Stanislav Spivak, MD, on Trends in the Use of Telepsychiatry
The use of telemedicine, the remote treatment of patients using telecommunication technology, has increased substantially over the last 20 years with the hope that the practice will help to reduce costs and improve access to care for patients living in underserved populations and in rural areas.
Telemedicine has also seen increases in use in the treatment of mental health. While various studies have examined the effectiveness of telepsychiatry, there is little evidence available on recent trends in telepsychiatry at the national level. In a recent study, researchers examined changes in the rates of use of telepsychiatry and from 2010 to 2017 and sought to identify factors influencing the likelihood of its use.
Consultant360 spoke with study author Stanislav Spivak, MD, Assistant Professor of Psychiatry and Behavioral Sciences at Johns Hopkins University and Medical Director of the Johns Hopkins Psychiatric Mobile Treatment program, about their findings.
Consultant360: How did you decide on the topic of your research?
Stanislav Spivak: I am excited about the possibilities of using telepsychiatry to increase care access, especially so for individuals who are hard to reach with traditional medicine, but there are so many open questions about adoption and use.
I direct the Psychiatric Mobile Treatment Team at Johns Hopkins for individuals with the most severe and persistent mental illnesses. For the past few years, we’ve been piloting various ways of using telepsychiatry to increase physician availability for patients who are unable, because of the severity of their illness, to participate in traditional healthcare. We found that the process works best when there is a mental health worker present with the patient to help facilitate the physician telepsychiatry visits. However, we have not been able to get reimbursement for these visits and the effort remains largely grant-funded. So, our experience exemplifies the possibility of using telemedicine to increase care access for a hard to reach population and some potential hurdles in implementation.
Being involved with telemedicine led us to want to get a broad snapshot of what’s happening with telepsychiatry nationally.
C360: What are some of the major factors that inhibit the growth of telepsychiatry availability?
SS: The challenges have changed over time. While previously there have been limitations on the technology side of things, such as having sufficient bandwidth for visits of necessary fidelity, more recently payment has been cited as the major factor influencing adoption.
I work primarily with individuals with serious mental illness who depend heavily on public insurance and there are certainly challenges in that context. For example, Maryland Medicaid currently requires prior authorization for behavioral health visits in order to reimburse. That is an example of an administrative barrier that can discourage providers from adopting telepsychiatry.
C360: What impact do you think the increase of availability of telepsychiatry has had on clinical practice?
SS: We are still in the process of determining how to best use telecommunications in medicine as there are so many different patient and provider scenarios.
One impact telepsychiatry can have is to increase access for patients who already have access to traditional care. For example, many facilities offer telehealth as another way to reach their provider at more convenient hours.
But I think the real excitement is using telepsychiatry to bring care to populations that can be hard to reach with traditional medicine. For example, there are folks out there with severe psychosis, which might lead them to avoid leaving their familiar environment, so going to a therapist or psychiatrist might be out of the question. Or there might not be a therapist or psychiatrist available at all.
C360: What knowledge gaps still exist in this area?
SS: I think we have plenty of issues to resolve. For example, from a logistics standpoint we have a sense that at least in Maryland, regulatory barriers with Medicaid could affect adoption but more data is needed.
In clinical terms, after piloting telepsychiatry with individuals with severe mental illness we found that things work best when there is a mental health provider of some sort present with the patient. That has been our clinical experience, but we need data. I suspect that there are many types of encounters and types of patients that will require unique and individualized approaches and many of those will need to be developed and then rigorously studied over time.