By Rajnish Mago, MD (bio)
Healthcare delivered by telemedicine has been increasing due to many reasons:
– Due to the availability of broadband internet, video conferencing is now widely available at relatively low cost.
– There is a shortage of clinicians, especially specialists, in many parts of the country. Telepsychiatry can increase access to care while also reducing clinician burnout (Gardener et al., 2020).
– Many studies have shown that psychotherapy for anxiety and depression can also be delivered safely and effectively by telepsychiatry (Tuerk et al., 2018).
– Telemedicine care is so much more convenient than in-person visits. Think of the time it saves patients and/or clinicians if they don’t have to commute.
– Telemedicine care is inexpensive, generally costing less than in-person care.
On this page, we will discuss some of the commonest questions that are asked by mental health clinicians who are considering starting to do part or all of their clinical work through telepsychiatry.
Warning and disclaimer! The contents on this page are provided to clinicians for general informational purposes only. They do not constitute specific advice for a particular clinician or situation. In the US, laws governing telepsychiatry vary from state to state and may change. So, clinicians must check with their state’s board of medicine and with their malpractice carrier before proceeding to use telepsychiatry to see patients.
What constitutes telepsychiatry?
Sorry–for reimbursement purposes, a telephone call alone is not considered telemedicine by either government or private insurances. To get reimbursed for a full visit, the visit HAS to have both audio and video. For a discussion of what tools can be used for telepsychiatry, see the following page: A comparison of telepsychiatry platforms.
Does telepsychiatry work?
Is the care delivered by telepsychiatry substandard? Not at all! Many studies have shown that the outcomes of treatment delivered by telepsychiatry are just as good as those from in-person care if not better (Hubley et al., 2016). Also, both patients and clinicians report high degrees of satisfaction with telepsychiatry visits.
Fancy equipment is NOT essential for telepsychiatry! We shouldn’t get too caught up in buying a special computer, microphone, headset, etc. The webcam and microphone built into the computer are usually good enough.
What is important is the internet speed at BOTH our end and the patient’s end. Both we and the patient can find out our internet speed easily by simply googling the words “test my internet speed”. See the image below.
When you click on “RUN SPEED TEST”, the test runs and in less than a minute, we get the results. See the image below:
One of the great things about telemedicine is that a clinician does not have to be in the same city or even the same state as the patient. But, if the patient and the clinician are in different states, which state does the clinician have to be licensed in?
Note: We may think or wish that the laws were different but they are what they are.
In 49 states (and in District of Columbia, Puerto Rico, and the Virgin Islands), the medical boards require that the physician providing care via telemedicine must be licensed in the state in which the patient is physically present at the time of the telemedicine session. That is typically the state where the patient lives, but it doesn’t have to be.
Because of this, many clinicians whose practice consists of a considerable amount of telemedicine care (or entirely so) get licensed in multiple states. This allows them to use telepsychiatry to see patients living in those states.
Note: We have to be licensed in the state where the patient physically is at the time of the telepsychiatry visit, not where the patient lives. For example, if a patient who lives in New York is visiting family in Florida at the time of the telepsychiatry visit, we would have to be licensed in Florida to be allowed to see the patient by telepsychiatry while they were in Florida.
Also, we, of course, have to be licensed in some state, but we don’t HAVE to physically be in that state at the time of the telepsychiatry session.
But, we should go the website of the state where the patient is and look at any special requirements or options that state may have. For example, in 12 states, the state boards of medicine issue a special purpose license or certificate allowing patients to be seen across state lines by telemedicine (Federation of State Medical Boards, 2019). That is, instead of needing to get a full, unrestricted license, we can get a limited license for seeing patients in that state only through telepsychiatry. In 6 states, the state boards of medicine require physicians to register with the board before practicing across state lines (Federation of State Medical Boards, 2019).
Note: This requirement to be licensed in the state where the patient is at the time of the visit does not apply to clinicians working in federal health care systems (Department of Veteran Affairs, Department of Defence, Indian Health Services). They can generally be licensed in any one state and see patients within that system who are located anywhere in the US. But, these clinicians should look up the rules and regulations of their organization about telepsychiatry to see if the organization has any other requirements.
To emphasize the importance of obtaining licensure before seeing a patient in another state via telepsychiatry, let me quote from a guide on telepsychiatry by PRMS, Inc, a leading malpractice carrier:
“If you are tempted to proceed without requisite licensure consider this. In many states the practice of medicine without a license is considered a criminal act. Should you be involved in a claim or a lawsuit, coverage may be denied as criminal acts are an exclusion under malpractice insurance policies. In a worst case scenario, you might find yourself subjected to criminal prosecution, licensing board actions, and a malpractice lawsuit all without defense coverage.”
Some malpractice insurance companies include coverage of telepsychiatry in their standard policies. But, some others do not and need us to purchase separate coverage to cover our telepsychiatry work.
So, it is VERY important that before seeing any patients through telepsychiatry, we should contact our malpractice insurance company to ask whether telepsychiatry is covered by our current policy.
Standard of care
Clinical care delivered through telepsychiatry is held to the same standards as in-person care. So, EVERYTHING that we would do in an in-person visit needs to be done, one way or another, in a telepsychiatry visit as well. If, for some reason, the quality of clinical care would be compromised if a particular patient is seen via telepsychiatry (this is not common), then that patient should not be seen by telepsychiatry.
Along with informed consent to the evaluation and the treatment, another specific informed consent needs to obtained AND documented—to care by telepsychiatry.
Commonly, getting this consent orally and documentinig it briefly is enough. But, some states may require written informed consent to telepsychiatry. So, when we are looking up state regulations about telepsychiatry, we should look this up as well.
The good news is that we can prescribe any medications that are not controlled substances without EVER seeing the patient in-person.
Under usual circumstances, for prescribing a medication that is a controlled substance, we have to first do an in-person medical examination. This is mandated by an important law called the Ryan Haight Online Pharmacy Consumer Protection Act of 2008, or more commonly, simply the Ryan Haight Act. The law does not specify whether the in-person examination has to be done just once before the very first prescription of the controlled substance or has to be repeated. It has been suggested that an in-person examination should probably be conducted at least once every two years to be in compliance with the Ryan Haight Act (American Psychiatric Association Telepsychiatry Toolkit).
There are some exceptions to the requirement to do an in-person examination before prescribing a controlled substance. For example (not a complete list):
– Prescribers who are covering for another prescriber (thank God!)
– When the patient is currently in a hospital or other facility that is registered with the Drug Enforcement Administration (DEA) AND the prescribing clinician has a DEA license in the state where the patient currently is.
But, the Controlled Substances Act contains certain exceptions to the requirement to conduct an in-person medical examination for prescribing a controlled substance through telemedicine. For example, that requirement is waived when the Secretary of Health and Human Services declares a public health emergency. On January 31, 2020, the Secretary of Health and Human Services did declare such a public health emergency. The DEA notes that “For as long as the Secretary’s designation of a public health emergency remains in effect, DEA-registered practitioners may issue prescriptions for controlled substances to patients for whom they have not conducted an in-person medical evaluation” (source)
To be able to act in an emergency, for every telepsychiatry visit, we should make sure we know:
1. Exactly where the patient is right now (the street address).
2. The patient’s phone number, in case we have to contact the patient by phone if the telepsychiatry platform fails.
Along with this, it has been recommended that, when possible, a “patient support person” should be identified who can help the patient with various things if needed. If such a support person is available, we should have that persons’ phone number as well.
A simple thing to remember is that if the police need to be called and dispatched to where the patient is, we should not call 911 because that call is routed locally to near where we are located. Instead, we would have to identify the police station closest to where the patient is located. One way to do this is to Google “police station near xxxxx” where xxxxx is the address where the patient is located.
Telemedicine platforms or vendors
Please see the following article on this website:
Reimbursement, billing, and coding
Please see the following article on this website:
Abrams J, Sossong S, Schwamm LH, Barsanti L, Carter M, Kling N, Kotarski M, Leddy J, Meller B, Simoni M, Sullivan M, Wozniak J. Practical Issues in Delivery of Clinician-to-Patient Telemental Health in an Academic Medical Center. Harv Rev Psychiatry. 2017 May/Jun;25(3):135-145. doi: 10.1097/HRP.0000000000000142. Review. PubMed PMID: 28475505.
American Psychiatric Association. Telepsychiatry Blog.
American Psychiatric Association. Telepsychiatry Toolkit
American Psychiatric Association. Child & Adolescent Telepsychiatry.
American Psychiatric Association and American Telemedicine Association. Best Practices in Videoconferencing-Based Telemental Health
American Telemedicine Association. Telehealth Policy and Reimbursement Vary Widely from State to State, ATA Report Finds. July 19, 2019.
Cowan KE, McKean AJ, Gentry MT, Hilty DM. Barriers to Use of Telepsychiatry: Clinicians as Gatekeepers. Mayo Clin Proc. 2019 Dec;94(12):2510-2523. doi: 10.1016/j.mayocp.2019.04.018. Review. PubMed PMID: 31806104.
Federation of State Medical Boards. Telemedicine Policies Board by Board Overview. Last revised November 2019.
Funicelli A. Telepsychiatry: Treating Patients In and Out of Your Home State. Psychiatric News. Published Online:12 Dec 2019. https://doi.org/10.1176/appi.pn.2019.12b19.
Gardner JS, Plaven BE, Yellowlees P, Shore JH. Remote Telepsychiatry Workforce: a Solution to Psychiatry’s Workforce Issues. Curr Psychiatry Rep. 2020 Jan 27;22(2):8. doi: 10.1007/s11920-020-1128-7. Review. PubMed PMID: 31989417.
Hubley S, Lynch SB, Schneck C, Thomas M, Shore J. Review of key telepsychiatry outcomes. World J Psychiatry. 2016 Jun 22;6(2):269-82. doi: 10.5498/wjp.v6.i2.269. eCollection 2016 Jun 22. PubMed PMID: 27354970; PubMed Central PMCID: PMC4919267.
Lambert K. Telepsychiatry: Who, What, Where, and How. Psychiatric News. Published Online:1 Feb 2016. https://doi.org/10.1176/appi.pn.2016.2a13
Mahmoud H. Telepsychiatry: Outgrowing Old Challenges. Psychiatric News. Published Online:5 Jul 2018. https://doi.org/10.1176/appi.pn.2018.6a3
McCann RA, Lingam HA, Felker BL, Caudill RL. Practical and Regulatory Considerations of Teleprescribing via CVT. Curr Psychiatry Rep. 2019 Nov 18;21(12):122. doi: 10.1007/s11920-019-1073-5. Review. PubMed PMID: 31741088.
Nelson EL, Cain S, Sharp S. Considerations for Conducting Telemental Health with Children and Adolescents. Child Adolesc Psychiatr Clin N Am. 2017 Jan;26(1):77-91. doi: 10.1016/j.chc.2016.07.008. Epub 2016 Oct 15. Review. PubMed PMID: 27837944.
PRMS. Telepsychiatry: A Primer. Available free at https://www.prms.com/media/2329/telepsychiatry_booklet.pdf
Shore JH, Yellowlees P, Caudill R, Johnston B, Turvey C, Mishkind M, Krupinski E, Myers K, Shore P, Kaftarian E, Hilty D. Best Practices in Videoconferencing-Based Telemental Health April 2018. Telemed J E Health. 2018 Nov;24(11):827-832. doi: 10.1089/tmj.2018.0237. Epub 2018 Oct 24. PubMed PMID: 30358514.
Tuerk PW, Keller SM, Acierno R. Treatment for Anxiety and Depression via Clinical Videoconferencing: Evidence Base and Barriers to Expanded Access in Practice. Focus (Am Psychiatr Publ). 2018 Oct;16(4):363-369. doi: 10.1176/appi.focus.20180027. Epub 2018 Oct 18. Review. PubMed PMID: 31975928; PubMed Central PMCID: PMC6493250.
Zagorski N. APA Releases Guidance for Videoconferencing With Patients. Psychiatric News. Published Online:7 Jun 2018. https://doi.org/10.1176/appi.pn.2018.6a14
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