Just a few short years ago, I was invited to write an editorial on telepsychiatry that I titled: “When will telepsychiatry reach its tipping point”? (Flaum, 2017). It accompanied and tried to make sense of an article in which analyses of multiple large databases of private insurance claims revealed that out of almost 4 million claims for behavioral health services over a 4-year period, only a tiny fraction, (less than .05%) were for services delivered via telehealth (Wilson, et al 2017). This finding was hard to understand in light of the fact that each of the major potential barriers to telehealth had been largely addressed at least a decade earlier. Briefly, these involved: 1) questions about patient and provider satisfaction; 2) adequate reimbursement; 3) technology limitations; and 4) privacy/HIPAA related concerns. Not only had each of these concerns been adequately resolved many years previously, but there was ongoing progress, especially around the technological limitations. So why did utilization of telehealth remain so limited (at least in the private sector)? I argued that the real barrier was that of inertia, i.e., we tend to do things the way we do them because that’s how we do them. And with the longstanding and ever-increasing discrepancy between demand and supply for mental health services, most psychiatrists already have more people knocking on their doors than they can see. Why change, especially to a platform that may seem less personal, if you don’t have to? The fact that telehealth was available, and was a reasonable option was not enough to change practice. What would it ultimately take for the “big tip,” I wondered. I concluded that piece by saying: “Something much bigger than psychiatry may have to tip before the telepsychiatry tipping point arrives.”
Well, now we know what that something turned out to be: A global pandemic. And with it, telehealth in general, and especially telepsychiatry, just tipped before our eyes in a very big way. I have heard one story after another recently, of provider groups large and small that went from doing little or no telepsychiatry to almost all of their services remotely, often over a period of a week or two. It is amazing how quickly and efficiently we can change when we have to.
But the questions and concerns I’m left with now are: Once having made this transition, will inertia once again take hold? Will we ever go back? Are we experiencing the beginning of the end of face-to-face psychiatric services?
I’ve been thinking about these questions to some extent since my first exposure to telepsychiatry over twenty years ago. At that time, I was a part of a research project comparing face-to-face vs. tele-psychiatric services in two rural community mental health centers. That study, like many others before and since, found no differences in clinical outcomes (Rohland et al, 2001) and high levels of patient satisfaction, especially after the first visit (Rohland, 2000). That is, patients tended to be a bit wary of it at first, but after the initial experience of a telepsychiatric visit, those concerns largely disappeared. Whenever I would talk about or present these kinds of findings (either in academic settings or informally), the most common questions or comments I’d get would be some version of… “so does that mean telepsychiatry is just as good as in-person services?” If so, why don’t we just do all services that way? It would sure help with access.” My response would usually involve caution about oversimplifying the interpretation of research results and add that if given the choice, either as a provider or a patient, all things being equal I’d choose in-person services every time. But the catch of course, is that all things are rarely equal. So, rather than thinking of equivalence, or whether one is “better than the other”, we need to think about relative advantages and disadvantages, probably on a case by case basis, and specific situations in which one or the other might be preferred. A few examples in which the balance might tip towards telehealth:
- A patient who lives in a remote area, and who has to travel a long distance to see any provider, may prefer to see someone via telehealth and save the time and expense related to the travel.
- A patient for whom English is not their first language may prefer a clinician who is fluent in their native language and might prefer seeing such a provider on a screen than one who they struggle to understand in-person
- A patient who has an uncommon illness or one that is not responding to first- or second-line treatment approaches may prefer to see a specialist via telehealth than a generalist in person.
- Similarly, a provider who has a particular area of interest and expertise about a relatively rare clinical occurrence may want to focus only on patients with that condition, but can only do so by broadening their geographic range via telehealth.
When does telepsychiatry work less well? When might the balance shift towards in-person? In my experience, an initial evaluation usually goes better face-to-face than virtually. Once I’ve actually sat in a room with a patient, it seems that the follow-up visits (whether they are done virtually or in-person) tend to go more smoothly. There seems to be an intangible quality, harder to measure or describe: I just feel I know the person better, and they know me better. It doesn’t have to happen on the first visit. Sometimes, I’ll do an intake via telehealth and perhaps even the next few visits virtually, but I find that once I have the opportunity to meet them in person, then my connection with them strengthens, and that tends to persist.
Another scenario that tips the balance for me towards in-person visits, is working with people who have significant hearing difficulties, which among my Senior Life Solutions patients is not at all an uncommon occurrence. Hearing difficulties can be a barrier to making a good connection with someone in any circumstance, but I usually find ways to overcome it in-person that I just can’t seem to do via telehealth. It tends to be frustrating for all involved.
These are just a few examples of the kinds of issues that I think we will need to think about now that telehealth has suddenly become ubiquitous. In what other kinds of cases or clinical situations are there clear advantages for face-to-face vs. telehealth visits? Should it be patient preference, provider preference, agency preference, payer preference? Who should decide, and based upon what?
Providers who work at PMC are probably far ahead of the curve on all of this, as PMC has been effectively using and facilitating telehealth for many years now. And wisely, PMC has avoided policies that mandate one or the other, leaving it to the clinical teams to decide. Ideally, this may be an opportunity for shared decision making on a case-by-case and/or visit-by-visit basis, i.e., a decision that incorporates and balances the preferences of the psychiatric provider, the on-site team and the patients, depending upon a host of factors.
I am hopeful that one of the silver linings of this difficult time will be that it will disrupt those things that we all did as a consequence of inertia and provide us an opportunity to rethink what and how we do things. And I hope when we are able to choose, once again, between telepsychiatric and in-person services, we will have the option to make those choices in a more informed and sophisticated manner, and in a way that optimally balances the best overall experience and outcomes for those we serve and for the population as a whole.
- Flaum M. When will telepsychiatry reach its “tipping point”? Psychiatric Services. 68:12, Dec, 2017.
- Wilson et al, Telehealth Delivery of Mental Health Services: An Analysis of Private Insurance Claims Data in the United States. 68:12, Dec, 2017
- Rohland, BM et al,: Telepsychiatry in the heartland: if we build it, will they come? Community Ment Health J. 2001 Oct;37(5):449-59.
- Rohland et al, Acceptability of Telepsychiatry to a Rural Population. Psychiatric Services. 51;5, May, 2000