INT’L. J. PSYCHIATRY IN MEDICINE, Vol. 48(1) 1-4, 2014
EDITORS’ NOTE
We are pleased to offer this special section to the International Journal of Psychiatry in Medicine on eHealth, specifically telemedicine, also known as telehealth, telepsychiatry, telepsychology, and various other iterations of the same theme. This special section contains four articles on telemedicine delivered evidence-based therapy, and a fifth article pushing the envelope even further to the realm of child behavior therapy through online interactive websites. In an age where providing patient-centered access to healthcare is the expectation, telehealth iterations provide a promising tool to bring good care to more people who are in need of it. This has obvious implications for patients who are simply physically unable to reach their providers’ offices. However, non-health factors, such as geographic isolation, lack of local expertise, and cost are also barriers that are now surmountable through telemedicine approaches. The benefits of convenience and cost-savings are further amplified when considering mental health conditions, where stigma and avoidance may combine to preclude treatment. Such is the case with disorders like eating and anxiety disorders, and most certainly Post-Traumatic Stress Disorder (PTSD) for whom social and professional stigma surrounding mental health problems are particularly salient [1]. Readers will note that four of these articles address Veterans and telemedicine. The Department of Veterans Affairs (VA) is currently the largest provider of telemedicine services in the world for medical conditions, and VA researchers are evaluating whether this technology can be applied to delivery of evidencebased mental health services while sustaining effectiveness. Virtually all VA telemedicine for mental health treatments currently connects patients from rural, community-based outpatient satellite clinics (CBOCs) to expert providers at larger Veterans Affairs Medical Centers (VAMCs) that offer specialty mental health services. This form of telehealth is associated with high levels of patient satisfaction and clinical outcomes that are comparable to in-person service delivery [2-6]. However, this treatment delivery model still requires patients to travel to office-based treatment sites, and the aforementioned pathology- and 1 Ó 2014, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/PM.48.1.a http://baywood.com
2 / EDITORS’ NOTE
system-level barriers are still present. This special section focuses on an even more patient-centered innovation, that is treatments patients can receive in their homes. HOME-BASED TELEHEALTH (HBT) Historically, Home Based Telehealth (HBT) was focused on remote monitoring, and more recently has been used to enhance management of chronic diseases such as diabetes, obstructive pulmonary disease, and congestive heart failure, preliminary research suggests HBT service delivery is associated with high patient satisfaction, reduced frequency and duration of inpatient hospital stays, and overall symptom improvement [7-9]. Although these preliminary data are promising, administrators and clinical providers have been reluctant to apply HBT service models to mental health interventions, citing concerns that HBT via video-conferencing may compromise therapeutic alliance, patient safety and confidentiality [10], issues addressed directly by the articles in this section. Considering such issues is important because HBT for mental health treatment offers several advantages over conventional, satellite clinic-based telehealth models. First, HBT bypasses stigma-related avoidance of office based mental health care; second, HBT removes many logistical barriers related to travel time and transportation; and third, HBT service delivery circumvents system-level barriers including infrastructure constraints (no need to rent satellite clinics). PRIVACY REQUIREMENTS, PRACTICE PRIVILEGES/LICENSURE Issues regarding patient confidentiality and data protections, licensure, and privileging are complicated in telemedicine and more so in HBT. Privacy issues, including meeting Health Insurance and Portability Act (HIPAA) standards have largely been resolved through a combination of encryption software and patient informed consent. Moreover, the federal government has proposed national standards outlining many of the licensing parameters, although many states have not adopted these standards at this time. Typically, medical records must reside where the patient is receiving services, whereas privileging processes are based on standards of the site from which the provider practices. Moreover, in the absence of interstate agreements, cross state telehealth is prohibited in many locations. One notable exception to this rule is when the provider and patient are both in federal facilities, such as the VA or Department of Defense (DoD). However, while this exception clearly includes the hub and spoke (main facility to satellite facility) model of telehealth, it leaves unaddressed the issue of HBT, where treatment originates from a central federal facility, but is received across state lines in the patient’s home. It is very likely that legislative action is needed wherein telehealth services originating from federal facilities are protected
EDITORS’ NOTE / 3
across state and even across national lines if they are being delivered to U.S. citizens, legal residents, or active duty personnel overseas. CONSIDERING OUR ARTICLES The five articles in this special section each make a unique contribution to the overall series. First, Shore et al. investigated the feasibility of a telemental health program from a central VA medical facility to veterans’ homes or other nonclinical setting. Several encouraging findings emerged including good patient satisfaction as well as reduced “no show” incidents compared to the more traditional clinic-based telehealth model. Second, Luxton et al. described a program for the assessment and management of suicide risk among depressed military service members and veterans receiving home-based treatment via web cam. The result is a best practices model for protecting patient safety within the context of a telehealth care delivery. Third, Hernandez-Tejada et al. examined parameters leading to early dropout from treatment in-person compared to telemedicine delivered exposure therapy for combat veterans suffering with PTSD. The telehealth delivery of PTSD exposure therapy showed the same dropout rate, but more sessions were received before withdrawal from treatment. Fourth, Price and Gros reported that attitudes toward telehealth (particularly familiarity with telehealth) were not related to treatment outcome, suggesting that telehealth may have broad applicability, even when not the modality of greatest preference. Finally, Davidson et al. showed that the delivery of a Behavioral Activation model to depressed adolescents via means of a telehealth model was a feasible approach likely to deliver positive patient results. REFERENCES 1. Pietrzak RH, Johnson DC, Goldstein MB, Malley JC, Southwick SM. (2009). Perceived stigma and barriers to mental health care utilization among OEF-OIF veterans. Psychiatric Services, 60, 1118-1122. 2. Frueh BC, Deitsch SE, Santos AB, Gold PB, Johnson MR, Meisler N, Magruder KM, Ballenger JC. (2000). Procedural and methodological issues in telepsychiatry research and program development. Psychiatric Services, 51, 1522-1527. 3. Frueh BC, Monnier J, Yim E, Grubaugh AL, Elhai JD, Yim E, Knapp E. (2007). A randomized study of telepsych for PTSD. Journal of Telemedicine & Telecare, 13, 142-147. 4. Germain V, Marchand A, Bouchard S, Drouin MS, Guay S. (2009). Effectiveness of cognitive behavioural therapy administered by videoconference for posttraumatic stress disorder. Cognitive Behavioral Therapy, 38, 42-53. 5. Germain V, Marchand A, Bouchard S, Guay S, Drouin M. (2009). Assessment of the therapeutic alliance in face-to-face or videoconference treatment for posttraumatic stress disorder. Cyberpsychology Behavior and Social Networking, 13, 29-35.
4 / EDITORS’ NOTE
6. Richardson LK, Frueh BC, Grubaugh AL, Egede L, Elhai JD. (2009). Current directions in videoconferencing tele-mental health research. Clinical Psychology, 16, 323-338. 7. Darkins A, Ryan P, Kobb R, Foster L, Edmonson E, Wakefield B, Lancaster AE. (2008). Care coordination/home telehealth: The systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemed Journal and e-Health, 14, 1118-1126. 8. DelliFraine JL, Dansky KH. (2008). Home-based telehealth: A review and meta-analysis. Journal of Telemedicine and Telecare, 4, 62-66. 9. Shore, P. (2011). Veterans receiving specialty PTSD treatment. Journal of Psychiatric Practices 2002, 8, 326-332. Meeting veterans where they’re at: Home-based telemental health. Paper presented at the 2011 Veterans Affairs National Mental Health Conference, Baltimore MD. 10. Bauer KA. (2001). Home-based telemedicine: A survey of ethical issues: CQ. Cambridge Quarterly of Healthcare Ethics, 10, 137.
John R. Freedy, MD, PhD Editor International Journal of Psychiatry in Medicine Ronald E. Acierno, PhD Associate Editor International Journal of Psychiatry in Medicine
EDITORS’ NOTE
We are pleased to offer this special section to the International Journal of Psychiatry in Medicine on eHealth, specifically telemedicine, also known as telehealth, telepsychiatry, telepsychology, and various other iterations of the same theme. This special section contains four articles on telemedicine delivered evidence-based therapy, and a fifth article pushing the envelope even further to the realm of child behavior therapy through online interactive websites. In an age where providing patient-centered access to healthcare is the expectation, telehealth iterations provide a promising tool to bring good care to more people who are in need of it. This has obvious implications for patients who are simply physically unable to reach their providers’ offices. However, non-health factors, such as geographic isolation, lack of local expertise, and cost are also barriers that are now surmountable through telemedicine approaches. The benefits of convenience and cost-savings are further amplified when considering mental health conditions, where stigma and avoidance may combine to preclude treatment. Such is the case with disorders like eating and anxiety disorders, and most certainly Post-Traumatic Stress Disorder (PTSD) for whom social and professional stigma surrounding mental health problems are particularly salient [1]. Readers will note that four of these articles address Veterans and telemedicine. The Department of Veterans Affairs (VA) is currently the largest provider of telemedicine services in the world for medical conditions, and VA researchers are evaluating whether this technology can be applied to delivery of evidencebased mental health services while sustaining effectiveness. Virtually all VA telemedicine for mental health treatments currently connects patients from rural, community-based outpatient satellite clinics (CBOCs) to expert providers at larger Veterans Affairs Medical Centers (VAMCs) that offer specialty mental health services. This form of telehealth is associated with high levels of patient satisfaction and clinical outcomes that are comparable to in-person service delivery [2-6]. However, this treatment delivery model still requires patients to travel to office-based treatment sites, and the aforementioned pathology- and 1 Ó 2014, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/PM.48.1.a http://baywood.com
2 / EDITORS’ NOTE
system-level barriers are still present. This special section focuses on an even more patient-centered innovation, that is treatments patients can receive in their homes. HOME-BASED TELEHEALTH (HBT) Historically, Home Based Telehealth (HBT) was focused on remote monitoring, and more recently has been used to enhance management of chronic diseases such as diabetes, obstructive pulmonary disease, and congestive heart failure, preliminary research suggests HBT service delivery is associated with high patient satisfaction, reduced frequency and duration of inpatient hospital stays, and overall symptom improvement [7-9]. Although these preliminary data are promising, administrators and clinical providers have been reluctant to apply HBT service models to mental health interventions, citing concerns that HBT via video-conferencing may compromise therapeutic alliance, patient safety and confidentiality [10], issues addressed directly by the articles in this section. Considering such issues is important because HBT for mental health treatment offers several advantages over conventional, satellite clinic-based telehealth models. First, HBT bypasses stigma-related avoidance of office based mental health care; second, HBT removes many logistical barriers related to travel time and transportation; and third, HBT service delivery circumvents system-level barriers including infrastructure constraints (no need to rent satellite clinics). PRIVACY REQUIREMENTS, PRACTICE PRIVILEGES/LICENSURE Issues regarding patient confidentiality and data protections, licensure, and privileging are complicated in telemedicine and more so in HBT. Privacy issues, including meeting Health Insurance and Portability Act (HIPAA) standards have largely been resolved through a combination of encryption software and patient informed consent. Moreover, the federal government has proposed national standards outlining many of the licensing parameters, although many states have not adopted these standards at this time. Typically, medical records must reside where the patient is receiving services, whereas privileging processes are based on standards of the site from which the provider practices. Moreover, in the absence of interstate agreements, cross state telehealth is prohibited in many locations. One notable exception to this rule is when the provider and patient are both in federal facilities, such as the VA or Department of Defense (DoD). However, while this exception clearly includes the hub and spoke (main facility to satellite facility) model of telehealth, it leaves unaddressed the issue of HBT, where treatment originates from a central federal facility, but is received across state lines in the patient’s home. It is very likely that legislative action is needed wherein telehealth services originating from federal facilities are protected
EDITORS’ NOTE / 3
across state and even across national lines if they are being delivered to U.S. citizens, legal residents, or active duty personnel overseas. CONSIDERING OUR ARTICLES The five articles in this special section each make a unique contribution to the overall series. First, Shore et al. investigated the feasibility of a telemental health program from a central VA medical facility to veterans’ homes or other nonclinical setting. Several encouraging findings emerged including good patient satisfaction as well as reduced “no show” incidents compared to the more traditional clinic-based telehealth model. Second, Luxton et al. described a program for the assessment and management of suicide risk among depressed military service members and veterans receiving home-based treatment via web cam. The result is a best practices model for protecting patient safety within the context of a telehealth care delivery. Third, Hernandez-Tejada et al. examined parameters leading to early dropout from treatment in-person compared to telemedicine delivered exposure therapy for combat veterans suffering with PTSD. The telehealth delivery of PTSD exposure therapy showed the same dropout rate, but more sessions were received before withdrawal from treatment. Fourth, Price and Gros reported that attitudes toward telehealth (particularly familiarity with telehealth) were not related to treatment outcome, suggesting that telehealth may have broad applicability, even when not the modality of greatest preference. Finally, Davidson et al. showed that the delivery of a Behavioral Activation model to depressed adolescents via means of a telehealth model was a feasible approach likely to deliver positive patient results. REFERENCES 1. Pietrzak RH, Johnson DC, Goldstein MB, Malley JC, Southwick SM. (2009). Perceived stigma and barriers to mental health care utilization among OEF-OIF veterans. Psychiatric Services, 60, 1118-1122. 2. Frueh BC, Deitsch SE, Santos AB, Gold PB, Johnson MR, Meisler N, Magruder KM, Ballenger JC. (2000). Procedural and methodological issues in telepsychiatry research and program development. Psychiatric Services, 51, 1522-1527. 3. Frueh BC, Monnier J, Yim E, Grubaugh AL, Elhai JD, Yim E, Knapp E. (2007). A randomized study of telepsych for PTSD. Journal of Telemedicine & Telecare, 13, 142-147. 4. Germain V, Marchand A, Bouchard S, Drouin MS, Guay S. (2009). Effectiveness of cognitive behavioural therapy administered by videoconference for posttraumatic stress disorder. Cognitive Behavioral Therapy, 38, 42-53. 5. Germain V, Marchand A, Bouchard S, Guay S, Drouin M. (2009). Assessment of the therapeutic alliance in face-to-face or videoconference treatment for posttraumatic stress disorder. Cyberpsychology Behavior and Social Networking, 13, 29-35.
4 / EDITORS’ NOTE
6. Richardson LK, Frueh BC, Grubaugh AL, Egede L, Elhai JD. (2009). Current directions in videoconferencing tele-mental health research. Clinical Psychology, 16, 323-338. 7. Darkins A, Ryan P, Kobb R, Foster L, Edmonson E, Wakefield B, Lancaster AE. (2008). Care coordination/home telehealth: The systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemed Journal and e-Health, 14, 1118-1126. 8. DelliFraine JL, Dansky KH. (2008). Home-based telehealth: A review and meta-analysis. Journal of Telemedicine and Telecare, 4, 62-66. 9. Shore, P. (2011). Veterans receiving specialty PTSD treatment. Journal of Psychiatric Practices 2002, 8, 326-332. Meeting veterans where they’re at: Home-based telemental health. Paper presented at the 2011 Veterans Affairs National Mental Health Conference, Baltimore MD. 10. Bauer KA. (2001). Home-based telemedicine: A survey of ethical issues: CQ. Cambridge Quarterly of Healthcare Ethics, 10, 137.
John R. Freedy, MD, PhD Editor International Journal of Psychiatry in Medicine Ronald E. Acierno, PhD Associate Editor International Journal of Psychiatry in Medicine
