Technological advances in the past decade have revolutionized telepsychiatry, which has seen significant changes amid the COVID-19 pandemic, according to a presenter at the American Society of Clinical Psychopharmacology Annual Meeting.
Jay Shore, MD, director of telemedicine programming in the department of psychiatry at University of Colorado Anschutz Medical Campus, provided an overview of telepsychiatry in the modern era alongside historical context of its development.
“In its first couple of decades in the 1960s and 1970s, telepsychiatry had a very slow start,” Shore said. “The equipment was incredibly expensive, [and] the work done in videoconferencing was mainly [through] government-funded grants for a year or two. … With the revolution of computing in the 1990s, we saw systems become more usable and affordable, with big systems like [those of Veterans Affairs] and Department of Defense.”
During the 2000s, large health care systems and insurance companies began to utilize telepsychiatry services, and web-based videoconferencing has now become “ubiquitous,” according to Shore. Results of randomized controlled trials conducted across the past 3 decades showed videoconferencing produces similar symptom and symptomatology outcomes compared with in-person treatment; however, it’s important for clinicians to recognize differences in processes because telepsychiatry comes with its own set of strengths and weaknesses, Shore said.
In the earlier days of telepsychiatry, Shore noted that clinicians tended to replicate in-person standards in their virtual conferences, but the modern technological era has presented opportunities for enhancements.
“Over the last decade, videoconferencing systems have been enabled by a whole host of technologies that have come into medicine, including text, email, patient portals, web-based treatments and even social networking in some cases,” Shore said. “We have begun to use videoconferencing not only to replicate what we’re doing in person, but to change some of the models of care and change some of the workflow. A great example of this is virtual integrated care, where [clinicians] blend in-person and virtual teams together with a hybrid mix, blending location of patient from home to clinic and having other technologies enhance care.”
According to Shore, hybrid care allows for the use of multiple mediums, but it also requires considerations such as determining which interactions should be done using which platform.
With the ongoing COVID-19 pandemic, the field of telepsychiatry underwent significant changes, including the rapid virtualization of all operations among many systems, as well as “sweeping” regulatory changes in numerous areas, Shore said. One such regulatory change is exemptions regarding in-state licensures.
“On a state-by-state basis, some states are allowing providers to treat patients without holding a license [in the patient’s state] during the COVID-19 emergency, although there are a lot of nuances,” Shore said. “Before clinicians dive in and treat a patient out of state, they should not only understand the licensing issues, but also site-of-practice, malpractice and standard-of-care issues that accompany doing so.”
Regarding the use of HIPAA-compliant technology, Shore noted a current misconception that HIPAA has been waived.
“The federal government has said that they will enforce HIPAA at their discretion, and no one is quite sure what that means,” Shore said. “They are saying that if HIPAA-compliant technology is not available, then it’s probably OK to use non-HIPAA-compliant technology, and that’s certainly what they’ve written, but it’s not waived. I like to point out that it’s in the language that they can decide whether to enforce that or not.”
With the use of videoconferencing technologies such as Zoom, media reports have noted a perceived phenomenon of “Zoom fatigue,” or exhaustion/burnout from overuse of Zoom and other virtual conferencing software, Shore said. However, discussion of this phenomenon may require nuance.
“The majority of people were not doing videoconferencing in psychiatry and had to rapidly adapt and may not have received adequate training,” Shore said. “Thus, videoconferencing may not have been strategically implemented into the workflow, and best practices may not have been adopted. When I train providers in videoconferencing, I have a gradated and gradual transition into the work and don’t throw them into it at 40 hours a week without some type of training and adaptation.”
Shore also provided a forward-looking statement on the impact the current pandemic may have on the field of psychiatry overall.
“I hope that we emerge with a better balance [of virtual and in-person care] at the end of this, and I certainly think we’ll have more integration of technology in mental health care,” Shore said. “There is going to be a transformation on both the delivery and funding structure for mental health systems. During this time of change, I think there will be many opportunities for improving those systems and those funding mechanisms.” – by Joe Gramigna
Shore J. Telepsychiatry in the age of COVID. Presented at: American Society of Clinical Psychopharmacology Annual Meeting; May 29-30, 2020 (virtual meeting).
Disclosures: Shore reports being chief medical officer of a company that offers telehealth services.