Telepsychiatry during the COVID-19 pandemic.

The US possesses the infrastructure and the technology to successfully offer digital care, and healthcare providers from different specialties have claimed that “healing at a distance” improves patient outcomes and captures the needs of vulnerable populations.1-3 Efforts to limit the spread of coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), with the implementation of lockdown measures have created an opportunity for mental health clinics to employ telemedicine—or, in the field of psychiatry and mental health—telepsychiatry.4 Telepsychiatry, also referred to as “telepsych,” is a subset of telemedicine that includes remote services, such as psychiatric evaluations, therapy (individual, group, and family), patient education, and pharmacologic and nonpharmacologic management.5

The Nebraska Psychiatric Institute first introduced telepsych in mental health practices in 1959, and this approach has since addressed several psychiatric disorders and problems.3,5,6 The adaptations necessitated by the COVID-19 pandemic, characterized by remote communications and services, are transforming mental health practices globally by expanding the availability of telepsych.7

Advanced practice registered nurses (APRNs) are equipped to contribute to the healthcare needs of the populations they serve. There are two types of APRN specialties that are trained specifically in psychopharmacology and psychotherapy to help patients across the lifespan: psychiatric-mental health nurse practitioners and psychiatric-mental health clinical nurse specialists. Both of these APRN specialties are qualified to provide telepsychiatry effectively and in many states have full-practice authority (FPA). There is increased accessibility to mental health services provided by a psychiatrist or APRN in states where APRNs have FPA.8 Telemedicine in psychiatry has observable efficacy in diagnostic and management decisions. Virtual platforms are achieving greater popularity among mainstream healthcare services, and studies show that telepsych can overcome barriers to care associated with patient difficulty in attending in-person sessions.2,5 However, while providers recognize the benefits of telepsych, they may be unaware of potential liability concerns as well as the clinical, technological, and ethical issues associated with this method. The purpose of this article is to describe the considerations impacting the use of telepsych in mental health and to enhance provider understanding of telepsych to enable more efficient and cost-effective care amid this pandemic and beyond.

Telepsych users

Using the internet and its applications can significantly expand the reach of quality mental healthcare by limiting geographic, economic, and human resource barriers.1 Because of COVID-19 containment efforts (including social distancing, quarantine, and isolation), healthcare providers face significant challenges in delivering care while complying with the rules, including scheduling patients and providing follow-up care.7 Because of these issues, telepsych services are expanding as in-office visits are declining globally.7 In lieu of potentially exposing patients and families to SARS-CoV-2 in the public arena, telepsych offers patients the ability to see their providers remotely, which may reduce patient anxiety, limit disease transmission, and allow providers to manage chronic mental health disorders.9 However, telepsych must be adapted to maintain a form of human contact while engaging in and maintaining continuity of care.1,9

Advantages. Telepsych can offer cost-effective care that benefits both patients and providers.10 This technology gives providers access to a larger number of patients, expands patient access to physicians and effective psychotherapies, and mitigates patient fear of privacy breaches and stigmatization because they are allowed to access healthcare from their home rather than in public.11 Patients who have limited mobility, lack transportation, or have insufficient economic resources may benefit from telepsych's accessibility in their homes. In addition, telepsych's cost-effectiveness and access to a larger pool of psychiatric providers is an attractive option for situations such as psychological treatment of children and adolescents in different settings.12 The implementation of telepsych is also creating new ways to ease workforce problems in attaining mental health care.11

Disadvantages. Despite its many advantages, the remote connection of telepsych can limit treatment efficacy.10 Concerns regarding stable access to video conferencing and the security of software can affect its use.10 With remote care, direct eye contact is often lacking, and providers may miss patients' lower and upper limb gestures due to the limited view.13 Providers need to observe these objective findings to formulate a comprehensive and accurate mental status examination. Distortion in communication may also alter information received and understood, leading to the misinterpretation of vital data.13 Therefore, telepsych may not be the right choice for patients and providers who lack technology competency or patients with limited ability to communicate.14 Further, telepsych is inapprpriate for hands-on physical exams or in instances where providers can only receive critical data through direct physical contact. An essential neurologic exam, such as examining touch and smell, may be insufficient via telepsych due to the limitations of the equipment used.13

Telepsych providers must also consider their patients' cognitive capacities, levels of risk, geographic distance to an emergency facility, and access to computers and the internet. Telepsych is insufficient when the technology does not allow mental health providers to meet established clinical standards, and it may not be useful for high-needs clients or those with complex symptom presentations.15 In addition, some patients may not have access to a technological device, such as a computer or smartphone, or internet access, which would force the telemedicine visit to take place via a traditional phone, further limiting the ability to perform a complete assessment.

Reimbursement

One clinical consideration is whether a practice can bill for telemedicine services. Twenty-eight states have passed parity legislation to guarantee reimbursement for telehealth services through Medicaid; however, Medicare still lags behind Medicaid in some states for reimbursement.16,17 Only 16 states legislate payment parity for telehealth services for private payers.16 On March 6, 2020, The Coronavirus Preparedness and Response Supplemental Appropriations Act was signed into law, which provided temporary exception to Medicare telehealth reimbursement requirements during the COVID-19 Public Health Emergency.18,19 As with any reimbursement program that has state-by-state requirements or guidelines, and despite the waivers, providers must abide by local regulations, which can vary significantly from state to state. This law enables the practice of social distancing to reduce the transmission of SARS-CoV-2 and allows beneficiaries in all areas of the country, both urban and rural, to receive telehealth services from their home. The Coronavirus Aid, Relief, and Economic Security (CARES) Act, passed on March 27, 2020, temporarily expanded support for telehealth, waiving the requirement for the provider to have seen the patient in the past 3 years before providing telemedicine services, and allowing for visits to take place over the phone if the patient did not have computer or internet access.20

Later in March 2020, further provisions for the telehealth expansion were announced, including that reimbursement rates for telepsych would be the same as if the provider were seeing the patient in person.19,21 Before this act, Medicare Part B would reimburse telehealth office visits for medication management, psychotherapy, consultations, and other specified medical or health services provided by an eligible provider at a different location using real-time audio or video communication. However, this would only apply if the service was rendered to the patient at a physician or practitioner's office, hospital, rural health clinic, federally qualified health center, hospital-based dialysis facility, skilled nursing facility, or a community mental health center located in certain eligible rural areas, and not at a patient's home.22

Malpractice insurance and licensure

Most states require providers using telehealth to have a license in the state in which the patient resides.23,24 As a result of the pandemic, many states have temporarily eased the restrictions on physicians, nurses, and emergency medical technicians working across state lines without licensure in that state to increase patient access to care. Providers must know what professional liability insurance policies include and whether malpractice insurance protects providers across state lines.18 Some malpractice insurance providers include telepsych as part of their standard coverage, whereas other carriers require additional policies when providing telepsych services.25 Many current professional liability policies exclude telehealth from coverage, so extra coverage would be necessary to ensure protection from liability issues.26,27

Technologic considerations

Providers offering telepsych services must consider the significant technical component associated with this approach from an information technology perspective to determine the best options for providing care.28 Before offering telepsych services, providers should address whether the practice has the infrastructure to provide telemedicine service, determine if they will offer services from the office or at home, and whether the practice will provide patients with access to computers or other technological devices.

Since some individuals do not have access to computers, internet, or smartphones, providers must be able to adapt to their patients' needs while still offering quality care. Aside from technology access, the most vital aspect to consider when choosing a platform for telepsych services is whether the platform complies with the Health Insurance Portability and Accountability Act (HIPAA), a set of standards for securing protected health information.29,30 Platforms that are HIPAA-compliant and explicitly designed for telemedicine are available for free and for purchase, and the use of a secured network, antivirus software, firewalls, and encryption are also essential for patient information and privacy.23,30-32 Furthermore, providers must consider an internet provider's broadband and bandwidth capabilities, which are crucial for the successful implementation of telepsych without interruptions.33 Hardware requirements remain the initial obstacle for telepsych (for example, computers and mobile devices, microphones, and cameras for live two-way interactions between patient and provider).34

Practice, ethical, and cultural considerations

For successful telepsych implementation and integration into practices, providers should establish specific policies regarding communication with patients. These policies should describe anticipated response times, how and when patients should contact a provider, and boundaries around ways in which patients can communicate with a provider. Providers should also participate in professional training (for example, continuing education, seminars, or webinars) before engaging in telepsych services.35

Ethical considerations involve informed consent and provider-patient expectations in approaching telemedicine services. Before starting a telepsych appointment, providers must develop a way to confirm the patient's identity and obtain and document consent for conducting the meeting via telehealth. This approach is especially important for cases involving minors since legal guardians must consent to the telemedicine services in some states.30 Providers should also present patients with the purpose, goals, procedures, limitations, potential risks, and benefits of care and techniques, and backup methods regarding connectivity challenges before providing services.30 It is vital that providers conduct an ongoing assessment of patient comfort levels with technology throughout treatment.36,37

When unsure if a patient should receive treatment via telepsych, providers should use an ethical decision-making model and consult with experienced colleagues.23,30 For example, managing boundaries and equitable access with telepsych patients can initially be challenging for a novice provider of telepsych and may require consulting with a more seasoned provider. Since many ethical situations can arise, providers must be familiar with the code of ethics for treating patients.37

Conclusion

As the uncertainty of the COVID-19 pandemic continues, telepsych will remain one of the leading platforms to help mental health providers care for their patients in a safe and cost-effective manner. After this pandemic, many APRNs and other mental health providers will have adapted to providing telepsychiatry in their practices and should advocate for many of the Centers for Medicare and Medicaid Services and legislative changes to remain in effect permanently to ensure continued access to care for the most vulnerable and rural populations. While this approach bridges the gap between providers, patients, and their families, APRNs must consider how to address reimbursement, licensure, liability, and technologic accessibility to integrate telepsych services during these challenging times.