Cross-Lingual Asynchronous Telepsychiatry: Disruptive Innovation?
Most X-rays are no longer physically taken by radiologists. Instead, the images are taken by a highly trained radiology technician and then sent to radiologists who write diagnostic reports that are returned to the referring physicians, often with advice on treatment or recommendations for further investigation. This process of asynchronous medical reporting and decision making has become common in a number of specialties, including radiology, pathology, cardiology, dermatology, and ophthalmology.
Similar to the way X-rays are now processed, we believe that video recordings could assist in the evaluation of psychiatric patients, especially now that digital recordings are so easy to create and upload. Recordings could be made in primary care clinics, patients' homes, or other environments and used as clinical data, sent to experts for evaluation. Specialty providers, such as psychiatrists, neurologists, pediatricians, and geriatricians, could evaluate the video data and provide asynchronous consultation and reporting. This approach is an improved version of the traditional “curbside consultation” that many specialist physicians are accustomed to providing for colleagues, whereby a video of the patient could be reviewed instead of a description of symptoms presented in a phone call or a hallway conversation. Video data could be combined with other electronic data, such as patient history or clinical notes, and transferred between providers through an electronic medical record (EMR), an excellent clinical example of improving health information exchange. The asynchronous platform could expand access to care for underserved individuals by making some specialist consultations more available, efficient, and relevant for referring providers.
To test this approach with psychiatric consultations in primary care, we conducted a study of asynchronous telepsychiatry (ATP) with a sample of 127 English- and Spanish-speaking patients in 2008–2009. We set out to examine the use of the ATP platform to provide language translations. Our goal was to show that, if feasible, ATP with language translation could expand the range of evaluating providers, thereby increasing access to care for non-English-speaking patients. We developed a secure ATP technical platform similar to an EMR, with the added capability of supporting video data. The ATP data sets, clinical interview video, and patient history were uploaded and reviewed by a psychiatrist who wrote a report containing a diagnostic assessment and treatment plan for the referring doctor to implement if he or she wished. The Spanish-speaking patients were interviewed in Spanish and assessed by Spanish-speaking psychiatrists and, after translation of the ATP data sets from Spanish to English through medical interpreters, by English-speaking psychiatrists. Inter-rater reliability between the English- and Spanish-speaking psychiatrists was acceptable. We concluded that ATP is a feasible clinical process and has a unique advantage over real-time care in that the patient's data can be altered (that is, via language translation) en route to the specialist, thereby broadening the scope of providers who can evaluate the data and presenting it to the reporting provider in a more focused way.
The final part of this first study of ATP was a cost-benefit analysis, where we demonstrated that ATP, using our model, was indeed a “disruptive innovation.” In other words, we changed the process of care in a way that was more cost-effective than either in-person psychiatric consultations or traditional real-time (synchronous) telepsychiatry consultations.
Further studies are needed to replicate these results and fully examine the feasibility, reliability, and validity of this process in larger samples and in nonresearch clinical settings. The ATP consultation process is ripe for research initiatives. Clinical outcome studies are needed, as is further examination of the best clinical and technological means of undertaking cross-language consultations. For instance, subtitles instead of an audio file translation, as we used, may be a better approach to language translation and could also be applied to sign language translation for deaf and hard-of-hearing individuals. We also predict that ATP could be available on portable devices (such as smartphones and computer tablets) to increase access to expert opinions anytime, anywhere. This is an exciting area for further research and clinical development and challenges the traditional paradigms of in-person psychiatric care by promoting the asynchronous consultation model of care in an online environment. It is our view that ATP is a disruptive health care process that has the potential to markedly change the way we deliver mental health care, to diminish language barriers and expand access to care.
