a code word be developed in case a family member, a child, for example, would inadvertently come into the patient’s room at the time of a telehealth session. There needs to be a way to communicate the need to take a short break to deal with such a personal situation.
Recommendations for Patients and their Family Members
So, what does all of this mean for patients? More choices and better options may be available or will soon be available via the inevitable forward of technology. Especially for those with “rare” diseases, like pituitary tumors and other disorders finding medical and mental health practitioners with the highly specific knowledge necessary to best treat these issues has been hard. The highly specialized Pituitary Centers of Excellence, for example, have made finding the right treatment team easier and more reassuring for patients and their family members but for many these centers are still often hundreds of miles away making trips to see the specialists hugely inconvenient, time-consuming, and costly (travel, hotels etc.in addition to actual medical costs). Of course, many physician appointments must be made in person, but certainly, some follow-up and consultative visits may be appropriate for telemedicine services.
There are many questions each patient will have and, deciding if telehealth is right will be an individual decision made with the medical or mental health provider. Most providers will provide a form outlining telehealth services and require the patient(s) to sign, but questions are still likely to remain. So, it is advisable to develop a list of items to pose to the provider to cover them all efficiently and thoroughly. Patients don’t have to be technology geeks to understand telemedicine, but a little knowledge is indeed helpful. The following is a list of questions that may help in deciding if telehealth is the best option:
- Is the platform/program used for the telemedicine services HIPPA compliant?
- What assurances are there that my privacy will be protected?
- Will the telemedicine sessions be video/audio recorded?
- Are telemedicine services covered by my health insurance? Is the rate any different from an in-person appointment with my doctor?
- What happens if I have to cancel an appointment or No Show? Is there a charge?
- What happens if the doctor/provider has to cancel or is running late?
- If telemedicine/telehealth doesn’t feel right for me, do I have a choice?
- Will a telehealth appointment be as good as if I see the doctor in person?
- What about the actual video? Will there be a way to check for proper lighting and sound so that my doctor/therapist can see and hear me?
- What do I do if I get a phone call or some other interruption during my telehealth appointment?
We hope this has provided patients, their families, physicians and mental health professionals with some thoughts and guidelines when considering telehealth services. As always, it is between the patient and the professional to determine how best to provide treatment services.
Linda is available via telemedicine to those within California. Contact her at firstname.lastname@example.org or (805) 619-0950.
And you can read Linda’s past articles on PWN and learn more about Linda’s work by going to her website at: www.lindamrio.com .
American Telemedicine Organization (2018). Retrieved October 11, 2018, from http://www.americantelemed.org/about/about-telemedicine
Glueckauf, Robert L.; Maheu, Marlene M.; Drude, Kenneth P.; Wells, Brittny A.; Wang, Yuxia; Gustafson, David J.; Nelson, Eve-Lynn. Survey of psychologists’ telebehavioral health practices: Technology use, ethical issues, and training needs. Professional Psychology: Research and Practice, Vol 49(3), June 2018, 205-219.
Telebehavioral Health Institute (2018). Retrieved October 11, 2018, from https://telehealth.org
The Joint Commission (2018). Retrieved October 14, 2018, from https://www.jointcommission.org/facts_about_joint_commission_accreditation_standards/
Truscelli, J.(2018, October). The AMA helps rather than hurts telehealth. Internet Health Management, October 2. Retrieved October 11, 2018, from https://www.digitalcommerce360.com/2018/10/02/the-ama-helps-rather-than-hurts-telehealth/
World Health Organization (2010). Telemedicine opportunities and developments in member state: Report on the second global survey on eHealth. Retrieved October 11, 2018, from http://www.who.int/goe/publications/goe_telemedicine_2010.pdf
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