Rural Telepsychiatry

For the past four decades, technology has been explored as a way to link health care professionals with facilities and programs in isolated areas to help provide medical and psychiatric care (1). In this paper, telepsychiatry is defined as the use of telecommunications technology to connect a patient or health care provider to another health care provider through audio or video transmission, permitting effective diagnosis, education, treatment, consultation, transfer of medical data, research, and other health care activities.

Telepsychiatry has been used as a partial solution to the problem of limited psychiatric services for remote clinics and hospitals or areas underserved by mental health specialists. Limitations of telepsychiatry include the costs of capital equipment, maintenance, transmission, and operations (1).

Current uses of telepsychiatry fall into one of four broad areas: educational, administrative, research, and clinical. Historically, educational uses have been an integral part of telepsychiatry programs (2,3). Clinical applications include diagnostic evaluations, medication management, consultations, and psychotherapy (3).

History of telepsychiatry

The technological changes that have occurred in this field over the last four decades closely mirror advances made in computers. The two most impressive changes have been the decreasing size and cost of the equipment. Use of the Internet and videoconferencing by the general population on desktop computers have fueled improvements in visual and audio quality.

Telepsychiatry is nearly as old as the use of two-way audiovisual telecommunications in health care. In 1959 the University of Nebraska began using two-way closed-circuit microwave television for medical treatment and education (4). Shortly afterward, a two-way closed-circuit microwave television system was established between the Nebraska Psychiatric Institute and Norfolk State Hospital in Nebraska providing consultations, education, training, and research (5). STARPAHC in the late 1950s carried out research in using audio and audiovisual telecommunications to provide medical service to astronauts in space and to provide general medical service to communities on the Papago Indian reservation in Arizona (6).

In 1968 an interactive television microwave link was established between Massachusetts General Hospital in Boston and a medical station at Logan Airport (7). Massachusetts General Hospital also provided telepsychiatric services to the Veterans Affairs hospital in Bedford, Massachusetts, beginning in 1968. In the 1970s services were expanded to schools and courts in the surrounding Boston community and to a nearby prison (8).

Early telepsychiatric systems were shut down for various reasons; a lack of system management has been cited as a primary reason (1). Lines of authority and responsibility were often unclear or absent. Many of the early systems were funded with government grants; the programs ceased when the grants ended. Reimbursement issues have plagued telepsychiatric systems up through the present. Equipment, maintenance, and transmission costs often are not covered by existing reimbursement plans and thus translate into additional provider costs when compared with costs of face-to-face interactions.

Application in the United States

Although numerous telepsychiatric programs are currently operating in the United States, two are especially noteworthy. Both have been recognized by their peers as being among the top ten outstanding telemedicine programs in the United States (9). Eastern Oregon's RodeoNet telepsychiatry program is a seven-year-old mental health program originally funded by an outreach grant from the Office of Rural Health Policy in 1991. The program is now reported to be self-sustaining and is achieving its mission of enhancing communication between providers and ensuring better distribution of specialist care. One key to its success is that the telepsychiatry program is built on Oregon's ED-NET network. ED-NET is a public system offering satellite video services and dial-up computer communications; operating costs are shared among participants.

Fewer than 50 psychiatric consultations a year are performed in the RodeoNet system (9); however, the direct costs of the consultations have been noted to be as much as 50 percent less than costs of face-to-face consultations. The cost of conducting patient commitment hearings over the RodeoNet system is five times less than the cost of the traditional commitment hearing process. RodeoNet program administrators assess outcome measures, including cost-efficiencies, time savings, user satisfaction, and quality. Such a system cannot be cost-effective with 50 consultations a year unless there is a pre-existing system such as ED-NET or a funded system. Planning for equipment, transmission, maintenance, operational costs, and depreciation of equipment is imperative.

An example of a successful multispecialty application is the Kansas University Medical Center's telemedicine program. This network has approximately 14 sites throughout rural Kansas and includes 12 specialty areas; oncology, neurology, and psychiatry conduct the most consultations (9). In 1996 about 100 multispecialty consultations a month were conducted via the system. The Kansas program started in 1990 as a demonstration project and became a full-fledged program in 1994. The telepsychiatric component is only one program within the system network; use of an existing network (cost-sharing) allows the telepsychiatric application to be successful.

A 1995 survey of six active telepsychiatry programs in the United States (3) indicated that the six programs had a total of 35 years of collective telepsychiatry service, with 504 documented patient encounters. The five programs that recorded the specific number of contacts with psychiatric patients reported a collective total of 372 weeks of active program use, with a mean±SD of 1.35±1.40 patient consultations a week. No program reported any adverse patient outcomes.

Feasibility would be nearly impossible given this usage rate unless costs of the telepsychiatric services were shared with other telemedical services. The only problem reported by any of the six programs was occasional difficulty with audio and video quality, which could distract from examination of the patient. Advances in technology and transmission have improved these limitations.

Future directions

Telepsychiatric systems such as RodeoNet provide models of excellence. Some issues are currently being debated. A physician licensed in one state who examines a patient in another state may be required to have a medical license in the other state. The patient's informed consent for the use of telemedicine equipment and videorecording and transmission of images may be required.

The penetration of managed care programs into rural areas will likely do more for the advancement of rural telepsychiatry than Medicare reimbursement. Managed health care systems and comprehensive state systems that are responsible for coverage of large rural or underserved areas are motivated to provide the best care for clients in the most cost-effective manner while using the least amount of intervention. Telepsychiatric services can augment an otherwise comprehensive program and provide a potentially cost-effective solution to rural mental health care delivery. Use of the Internet and the World Wide Web to provide some of these services is realistic. Clinicians have established Web pages and Internet addresses for patient interactions. It remains to be seen how such activities can be carried out on a more comprehensive and economical scale.

Rural telepsychiatry is ideally suited to provide mental health services to persons whose access to services may have been restricted in the past or who have never had the opportunity to receive such services. Telepsychiatry has the potential to be a cost-effective solution in providing mental health services in rural or underserved areas.

Dr. Brown is associate professor of psychiatry at Emory University School of Medicine and medical director of Wesley Woods Geriatric Hospital, 1841 Clifton Road, N.E., Atlanta, Georgia 30329 (e-mail, [email protected]). This paper is one of several on rural psychiatry in this issue.