1 Telepsychiatry: Challenges and Solutions Through Experience

2 Disclosures

3 Addressing the Shortage of Psychiatrists

4 Problem . . . 26.2% of all adult Texans will experience a Mental Health problem each year (5.4M Texans) Nearly one in 20 adults live with a serious (chronic) mental illness (1M Texans) 60% of adults with a mental illness received no mental health services in the previous year (3.26M Texans) 24% of state prisoners have “a recent history of a mental health condition” (35,280 Texans = Pop. Waxahachie>Del Rio) The average delay between onset of mental health symptoms and intervention is years Average ED wait-time for disposition to Psychiatric unit or Mental Health facility in Texas: 23 hours. In most cases this wait time includes no intervention aside from basic needs and 1:1 watch A major barrier in providing Texans with Quality Mental Healthcare is the longstanding lack of access to care. -Stats provided by NAMI (National Alliance on Mental Illness) -population numbers estimated from 2017 projections from TX Dept of State Health Services. Projected total population of Texas in 2017 = 28,797,290 (28% of total pop are age 18 and under; adult= 20,734,049) age % is per the US Census Bereau online report from March 2016 Nami.org

5 Origin of the Problem . . . Provider Shortage Profit Centers10% decline in provider workforce between Currently 5.7 Psychiatrists per 100,000 people in Texas Profit Centers Provider Distribution 39% of all Psychiatrists live in California, New York, Texas, Pennsylvania and Florida; only New York maintains an “adequate” number to care for that state’s population Provider population is declining due to – --Aging of the current workforce, 59% of psychiatrists are age 55 or older making us the 3rd oldest group of medical specialists, low rates of reimbursement, burnout, burdensome documentation requirements and restrictive regulations Merrit Hawkins report states that “adequate mental healthcare” for any given population requires at least 14.7 psychiatrists per 100,000 people (both for direct care and supervision of mid level providers) – only DC, Massachusetts, Vermont, Rhode Island, Connecticut, New York maintain an “adequate” number of psychiatrists to support their populations Profit Centers – traditionally behavioral health services do not reimburse as well as procedure based services such as surgery and interventional cardiology

6 How do we fix the Problem . . .Money – Organizations such as NAMI, NIMH and the NCBH have recomendations Increased reimbursement for services Payment models based on quality not volume Provider incentives – loan reimbursement plans (Texas…) Provider Training Programs – Care teams, Medical Home Model Legislation – HB 1023, SB 1107 TELEPSYCHIATRY National Alliance on Mental Illness National Institute for Mental Health National Council for Behavioral Health Texas loan reimbursement specifically excludes Telemed providers Recent Legisation illustrates the fact that state administrators are recognizing Telemedicine as a viable solution to the current mental health access problem

7 HB 1023 Passed in 2013 Tasked the Health and Human Services Commission and the Dept. of State Health Services with monitoring stats and making recommendations to address the mental health workforce shortages in the state. Increase the size of the mental health workforce Improve the distribution of the mental health workforce Improve the diversity of the mental health workforce Supporting innovative educational models (for the workforce) Improving data collection and analysis (ie: EMR reporting requirements) Formal acknowledgment of a “problem”

8 SB 1107 Passed in May 2017 (not signed as of 5/30/17)Expands access to Telemedicine Services Eliminates the face-to-face consultation requirement for medical services as imposed by the “Teledoc Letter” Specifically does not limit Mental Health access Allows for the creation of a Doctor-Patient Relationship without an In-person encounter Prohibits Health Plans from excluding Telemedicine service coverage Enforces team approach Non-Mental Health interventions via Telemed must be reported to the PCP within 72 hours Provides official definitions: Telemedicine – TX provider caring for a TX patient in another physical location but connected by Audio and/or Video technologies (synchronous or asynchronous) Since 2011, Teladoc—one of the country’s largest telehealth services providers (Headquartered in Dallas)—has been embroiled in conflict with the Texas Medical Board, chiefly stemming from a letter the board sent to Teladoc concerning Teladoc’s prescribing of medications without first establishing a patient relationship through a face-to-face meeting.  In 2015, Teladoc sued the Texas Medical Board alleging that its implementing regulations of the Texas telemedicine and telehealth statute violate antitrust laws—ultimately stifling both access to care and provider competition by adding an unnecessary hurdle for tele-providers. The case has been stayed until mid-April pending settlement.  In September 2016, the Federal Trade Commission (FTC) and US Department of Justice (DOJ) advocated in support of Teladoc and the broad use and adoption of telehealth.

9 Why Telepsych? Lower cost for care (provider pay and recruitment, electronic records) Improved Provider Access Provider Distribution Problems are eliminated 24 hour access Improved Care Quality Cost: January 2015 the American Hospital Association reported an 11% decrease in the cost of care when using Telehealth services. Not psychiatry specific. no costs for providers to buy business attire (dress pants or shoes), no travel costs to the provider (exception – providing controlled substances, travel to site for face to face appointments once per 2 years) Access: Providers can live where they want and clinics do not have to recruit providers to what may be a less desirable location Telepsych providers can be available outside normal work hours, when on site staff or regular staff are sleeping, off work or on vacation Quality: Lower quality providers no not have to be retained out of a fear that they cannot be replaced These stats are from the Telemedicine company we work for but I will not say the name of the company as a shameless advertisement… --Only included as an example to extrapolate future improvements in Mental Health provider access. 47 providers serving 24 clinics (over 3000 hours per month) plus a 24 hour crisis coverage program serving 6 different facilities. It is easy to state that most of these provider hours are served in locations that have difficulty recruiting on site staff.

10 Ryan Haight Act – Impact on Telepsychiatry

11 Telepsychiatry and the Ryan Haight Online Pharmacy Consumer Protection ActText of Law – Summary Federal Register DEA Special Telemedicine Registration Rule Notice Law passed in 2008 to address obtaining controlled substances from internet pharmacies Ryan Haight died from OD of Vicodin that he got online Doctors issuing prescriptions to patients without pre-existing doctor-patient relationship

12 Ryan Haight Act - Purpose2008 DEA acting Administrator Michele M. Leonhart: "Cyber- criminals illegally peddling controlled substances over the Internet have invaded households and threatened America's youth for far too long by supplying pharmaceuticals with a few clicks of a mouse and a credit card number"

13 Ryan Haight Act - ExclusionsCertain hospitals or medical facilities operated by the federal government or by an Indian tribe or tribal organization Other persons or entities the exclusion of which the Attorney General and the Secretary of Health and Human Services find to be consistent with effective controls against diversion and the public health and safety

14 Ryan Haight - TelemedicineDefinition change January 15, 2010 The patient is being treated by, and physically located in, a DEA registered hospital or clinic, or in a VA hospital or clinic Is being conducted while patient is being treated by, and in physical presence of a practitioner By a practitioner employed or contracted by Indian Health Service or VA During a public health emergency declared by the Secretary of HHS. Special registration. The practice of telemedicine is being conducted by a practitioner who has obtained from the Administrator a special registration under section 311(h) of the Act (21 U.S.C. 831(h))

15 Ryan Haight - TelemedicinePractice of Telemedicine Definitions: The practice of telemedicine is being conducted under any other circumstances that the Administrator and the Secretary of Health and Human Services have jointly, by regulation, determined to be consistent with effective controls against diversion and otherwise consistent with the public health and safety.

16 Example Psychiatrist sees patient by telemedicine at an outpatient clinic that is not registered with DEA Psychiatrist issues prescription for a controlled substance Is this a possible violation of the Ryan Haight Act?

17 Example Psychiatrist sees patient in person, issues a controlled substance, and then unexpectedly out of the office for 2 months Covering psychiatrist sees patient by telemedicine and issues controlled substance

18 Example Psychiatrist issues controlled substance after seeing a patient for the first time by telemedicine, with DEA registered clinician in the physical presence of the patient

19 Example Psychiatrist at a local clinic (not DEA registered) has been seeing a patient in person for a number of years and has issued a controlled substance A new psychiatrist picking up the patient (not covering) sees the patient for the first time by telemedicine, and issues a controlled substance

20 What has been done Attempts to register clinics with DEADiscussions with the Texas Council (message September 10, 2014) Letter from HHSC and DSHS in support DEA officials stated they had no plans to single out Texas telemedicine providers for enforcement or audit activities Clinics don’t prescribe or dispense controlled substances

21 What can be done? Allow clinics to register with the DEA under current rules, or under new ones (special clinic telemedicine DEA registration)

22 Telemedicine Special Registration Proposal, Spring 2015One specific category within the Act’s definition of the ‘‘practice of telemedicine’’ includes ‘‘a practitioner who has obtained from the [DEA Administrator] a special registration under [21 U.S.C. 831(h)].’’ 21 U.S.C. 802(54)(E). The Act also specifies certain criteria that DEA must consider when evaluating an application for such a registration. However, the Act contemplates that DEA must issue regulations to effectuate this special registration provision. The DEA proposes to amend the registration requirements to permit such a special registration.

23 Other ideas American Telemedicine Association letter, October 6, 2015Recommends a plan that outlines: Distinctions between telepsychiatry and other forms of telemedicine The creation of a mechanism for sites and/or prescribers to register to prescribe controlled substances via telemedicine Suggestions on how to update Form 224 to contemplate telemedicine registration Suggestions for eligibility requirements of applicants seeking telemedicine registration Legal and regulatory background information

24 Telemedicine solutions: Redefining the treatment team

25 “HELP! My doctor doesn’t listen to me”WSJ article Dec ’15. Doctors spend too much time on the screen, struggling to complete the ehr, bill, order labs, etc. Patients are angry. MOVE TO JAMA article….

26 JAMA, November 2015 “High computer use by clinicians in safety-net clinics was associated with lower patient satisfaction…. multitasking clinicians may miss openings for deeper connection with their patients,”  Neda Ratanawongsa, M.D., M.P.H.,  Ratanawongsa N, Barton JL, Lyles CR, Wu M, Yelin EH, Martinez D, Schillinger D. Association Between Clinician Computer Use and Communication With Patients in Safety-Net Clinics. JAMA Intern Med. 2016;176(1): doi: /jamainternmed

27 JAMA, November 2015 High computer use-”negative rapport building”“NO…” statements Less “social” rapport Ratanawongsa N, Barton JL, Lyles CR, Wu M, Yelin EH, Martinez D, Schillinger D. Association Between Clinician Computer Use and Communication With Patients in Safety-Net Clinics. JAMA Intern Med. 2016;176(1): doi: /jamainternmed

28 Solutions: TelemedicineProvider IS the screen Physician can enter E.H.R. while seeing patient, or immediately after, with posture unchanged Patients consistently report high satisfaction with telemedicine encounters, overall. 1

29 Telemedicine SatisfactionOverall, high rates of satisfaction rated by both providers and patients Few adverse effects Confidentiality concerns Emergency precautions Hubley et al, World J Psychiatry Jun 22; 6(2): 269–282.

30 SB 1107: Expanding telemedicine…?Broadens scope of the provider-patient relationship Pre-existing, with periods of communication via audiovisual communication in which provider is at location separate from patient Synchronous AV communication Convey understanding of call coverage Explanation of events/proceedings to PCP within 72 hrs, if patient grants permission “Store and forward” Images, PHI securely transmitted to provider at outside location i.e., radiology, pathology, dermatology images reviewed by practitioner The relationship net is cast wide. Therefore, the need to capture all health data and work within the team that much more imperative.

31 Challenge: Build the TeamNo “islands” in good care Changes with SB1107 Without “presenters”, how to build the team, ensure good care

32 “Nurse, I TOLD YOU!” This is the laughable, old model, of medical care where the provider/doctor comes to the nurses’ station, yells at staff to get something done, etc. Can’t be done in telemedicine. Information must be conveyed effectively and at a mutually agreeable time. Both parties are invested in maximizing time and information from the encounter.

33 Solutions: Virtual Treatment Team24/7 care divided in 3 shifts Overnight admissions visible to treating providers EHR access Outpatient-Crisis-Inpatient Immediate access to history Medical Directorship Review meetings

34 Virtual Treatment Teams: Therapeutic InterventionsFamily Based Therapy for treatment of Eating Disorders Univ of Chicago Multidisciplinary Team Anderson, K.E., Byrne, C., Goodyear, A. et al. J Eat Disord (2015) 3: 25. doi: /s Utilize scarce resources of trained therapist Deliver care to outlying communities Excellent attendance; authors cite lack of impact of weather, traffic Enhanced experience: frequent name usage Physical charts made electronic for multidisciplinary approach Availability of multiple attendees on one call

35 Virtual Treatment Team: future effortsIntegrate primary/OB and mental health care visits Facilitate family meetings at facility sites Improve wait times in emergency departments and urgent cares Consultative services: ICU, maternity, internal medicine and pediatrics

36 References Anderson, K.E., Byrne, C., Goodyear, A. et al. J Eat Disord (2015) 3: 25. doi: /s Hubley et al, World J Psychiatry Jun 22; 6(2): 269–282. Ratanawongsa N, Barton JL, Lyles CR, Wu M, Yelin EH, Martinez D, Schillinger D. Association Between Clinician Computer Use and Communication With Patients in Safety-Net Clinics. JAMA Intern Med. 2016;176(1): doi: /jamainternmed Reddy, Is your Doctor Getting too much Screen Time?. Wall Street Journal. Dec 2015