The Technological Transformation of Psychiatric Care— Telepsychiatry Comes of Age

Over the past decade, live interactive videoconferencing - telepsychiatry - has emerged as a valid and effective means of care delivery (Hilty et al., 2013). Telepsychiatry bridges gaps in geography and services, increasing access and availability of mental health treatments. Its promise as a catalyst for reorganizing models and structures of mental health care is beginning to be demonstrated including improving quality of care and posing solutions for addressing escalating health care costs (Fortney et al., 2015).

Telepsychiatry has had an interesting evolution as a field. Although many assume it originated in the 1990s during the birth of the internet and revolutions in computing, videoconferencing pilots in psychiatry actually began in the 1950s (Brown, 1998). The technological developments of the 1990s laid the foundation for telepsychiatry‘s sustainable and widespread deployment. Arguably, videoconferencing conceptually is another tool for communication in mental health such as the telephone. However telepsychiatry has developed as a distinct field in psychiatry, whereas communication via telephone is part of daily practice. Telepsychiatrists often contend that the ultimate endpoint for full integration of telepsychiatry into psychiatry is when videoconferencing also becomes just another tool of care delivery without its current set of distinctions. Other specialties in medicine have seen technology initially labeled as “telemedicine” become standard and integrated methods for providing care such as the store and forward imaging techniques of “teleradiology” and “telepathology”. Telepsychiatry has yet to achieve this integration, not only because of technical and administrative complexities (e.g. licensure, funding, connectivity), but also because of the direct impact of videoconferencing on the psychiatric encounter, necessitating adaption of clinical processes.

There is strong concurrence on standards for implementation and adaption of telepsychiatry into clinical environments including multiple guidelines and best practices (Shore 2013). Over the past two decades its dissemination has blossomed in many organizations from pilot programs to sustained services to enterprise level solutions. The current adoption of telepsychiatry across federal, academic, community and private settings is widespread but uneven, despite the scientific evidence supporting its use. Telepsychiatry’s evolution has occurred during our society’s transformation from an industrial base to a digital one. Western medicine in general is also struggling with this transformation while in the midst of a concurrent crisis in the financing of healthcare. Telepsychiatry specifically offers potential solutions to the challenge of restructuring health care to increase quality and efficiency of care along the lines of the laudable goals of the Institute of Medicine’s Triple Aim (improve population health and outcomes for individual patient while reducing cost) (Richardson et al., 2001). Whether telepsychiatry is able to achieve these goals over the coming decade will depend on deepening an understanding of the nuances and successful implementation of telepsychiatry into multiple models of care delivery.

The purpose of this special issue is to provide a pragmatic overview of the current state of telepsychiatry by reviewing the evidence base and providing clinical and administrative guidance for executing telepsychiatry in all of its applications. This issues focuses specifically on telepsychiatry as videoconferencing. It does not address other important technologies impacting psychiatry such as mobile technologies, email, web-directed therapies, virtual reality, social networking or health information technology. These technologies will also have significant impact on the structure and process of psychiatric care going forward but are newer, less developed, and have smaller evidence basis than videoconferencing.

This special issue is fortunate to have brought together a stalwart collection of contributing authors who are leaders and pioneers in telepsychiatry to share their work and expertise. It begins with my perspective on the history of telepsychiatry within the larger context of changes in society and medicine, followed by recommendations on strategic directions for psychiatrists and their organizations. Dr. Yellowlees, a founding pioneer with the development of rural telepsychiatry services in Australia in the 1990s, and his team delve into the impact of telepsychiatry on the doctor-patient relationship and its implications for providers. We then turn to managing ethical issues that can arise in these new clinical environments. Adapting ethical frameworks that serve psychiatry rather than developing completely new perspectives is a topic presented by Drs. Skimming and Sabin. Dr. Caudill reviews institutionally based telepsychiatry, where much of the initial growth of telepsychiatry occurred. Dr. Moreland and colleagues address web-based videoconferencing. This is a relative recent area that is having tremendous impact in transforming where telepsychiatry is delivered, moving care more directly into patients’ environments. Telepsychiatry for children and adolescents is presented by Dr Gloff, with collaboration from national child telepsychiatry experts. In this arena telepsychiatry is a powerful tool to tackle the workforce shortages confronting mental health care for children and adolescents.

Dr. Fortney et al. discuss telepsychiatry’s growing applications for integrated care, which is being envisioned as a model of health system transformation. Telepsychiatry helps to increase both access and timeliness for integrated care services, including its ability to couple together small and remote primary care practices to create efficiency for psychiatric delivery. International telepsychiatry’s ability to distribute psychiatric care across vast geographies and populations, often focusing on the development of health care systems and disaster support, is explored by Dr. Augusterfer and the Harvard Refugee program. Drs. Turvey and Roberts then consider and recommend strategies on the concurrent use of other technologies (eg. HIT) that enable videoconferencing adaption into psychiatric care. Vaughn and Voyles, along with Dr. Thomas, apply their experience in healthcare financing and structure reform to the current funding and re-imbursement challenges impacting telepsychiatry. This special issue concludes with Dr. Hilty and associates’ important recommendations on how current and future generations of psychiatrists receive training and education in telepsychiatry. It is critical for psychiatry to be able to create a workforce knowledgeable and proficient in evolving healthcare technologies including videoconferencing.

The release of this special issue coincides with a tipping point in telepsychiatry’s continued emergence and expansion into mainstream psychiatry. It’s hoped that this issue will serve as a useful instrument to broaden understanding of the field and stimulate others to explore new models for telepsychiatry in the transformation of psychiatric care delivery.

Jay H. Shore, MD MPH Director of Telemedicine, University of Colorado Anschutz Medical Campus Helen and Arthur E Johnson Depression Center.Associate Professor, Centers for American Indian and Alaska Native Health, Colorado School of Public Health and Department of Psychiatry, School of Medicine, University of Colorado Anschutz Medical Campus.