Emergency telepsychiatry

Optimizing an Adolescent Hybrid Telemedical Mental Health Service: Staff Scheduling using Mathematical Programming (Preprint)

BACKGROUND

According to the World Health Organization, globally, one in seven 10- to 19-year-olds experiences a mental disorder, accounting for 13% of the global burden of disease in this age group. Half of all mental illnesses begin by the age of 14 years and some teenagers with severe presentations must be admitted to the hospital and assessed by highly skilled mental health care practitioners. Digital telehealth solutions can be useful for the assessment of young individuals remotely. Ultimately, this technology can save travel costs for the health service rather than assessing adolescents in person at the corresponding hospital. Especially in rural regions, where travel times can be high, this innovative approach can make a difference to patients by providing quicker assessments.

OBJECTIVE

The aim of this study is to share insights on how we developed a decision support tool to assign staff to days and locations where adolescent mental health patients are assessed face to face. Where possible, patients are seen through video consultation. The model not only seeks to reduce travel times and consequently carbon emissions but also can be used to find a minimum number of staff to run the service.

METHODS

To model the problem, we used integer linear programming, a technique that is used in mathematical modeling. The model features 2 objectives: first, we aim to find a minimum coverage of staff to provide the service and second, to reduce travel time. The constraints that are formulated algebraically are used to ensure the feasibility of the schedule. The model is implemented using an open-source solver backend.

RESULTS

In our case study, we focus on real-world demand coming from different hospital sites in the UK National Health Service (NHS). We incorporate our model into a decision support tool and solve a realistic test instance. Our results reveal that the tool is not only capable of solving this problem efficiently but also shows the benefits of using mathematical modeling in health services.

CONCLUSIONS

Our approach can be used by NHS managers to better match capacity and location-dependent demands within an increasing need for hybrid telemedical services, and the aims to reduce traveling and the carbon footprint within health care organizations.

Telepsychiatry for conflict-affected settings: Feasibility, ethics, barriers and prospects

Telehealth is being broadly developed in all fields of medicine, and online visits seem a particularly suitable alternative to in-person visits in outpatient psychiatry especially in conflict setting. Telepsychiatry has numerous advantages over in-person visits.

Comparable reliability and acceptability of telepsychiatry and face-to-face psychiatric assessments in the emergency room setting

OBJECTIVE

This study aims to compare the reliability and acceptability of psychiatric interviews using telepsychiatry and face-to-face modalities in the emergency room setting.

METHODS

In this prospective observational feasibility study, psychiatric patients (n = 38) who presented in emergency rooms between April and June 2020, went through face-to-face and videoconference telepsychiatry interviews in a non-randomised varying order. Interviewers and a senior psychiatry resident who observed both interviews determined diagnosis, recommended disposition and indication for involuntary admission. Patients and psychiatrists completed acceptability post-assessment surveys.

RESULTS

Agreement between raters on recommended disposition and indication for involuntary admission as measured by Cohen's kappa was 'strong' to 'almost perfect' (0.84/0.81, 0.95/0.87 and 0.89/0.94 for face-to-face vs. telepsychiatry, observer vs. face-to-face and observer vs. telepsychiatry, respectively). Partial agreement between the raters on diagnosis was 'strong' (Cohen's kappa of 0.81, 0.85 and 0.85 for face-to-face vs. telepsychiatry, observer vs. face-to-face and observer vs. telepsychiatry, respectively).Psychiatrists' and patients' satisfaction rates, and psychiatrists' perceived certainty rates, were comparably high in both face-to-face and telepsychiatry groups.

CONCLUSIONS

Telepsychiatry is a reliable and acceptable alternative to face-to-face psychiatric assessments in the emergency room setting. Implementing telepsychiatry may improve the quality and accessibility of mental health services.Key pointsTelepsychiatry and face-to-face psychiatric assessments in the emergency room setting have comparable reliability.Patients and providers report a comparable high level of satisfaction with telepsychiatry and face-to-face modalities in the emergency room setting.Providers report a comparable level of perceived certainty in their clinical decisions based on telepsychiatry and face-to-face psychiatric assessments in the emergency room setting.

Smart City and Crisis Management: Lessons for the COVID-19 Pandemic

COVID-19 shocked cities around the world and revealed the vulnerability of urban lives and functions. Most cities experienced a catastrophic disturbance that has lasted for a long time. Planning plays a critical role in responding efficiently to this crisis and enabling rapid functional recovery in the post-disaster era. Cities that have implemented digitalization initiatives and programs are likely to have more capacity to react appropriately. Specifically, digitalized cities could ensure the well-being of their residents and maintain continuity of urban functions. This research aims to analyze the role of technology in crisis management in the last two decades and provide appropriate policy recommendations for dealing with the COVID-19 pandemic. Systematic literature review and subjective content analysis are employed to investigate the effects of technology on community well-being and making cities more resilient in past crises. This study shows that different technology-driven policies and actions enable crisis management, enhance community well-being, and increase urban resilience. Technology has enhanced coping and recovery capacities by increasing participation and social connectedness, enhancing physical and mental health and maintaining the functionality of education and economic systems. These have been achieved through various solutions and technologies such as social media, telehealth, tracking and monitoring systems, sensors and locational applications, teleworking systems, etc. These solutions and technologies have also been used during the COVID-19 pandemic to enhance community well-being and sustain urban functions. However, technology deployment might have adverse effects such as social exclusion, digital divide, privacy and confidentiality violation, political bias and misinformation dissemination, and inefficient remote working and education. It is suggested that to mitigate these side effects, policymakers should liberate the process of digitalization, increase the accessibility to digital services, and enhance digital literacy.

Treating Pediatric and Geriatric Patients at Risk of Suicide in General Emergency Departments: Perspectives From Emergency Department Clinical Leaders

STUDY OBJECTIVE

We explored emergency department clinical leaders' views on providing emergency mental health services to pediatric and geriatric patients with suicidal ideation and suicide attempts.

METHODS

We conducted semistructured interviews with a total of 34 nursing directors, medical directors, and behavioral health managers at 17 general hospital EDs across the United States, using purposive sampling to ensure variation among hospitals. Interviews were audio-recorded, transcribed verbatim, and coded and analyzed using Atlas.ti and a directed content analysis approach.

RESULTS

Respondents from across a range of ED types expressed concerns regarding the capacity of their EDs to meet mental health needs of children and older adults. They experienced emotional distress over the increasing number of pediatric patients presenting to EDs with suicidal ideation/suicide attempt and described EDs as inappropriate environments for young patients with suicidal ideation/suicide attempt. Similarly, leaders expressed feeling ill-equipped to diagnose and treat geriatric patients with suicidal ideation/suicide attempt, who often had medical comorbidities that complicated treatment planning. Respondents noted that pediatric and geriatric patients frequently boarded in the ED. Some felt compelled to use creative solutions to provide safe spaces for pediatric and geriatric patients. Respondents voiced frustration over the lack of outpatient and inpatient mental health services for these patients.

CONCLUSION

Clinical leaders in EDs across the nation expressed distress at feeling they were not adequately equipped to meet the needs of pediatric and geriatric patients with suicidal ideation/suicide attempt. Future innovations to provide ED care for children and older adults with suicidal ideation/suicide attempt might include training for ED teams, access to specialist mental health clinicians through telehealth, and adaptations of physical spaces.

Psychiatric Profiles of eHealth Users Evaluated Using Data Mining Techniques: Cohort Study

BACKGROUND

New technologies are changing access to medical records and the relationship between physicians and patients. Professionals can now use e-mental health tools to provide prompt and personalized responses to patients with mental illness. However, there is a lack of knowledge about the digital phenotypes of patients who use e-mental health apps.

OBJECTIVE

This study aimed to reveal the profiles of users of a mental health app through machine learning techniques.

METHODS

We applied a nonparametric model, the Sparse Poisson Factorization Model, to discover latent features in the response patterns of 2254 psychiatric outpatients to a short self-assessment on general health. The assessment was completed through a mental health app after the first login.

RESULTS

The results showed the following four different profiles of patients: (1) all patients had feelings of worthlessness, aggressiveness, and suicidal ideas; (2) one in four reported low energy and difficulties to cope with problems; (3) less than a quarter described depressive symptoms with extremely high scores in suicidal thoughts and aggressiveness; and (4) a small number, possibly with the most severe conditions, reported a combination of all these features.

CONCLUSIONS

User profiles did not overlap with clinician-made diagnoses. Since each profile seems to be associated with a different level of severity, the profiles could be useful for the prediction of behavioral risks among users of e-mental health apps.

Beam Me Out: Review of Emergency Department Telepsychiatry and Lessons Learned During COVID-19

PURPOSE OF REVIEW

The aim of this review is to critically evaluate recent literature on the use of telepsychiatry in emergency departments (EDTP) and synthesize the evidence on telepsychiatry during public health emergencies. We also report on experiences and success stories from a state-wide EDTP program in South Carolina during the COVID-19 pandemic.

RECENT FINDINGS

We identified 12 peer-reviewed articles published between January 2019 and February 2021 that evaluated EDTP interventions and their impact on patient outcomes. The recent evidence on EDTP shows a significant association between EDTP implementation or use and decreased patients' wait time in emergency department (ED), shorter length of stay in certain settings, reduced ED revisit rates, improved ED patient disposition (e.g., more discharge to home, less observational stays, and decreased inpatient admissions), and reduced follow-up encounters involving self-harm diagnosis. The EDTP virtual delivery model can help healthcare systems reduce burden of public health emergencies on providers, staff, and patients alike. While a disruption of magnitude seen by COVID-19 may be infrequent, strategies used during the pandemic may be implemented to enhance care in rural settings, and/or enhance preparedness of communities and healthcare systems during more commonly occurring natural disasters.

A Novel Emergency Telepsychiatry Program in a Canadian Urban Setting: Identifying and Addressing Perceived Barriers for Successful Implementation: Un nouveau programme de télépsychiatrie d'urgence en milieu urbain canadien: Identifier et aborder les obstacles perçus d'une mise en œuvre réussie

OBJECTIVES

To report on the perceived barriers surrounding the use of telepsychiatry for emergency assessments and our approach to overcoming those barriers to achieve successful implementation of a program to increase access to emergency psychiatric assessment in a Canadian urban setting.

METHODS

We conducted a survey of emergency care staff to inform the implementation of an emergency telepsychiatry program in the urban setting of Winnipeg, Manitoba, where hospitals have variable on-site emergency psychiatric coverage. We analyzed survey responses for perceived barriers we would need to address in implementation. We employed implementation strategies for each barrier and scaled the program to three sites over the first year. Data from the first year were collected including number of telepsychiatry assessments, reasons for referral, wait time, and percentage of patient transfers avoided.

RESULTS

Survey respondents (N = 111) had little prior exposure to telepsychiatry, but the majority were open to its use for emergency psychiatric assessments in the region. We identified three categories of perceived barriers: clinical, logistical/technical, and readiness barriers. Implementation planning addressed each barrier, and a hub-and-spoke program was launched. After the first year, the program had one hub serving three spokes, and 243 emergency telepsychiatry assessments had been completed. After 12 months, we were avoiding 65% of patient transfers.

CONCLUSIONS

By conducting a user survey to identify perceived barriers, and addressing these during implementation, we successfully scaled our emergency telepsychiatry program across our region. Our report of this experience may benefit others attempting to implement a similar program.

Telepsychiatry and integrated primary care: setting expectations and creating an effective process for success

Telepsychiatry, especially in the form of live interactive videoconferencing, has greatly advanced the availability and use of specialist psychiatric consultations in primary care settings. Nevertheless, reliance on telepsychiatry, with corresponding decreases in direct face-to-face interaction between primary care providers and psychiatrists, can create unique challenges such as reducing the availability of non-verbal cues, and preventing the informal interactions that are so necessary for clarifying clinical and process details and for building essential team-based trust and rapport. Written from the perspective of an integrated psychiatrist, this article offers recommendations for a formal process to optimize virtual care coordination by setting clear expectations and providing communication tools for an effective and efficient telepsychiatry enabled integrated service.

Impact of integrating psychiatric assessment officers via telepsychiatry on rural hospitals' emergency revisit rates

OBJECTIVE

To assess the impact of integrating Psychiatric Assessment Officers (PAO) and telepsychiatry in rural hospitals on their all-cause emergency department (ED) revisit rates. As a pilot project, a full-time PAO was embedded in each of three rural hospitals in New York State and was augmented by telepsychiatry.

METHOD

A retrospective data analysis using ED census data obtained from the hospitals. The intervention group, defined as those patients treated by PAOs, was compared via a difference-in-difference method against a contemporaneous comparison group defined as those who visited the same EDs and had PAO-qualifying behavioral health diagnoses but were not seen by PAOs.

RESULTS

The intervention group was associated with an approximately 36% lower all-cause ED revisit rate during the first 90-day period (i.e. 1-90 days) following the initial PAO treatment (p = .003). A reduction of the similar magnitude (44%) persisted into the subsequent 90-day period (i.e., 91-180 days since the initial PAO treatment; p < .001).

CONCLUSION

The PAO telepsychiatry pilot program suggests a potential way to provide relief for overburdened EDs in rural communities that lack resources to treat patients with severe behavioral health symptoms.

Potentially avoidable inter-facility transfer from Veterans Health Administration emergency departments: A cohort study

BACKGROUND

Inter-facility transfer is an important strategy for improving access to specialized health services, but transfers are complicated by over-triage, under-triage, travel burdens, and costs. The purpose of this study is to describe ED-based inter-facility transfer practices within the Veterans Health Administration (VHA) and to estimate the proportion of potentially avoidable transfers.

METHODS

This observational cohort study included all patients treated in VHA EDs between 2012 and 2014 who were transferred to another VHA hospital. Potentially avoidable transfers were defined as patients who were either discharged from the receiving ED or admitted to the receiving hospital for ≤1 day without having an invasive procedure performed. We conducted facility- and diagnosis-level analyses to identify subgroups of patients for whom potentially avoidable transfers had increased prevalence.

RESULTS

Of 6,173,189 ED visits during the 3-year study period, 18,852 (0.3%) were transferred from one VHA ED to another VHA facility. Rural residents were transferred three times as often as urban residents (0.6% vs. 0.2%, p < 0.001), and 22.8% of all VHA-to-VHA transfers were potentially avoidable transfers. The 3 disease categories most commonly associated with inter-facility transfer were mental health (34%), cardiac (12%), and digestive diagnoses (9%).

CONCLUSIONS

VHA inter-facility transfer is commonly performed for mental health and cardiac evaluation, particularly for patients in rural settings. The proportion that are potentially avoidable is small. Future work should focus on improving capabilities to provide specialty evaluation locally for these conditions, possibly using telehealth solutions.

Telepsychiatry Use in U.S. Mental Health Facilities, 2010-2017

OBJECTIVE

The study examined the use of telepsychiatry in U.S. mental health facilities between 2010 and 2017.

METHODS

Changes over time in the availability of telepsychiatry were examined by using multiple waves of a national survey of mental health facilities. State and facility correlates of offering telepsychiatry in 2017 were examined.

RESULTS

The proportion of state facilities that self-reported offering telepsychiatry increased significantly from 15.2% in 2010 to 29.2% in 2017, with wide variability among states.. In 2017, facilities with telepsychiatry were more commonly publicly owned than to have others forms of ownership (odds ratio [OR]=2.72, 95% confidence interval [CI]=2.47-2.99, p<0.001), although the percentage of privately owned facilities offering telepsychiatry has increased significantly since 2010 (OR=2.94, 95% CI=2.14-4.05, p<.001). Facilities offering telepsychiatry had lower odds of receiving funding from Medicaid (OR=0.86, 95% CI=0.75-0.98, p<0.001) but higher odds of receiving funding from all other sources. Facilities in states that did not fund telepsychiatry had lower odds of offering these services in 2017 (OR=0.57, 95% CI=0.51-0.62, p<0.001). Telepsychiatry was more commonly offered in states with higher proportions of rural population (OR=1.64, 95% CI=1.45-1.85, p<0.001) and designated medically underserved areas (OR=1.36, 95% CI=1.25-1.47, p<0.001), compared with other states.

CONCLUSIONS

Nearly twice as many U.S. mental health facilities offered telepsychiatry in 2017 than in 2010. Medicaid funding lagged behind other funding sources, suggesting state administrative barriers. Telepsychiatry was commonly used by facilities in medically underserved and rural areas.

Tele-emergency behavioural health in rural and underserved areas

INTRODUCTION

Challenges accessing behavioural health services in rural and underserved areas are compounded by severe shortages of behavioural health specialists, and difficulties placing patients. Tele-emergency (tele-ED) behavioural health is a promising solution for enhancing access to specialists and assisting in patient placement. This paper describes two tele-ED behavioural health models in the Midwest delivering mental- and substance use disorder services to rural and underserved adult populations.

METHODS

We performed an in-depth examination of two tele-ED behavioural health programmes and their consultation processes. We provide a retrospective case-control analysis of patient characteristics, patient diagnoses, and disposition status for each model. Data were collected from 19 spoke hospitals across the two programmes between November 2015 and December 2017.

RESULTS

Tele-ED was activated in 15% of the Avera Health sample and 58% of the Union Hospital sample. This is primarily a reflection of the sample selection process in each model and how each programme is operationalised. Suicide and/or poisoning by drugs were the most frequent diagnoses followed by mood disorders. Rate of transfer to another inpatient facility was much higher for tele-ED cases than controls in both models.

DISCUSSION

This paper describes how two distinct tele-ED behavioural health models operating in unique contexts address challenges in access and placement for patients in rural and underserved areas presenting to EDs with behavioural health conditions. The notable difference in disposition rates between cases and controls is indicative of the impact each model is having on care practices and processes.

Best Practices in Tele-Teaming: Managing Virtual Teams in the Delivery of Care in Telepsychiatry

PURPOSE OF THE REVIEW

To review and organize best practices around management of virtual teams for psychiatrists working in team-based telepsychiatry services.

RECENT FINDINGS

An early but evolving literature in telepsychiatric team-based care is beginning to examine the importance of team function. Psychiatrists will increasingly have opportunities to engage in team-based telepsychiatry in evolving models that improve outcomes, enhance quality, and expand access to behavioral health treatments. While the literature is limited in psychiatry and medicine on virtual teams, there is a growing literature from applied psychology and business. This article synthesizes these findings along with lessons learned from the field to provide recommendations for psychiatrists involved in team-based telepsychiatry. Providing this type of care involves mastering the management of virtual teams. Psychiatrists are well positioned to play a distinctive and central leadership role for team-based telepsychiatry.

Use of Telepsychiatry in Emergency and Crisis Intervention: Current Evidence

PURPOSE OF REVIEW

The aim of this review is to evaluate recent literature on the use of telepsychiatry in mental crises or emergency situations.

RECENT FINDINGS

Results from recent studies which evaluated the implementation of a telepsychiatric consultation model in emergency departments point at a reduction of length of stay and a drop in admissions, increased cost-effectiveness, and improved satisfaction of patients and staff. There was almost no empirical evidence on videoconferencing in crisis intervention within the context of crisis resolution teams or online therapies. No study reporting on telepsychiatry videoconferencing in the context of disasters was found. There is still very little but increasing empirical evidence supporting the implementation of telepsychiatry in emergencies. Other mental crisis-related implementation settings remain to be researched. The implications and future research potential are discussed.

Leveraging Technology in Post-Disaster Settings: the Role of Digital Health/Telemental Health

THE PURPOSE REVIEW

This paper will review the literature on global disasters and the mental health impact of disasters, and discuss the use of digital health/telemental health in providing care in post-disaster settings.

RECENT FINDINGS

Global disasters, natural and manmade, are on the rise. As a consequence, there are increases in the health and mental health impact in the affected populations. We examine the literature on the health and mental health impact of disasters and the role of digital health/telemental health in response to meeting those needs. We examine the use of digital health/telemental health in two case examples, one of a natural disaster and one of a man-made disaster. Finally, we examine a blended telemental health model for collaboration between mental health and primary care providers in post-disaster settings. Digital health/telemental health is positioned on the cusp of the technology explosion, thus bringing much needed medical and mental health care to previously under-served populations.

Telepsychiatric Evaluation and Consultation in Emergency Care Settings

Telepsychiatric care in the emergency setting is a viable and accessible modality that helps address the needs of patients, families, and communities. An expanding literature base for telepsychiatry in multiple clinical settings has shown benefits, including increased access to care, equal efficacy to face-to-face encounters, cost efficiency, decreased wait-times, decreased unnecessary psychiatric hospitalizations, and high levels of patient satisfaction. The evidence base for emergency telepsychiatry is growing for pediatric populations. Increased use of the modality is part of the solution to address high demand for pediatric psychiatric expertise in emergency rooms and to help bridge service gaps in parts of the country.

The Current State of Telemedicine in Urology

Telemedicine use in urology is an evolving practice. In this article, the authors review the early experience of telemedicine specifically as it relates to urologic practice and discuss the future implications and the utility of telemedicine as it applies to other fields.

Usefulness of videoconferencing in psychiatric emergencies -- a qualitative study

High quality health services for psychiatric emergencies are difficult to maintain 24 h a day in sparsely populated areas, where the availability of specialists are limited. To overcome this challenge, the University Hospital of North Norway implemented an on-call system in psychiatric emergencies, by which psychiatrists are accessible 24/7 for telephone and videoconferencing consultations with patients and nurses at three regional psychiatric centers. The purpose of this study was to explore the usefulness of videoconferencing consultations in psychiatric emergencies. The on-call psychiatrists and nurses at the regional psychiatric centers who participated in at least one videoconferencing consultation were recruited for semi-structured interviews: 5 psychiatrists and 19 nurses for a total of 24 participants. The interviews were performed from July of 2012 to June of 2013. The interviews were transcribed and analyzed using a stepwise-deductive-inductive approach supported by the HyperRESEARCH analysis software. After the introduction of the videoconferencing system, telephone consultations were still used for straightforward situations when further treatment or admission decisions were obvious. Videoconferencing consultations, during which patients were present, were useful for challenging situations when there was 1) uncertainty regarding the degree of illness or the level of treatment, 2) a need to clarify the severity of the patient condition, 3) a need to build an alliance with the patient, and 4) disagreement either between health personnel or between the patient and health personnel. Videoconferencing is useful for challenging and complex psychiatric emergencies and is a suitable tool for building high quality, decentralized psychiatric services.

Telemental Health Care, an Effective Alternative to Conventional Mental Care: a Systematic Review

Background and Objectives

Due to the high costs of conventional mental health care, there has been a rise in the application of web-based technologies in recent years, i.e., telemental health care. We conducted this systematic review in 2017, using high quality research articles on the applications, technologies, advantages and challenges associated with telemental health care published since year 2000.

Methods

We used a combination of relevant key words to search four major databases, such as "Web of Sciences, Embase, PubMed and Science Direct". From among 156 articles, which had been published since 2000, twenty five articles met all of the inclusion criteria and were selected for the final review. The information extracted from these articles were used to construct Tables 1 and 2. Also, the materials derived from 55 credible articles were used as further support and complementary facts to substantiate the information presented in the Discussion section.

Results

The findings revealed that telemental health care is an extended domain supportive of conventional mental health services. Currently, telemental health care has multiple capabilities and technologies for providing effective interventions to patients with various mental illnesses. It provides clinicians with a wide variety of innovative choices and strategies for mental interventions, in addition to significant future potentials.

Conclusions

Telemental health care can provide effective and adaptable solutions to the care of mental illnesses universally. While being comparable to in-person services, telemental health care is particularly advantageous and inexpensive through the use of current technologies and adaptable designs, especially in isolated communities.

Institutionally based videoconferencing

The delivery of psychiatric care via video-teleconferencing (VTC) technology is thought to have reached a tipping point. As a medical speciality with relatively few material or technical requirements for service delivery, psychiatry has been one of the earliest to embrace the possibility of providing evaluations and treatment at a distance. Such technical infrastructure as is necessary can often be found in the institutions already in existence. It was natural therefore that institutionally based telepsychiatry would lay the foundation for the development of the field. In this article we review the history and development of institutional VTC in a wide variety of clinically supervised settings such as hospitals, outpatient clinics, and forensic settings. We cite evidence supporting institutionally sponsored use and expand on key takeaways for the development and expansion of videoconferencing in these settings. We also speculate on the future direction and development of psychiatric care provided by these arrangements.

Need for and Steps Toward a Clinical Guideline for the Telemental Healthcare of Children and Adolescents

OBJECTIVE

This article identifies and describes key considerations toward the development of a clinical guideline intended to optimize telemental healthcare (TMH) of children and adolescents.

METHODS

The literature was searched with key terms and title words. Of 2824 articles that met primary or secondary key word search criteria, 326 met both criteria, and 118 thematically related directly to child and adolescent TMH. Only 44 studies met levels of evidence I-III and expert recommendation criteria used in clinical guidelines; review of their references found 8 additional studies (52 total). Data from adult, child, and adolescent in-person psychiatric care and adult TMH were applied to provide context in developing the key considerations.

RESULTS

TMH guidelines for adults are well delineated, and TMH guidelines for children and adolescents are likely to closely overlap in terms of general clinical, technical, and administrative issues. However, for a child and adolescent focus, modifications of existing general guidelines appear necessary; for example, based on developmental status, family involvement, and patient-site modifications for space and sound. Additional clinical issues include specify who, exactly, is the "patient" (i.e., the patient, family, and /or other stakeholders), modalities of care (i.e., age-related psychotherapies such as play therapy or behavior management), and psychopharmacology.

CONCLUSIONS

Specific clinical, administrative, and technical issues are key considerations - based on the nuances of established child and adolescent mental healthcare - and must be considered in developing a clinical guideline for TMH of these patients. Developing such guidance should proceed from a careful review of the growing evidence base, and through expert consensus processes.

Impact of a Telepsychiatry Program at Emergency Departments Statewide on the Quality, Utilization, and Costs of Mental Health Services

OBJECTIVE

This study estimated the impact of a statewide, centralized telepsychiatry service provided in nonpsychiatric emergency departments (EDs) on use of mental health services.

METHODS

Individuals treated via telepsychiatry were compared with a matched control group of individuals with mental health diagnoses who were treated in nonparticipating hospitals. Bivariate and two-part and generalized linear regression models were used to assess differences between the two groups in outpatient follow-up, hospital admission following the ED visit, length of hospital stay if admitted, and inpatient and total costs.

RESULTS

Between March 2009 and June 2013, there were 9,066 patients with at least one telepsychiatry visit. Of these, 7,261 had index telepsychiatry visits that the authors were able to successfully match. Compared with the matched control group, telepsychiatry recipients were more likely to receive 30-day outpatient follow-up (46% versus 16%, p<.001) and 90-day outpatient follow-up (54% versus 20%, p<.001). Telepsychiatry recipients were less likely than the control group to be admitted to the hospital during the index ED visit (11% versus 22%, p<.001). The combined effect of having a telepsychiatry consult during the index ED visit was a reduction of .86 days in inpatient length of stay. Thirty-day inpatient costs were $2,336 (p=.04) lower for the telepsychiatry versus the control group, but 30-day total health care costs were not statistically different.

CONCLUSIONS

Telepsychiatry delivered in the ED through a centralized coordinated program has great promise for improving linkage with outpatient mental health services while reducing inpatient utilization and hospital costs.

TELEMEDICINE VERSUS IN-PERSON DELIVERY OF COGNITIVE PROCESSING THERAPY FOR WOMEN WITH POSTTRAUMATIC STRESS DISORDER: A RANDOMIZED NONINFERIORITY TRIAL

BACKGROUND

This study examined the effectiveness of telemedicine to provide psychotherapy to women with posttraumatic stress disorder (PTSD) who might be unable to access treatment. Objectives were to compare clinical and process outcomes of PTSD treatment delivered via videoteleconferencing (VTC) and in-person (NP) in an ethnically diverse sample of veteran and civilian women with PTSD.

METHODS

A randomized controlled trial of Cognitive Processing Therapy, an evidence-based intervention for PTSD, was conducted through a noninferiority design to compare delivery modalities on difference in posttreatment PTSD symptoms. Women with PTSD, including 21 veterans and 105 civilians, were assigned to receive psychotherapy delivered via VTC or NP. Primary treatment outcomes were changes in PTSD symptoms in the completer sample.

RESULTS

Improvements in PTSD symptoms in the VTC condition (n = 63) were noninferior to outcomes in the NP condition (n = 63). Clinical outcomes obtained when both conditions were pooled together (N = 126) demonstrated that PTSD symptoms declined substantially posttreatment (mean = -20.5, 95% CI -29.6 to -11.4) and gains were maintained at 3- (mean = -20.8, 95% CI -30.1 to -11.5) and 6-month followup (mean = -22.0, 95% CI -33.1 to -10.9. Veterans demonstrated smaller symptom reductions posttreatment (mean = -9.4, 95% CI -22.5 to 3.7) than civilian women (mean = -22.7, 95% CI -29.9 to -15.5.

CONCLUSIONS

Providing psychotherapy to women with PTSD via VTC produced outcomes comparable to NP treatment. VTC can increase access to specialty mental health care for women in rural or remote areas.

A transferable telepsychiatry model for improving access to emergency mental health care

The Mental Health Emergency Care-Rural Access Programme (MHEC) aims to improve access to specialist emergency mental health care in rural and remote communities in New South Wales. It provides a range of services including emergency telephone triage and video assessment. The present report provides a detailed description of the structure and function of the MHEC model, and identifies matters concerning adaptation and transferability. Structure: the MHEC can be contacted 24 hours/day, every day of the year; no caller is refused assistance. Function: the MHEC provides information services, clinical services and other programme activities. Adaptation of the model and implementation elsewhere (transferability) should be informed by local needs, existing practices and the components of access. The programme has already attracted the attention of two other regions in Australia interested in implementing emergency telepsychiatry programmes. The MHEC model is a practical solution for improving access to specialist emergency mental health care in underserved areas.

Usefulness of telepsychiatry: A critical evaluation of videoconferencing-based approaches

Telepsychiatry, i.e., the use of information and communication technologies to provide psychiatric services from a distance, has been around for more than half a century now. Research over this period has shown that videoconferencing-based telepsychiatry is an enabling and empowering form of service delivery, which promotes equality of access, and high levels of satisfaction among patients. The range of services offered by videoconferencing-based telepsychiatry, potential users and points of delivery of such services are theoretically limitless. Telepsychiatry has both clinical utility and non-clinical uses such as administrative, learning and research applications. A large body of accumulated evidence indicates that videoconferencing-based telepsychiatric assessments are reliable, and clinical outcomes of telepsychiatric interventions are comparable to conventional treatment among diverse patient populations, ages and diagnostic groups, and on a wide range of measures. However, on many aspects of effectiveness, the evidence base is still relatively limited and often compromised by methodological problems. The lack of cost-effectiveness data in particular, is a major hindrance, raising doubts about the continued viability of telepsychiatric services. Added to this are the vagaries of technology, negative views among clinicians, poor uptake by providers, and several legal, ethical and administrative barriers. These hamper the widespread implementation of telepsychiatry and its integration with routine care. Though further advances in technology and research are expected to solve many of these problems, the way forward would be to promote telepsychiatry as an adjunct to conventional care, and to develop hybrid models, which incorporate both traditional and telepsychiatric forms of mental health-care.

A Systematic Review of the Use of Telepsychiatry in Acute Settings

Telepsychiatry is increasingly being used in many parts of the world. We performed a systematic review of the literature on the use of telepsychiatry in acute treatment settings using MEDLINE, EMBASE, and PsycINFO from inception to June 2013 using the following key words: acute telepsychiatry, teleconsultation, teleconferencing, telemedicine, emergency telepsychiatry, and e-mental health. Only articles in English were included. All study abstracts were reviewed by both authors independently to assess whether the topic of the paper was relevant to the review. References were selected independently until no new papers were found. If there was a disagreement, a discussion between the authors took place. A leading expert in this field was contacted to check for gray literature. The review included 23 papers. No meta-analyses or systematic reviews were found. The main results are (1) that patients have a positive attitude toward the technology and show a high level of satisfaction with telepsychiatry, (2) that the use of telepsychiatry is correlated with decreased admissions to psychiatric inpatient units, (3) that the quality of clinical interaction in telepsychiatry is similar to that in face-to-face care, and (4) that telepsychiatry seems to be cost effective. The use of telepsychiatry seems to be a viable and relatively inexpensive option for use in places where access to emergency services is difficult.

Telepsychiatry: Effective, Evidence-Based, and at a Tipping Point in Health Care Delivery?

Patient-centered health care questions how to deliver quality, affordable, and timely care in a variety of settings. Telemedicine empowers patients, increases administrative efficiency, and ensures expertise gets to the place it is most needed--the patient. Telepsychiatry or telemental health is effective, well accepted, and comparable to in-person care. E-models of care offer variety, flexibility, and positive outcomes in most settings, and clinicians are increasingly interested in using technology for care, so much so that telepsychiatry is now being widely introduced around the world.

Video-confidence: a qualitative exploration of videoconferencing for psychiatric emergencies

Background

In psychiatric emergencies in rural areas the availability of psychiatrists are limited. Therefore, tele-psychiatry, via real-time videoconferencing (VC), has been developed to provide advanced consultative services to areas that lack psychiatrists. However, there is limited research on the use of VC for psychiatric emergencies. The University Hospital of North Norway has been the first hospital in Norway to implement this type of service by developing a new on-call system for psychiatric emergency practice through which psychiatrists are accessible by telephone and VC 24 hours a day for consultations with patients and nurses at three regional psychiatric centres. This study explores patients’, psychiatrists’ and nurses’ experiences of using VC for psychiatric emergencies, as well as how the technology influenced their confidence.

Methods

In this study, we used a qualitative explorative research design. With a particular focus on users’ experiences of VC, we conducted 29 semi-structured interviews with patients, psychiatrists and nurses who had participated in a VC consultation in at least one psychiatric emergency.

Results

Our findings show that access to the VC system increased the experience of confidence in challenging psychiatric emergencies in four ways: (1) by strengthening patient involvement during the psychiatric specialist’s assessment, (2) by reducing uncertainty, (3) by sharing responsibility for decisions and (4) by functioning as a safety net even when VC was not used.

Conclusions

This study has demonstrated that an emergency psychiatric service delivered by VC may improve the confidence of psychiatrists, nurses and patients in challenging psychiatric emergencies. VC can serve as an effective tool for ensuring decentralised high-quality psychiatric services for emergency care.

Assessing program efficiency: a time and motion study of the Mental Health Emergency Care - Rural Access Program in NSW Australia

The Mental Health Emergency Care-Rural Access Program (MHEC-RAP) is a telehealth solution providing specialist emergency mental health care to rural and remote communities across western NSW, Australia. This is the first time and motion (T&M) study to examine program efficiency and capacity for a telepsychiatry program. Clinical services are an integral aspect of the program accounting for 6% of all activities and 50% of the time spent conducting program activities, but half of this time is spent completing clinical paperwork. This finding emphasizes the importance of these services to program efficiency and the need to address variability of service provision to impact capacity. Currently, there is no efficiency benchmark for emergency telepsychiatry programs. Findings suggest that MHEC-RAP could increase its activity without affecting program responsiveness. T&M studies not only determine activity and time expenditure, but have a wider application assessing program efficiency by understanding, defining, and calculating capacity. T&M studies can inform future program development of MHEC-RAP and similar telehealth programs, both in Australia and overseas.

Mobile Tele-Mental Health: Increasing Applications and a Move to Hybrid Models of Care

Mobile telemental health is defined as the use of mobile phones and other wireless devices as applied to psychiatric and mental health practice. Applications of such include treatment monitoring and adherence, health promotion, ecological momentary assessment, and decision support systems. Advantages of mobile telemental health are underscored by its interactivity, just-in-time interventions, and low resource requirements and portability. Challenges in realizing this potential of mobile telemental health include the low penetration rates of health applications on mobile devices in part due to health literacy, the delay in current published research in evaluating newer technologies, and outdated research methodologies. Despite such challenges, one immediate opportunity for mobile telemental health is utilizing mobile devices as videoconferencing mediums for psychotherapy and psychosocial interventions enhanced by novel sensor based monitoring and behavior-prediction algorithms. This paper provides an overview of mobile telemental health and its current trends, as well as future opportunities as applied to patient care in both academic research and commercial ventures.

Successful provision of emergency mental health care to rural and remote New South Wales: an evaluation of the Mental Health Emergency Care-Rural Access Program

OBJECTIVE

To evaluate a rural emergency telepsychiatry program, the Mental Health Emergency Care-Rural Access Program (MHEC-RAP), which aims to improve access to emergency mental health care for communities throughout western New South Wales (NSW).

METHODS

A descriptive analysis of service activity data from the introduction of the MHEC-RAP in 2008 to 2011 using Chi-squared tests and linear regression modelling to assess change and trends over time.

RESULT

There were 55959 calls to the MHEC-RAP, 9678 (17%) of these calls initiated an MHEC-RAP service (~2500 each year). The use of video assessment increased over 18 months, then levelled off to an average of 65 each month. Health care provider use increased from 54% to 75% of all contacts, and 49% of MHEC-RAP patients were triaged 'urgent'. Most (71%) were referred from the MHEC-RAP for outpatient care with a local provider. The proportion of MHEC-RAP patients admitted to hospital initially increased by 12%, then declined over the next 2 years by 7% (by 28% for admissions to a mental health inpatient unit (MHIPU)).

CONCLUSION

The MHEC-RAP is well established. It has achieved acceptable levels of service activity and continues to be as used as intended. Further research is required to confirm how the MHEC-RAP works in terms of process and capacity, how it has changed access to mental health care and to document its costs and benefits. WHAT IS KNOWN ABOUT THE TOPIC? Rural and remote communities have poorer access to and use of mental health services. Telehealth care is a reliable and accepted means for providing non-urgent mental health care. WHAT DOES THIS PAPER ADD? The MHEC-RAP is a practical and transferable solution to providing specialist emergency mental health care, and support for local providers, in rural and remote areas via telehealth. There is a possible impact upon the problem of recruiting and retaining a mental health workforce in rural and remote areas. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? Providing reliable remote access to specialist mental health assessment and advice while supporting providers in rural communities can result in better outcomes for patients and services alike.

The effectiveness of telemental health: a 2013 review

INTRODUCTION

The effectiveness of any new technology is typically measured in order to determine whether it successfully achieves equal or superior objectives over what is currently offered. Research in telemental health-in this article mainly referring to telepsychiatry and psychological services-has advanced rapidly since 2003, and a new effectiveness review is needed.

MATERIALS AND METHODS

The authors reviewed the published literature to synthesize information on what is and what is not effective related to telemental health. Terms for the search included, but were not limited to, telepsychiatry, effectiveness, mental health, e-health, videoconferencing, telemedicine, cost, access, and international.

RESULTS

Telemental health is effective for diagnosis and assessment across many populations (adult, child, geriatric, and ethnic) and for disorders in many settings (emergency, home health) and appears to be comparable to in-person care. In addition, this review has identified new models of care (i.e., collaborative care, asynchronous, mobile) with equally positive outcomes.

CONCLUSIONS

Telemental health is effective and increases access to care. Future directions suggest the need for more research on service models, specific disorders, the issues relevant to culture and language, and cost.

Agreement between telepsychiatry assessment and face-to-face assessment for Emergency Department psychiatry patients

We compared psychiatrists' evaluations of Emergency Department (ED) mental health patients made face-to-face or by telemedicine. In a 39-month study, 73 patients presenting in the ED were enrolled after initial screening. Patients were interviewed by a psychiatrist either face-to-face in the ED or remotely by video. A second psychiatrist, acting as an observer, was in the room with the patient and independently completed the assessment. Based on the primary diagnosis of the interviewer, 48% of patients had a depressive disorder, 18% a substance use disorder, 14% a bipolar disorder, 11% a psychotic disorder, 6% an anxiety disorder and 4% other disorders. The raw agreement between the psychiatrists about disposition when both used face-to-face assessment was 84% and it was 86% when one used telemedicine. Using Cohen's kappa to evaluate agreement, there were no significant differences for disposition recommendation, strength of recommendation, diagnosis or the HCR-20 dangerousness scale. There was no significant difference for the intraclass correlation coefficients for the suicide scale. The results provide preliminary support for the safe use of telepsychiatry in the ED to determine the need for admission to inpatient care.

VIDEOCARE: decentralised psychiatric emergency care through videoconferencing

BACKGROUND

Today the availability of specialists is limited for psychiatric patients in rural areas, especially during psychiatric emergencies. To overcome this challenge, the University Hospital of North Norway has implemented a new decentralised on-call system in psychiatric emergencies, by which psychiatrists are accessible by videoconference 24/7. In September 2011, the new on-call system was established in clinical practice for patients and health staff at three regional psychiatric centres in Northern Norway. Although a wide variety of therapies have been successfully delivered by videoconference, there is limited research on the use of videoconferenced consultations with patients in psychiatric emergencies. The aim of this study is to explore the use of videoconference in psychiatric emergencies based on the implementation of this first Norwegian tele-psychiatric service in emergency care.

METHODS/DESIGN

The research project is an exploratory case study of a new videoconference service in operation. By applying in-depth interviews with patients, specialists and local health-care staff, we will identify factors that facilitate and hinder use of videoconferencing in psychiatric emergencies, and explore how videoconferenced consultations matter for patients, professional practice and cooperation between levels in psychiatric care. By using an on-going project as the site of research, the case is especially well-suited for generating reliable and valid empirical data.

DISCUSSION

Results from the study will be of importance for understanding of how videoconferencing may support proper treatment and high-quality health care services in rural areas for patients in psychiatric emergencies.

Student perceptions of a hands-on practicum to supplement an online eHealth course

Background

Since 2000, the Centre for Online Health (COH) at The University of Queensland has offered a range of online eHealth courses at the undergraduate and postgraduate level. While online learning has a number of advantages, in some domains, it can present some challenges to the development of practical skills and experience.

Objective

To assess students’ perceptions of the value of an eHealth practicum.

Methods

To supplement our online learning program, we introduced an eHealth practicum component that aimed to expose students to a range of clinically relevant learning experiences. Subsequently, by means of a questionnaire, student perceptions of the practicum were assessed.

Results

Over two semesters, a total of 66 students participated in the eHealth practicum, and questionnaire responses were very positive. The majority of students agreed that the practicum allowed them to gain necessary skills in eHealth applications (59%) and provided them with an opportunity to explore ways of using different eHealth tools for the delivery of health care at a distance (62%).

Conclusions

The study shows that a practical component in eHealth teaching was well received by students. While online teaching is appropriate for providing knowledge, the opportunity to develop practical skills may encourage students to use eHealth techniques in their future practices.

National telemental health responses to a major bushfire disaster

In response to the Victorian bushfire disaster in 2009, various telemental health services were provided by three national agencies: Kids Helpline (BoysTown), MensLine Australia (Crisis Support Services) and Lifeline Australia. All provider agencies used their existing national service structures and staff resources, which were expanded to respond to bushfire-related service demand. We examined service provider reports and conducted key informant interviews. Despite a lack of quantitative data on consumer outcomes and perspectives, it appears that all three telemental health services experienced significant increases in overall service uptake levels in the wake of the bushfires. Uptake of specialized telephone-, web-, email- and crisis counselling services was substantial, although that of callback services was very limited. Potential clients encountered specific barriers in relation to service access and the callback model. The bushfire experience highlighted the impact of transitory living circumstances and the increased complexity of post-disaster calls on service provision. Telemental health services need to be integrated into mainstream services and disaster response structures.

Remote care by telemedicine in the ICU: many models of care can be effective

PURPOSE OF REVIEW

Telemedicine, by the use of audiovisual technologies, is increasingly being used to assist in patient care by ICUs unable to be staffed by consultant intensivists. This review discusses the recent evaluation of these services and their potential role in managing intensive care patients.

RECENT FINDINGS

Models of care range from complete remote 24 h surveillance requiring direct video observation to a consultation liaison service only requiring conventional telephone links. There has been a rapid adoption of such services especially in North America where access to on-site intensive care specialists is limited for the volume of intensive care being undertaken. Early work suggests savings in terms of cost and length of stay with an improvement in compliance with care protocols. However, later work is not as supportive of such services, possibly related to differing care infrastructures and the organization of individual units. The key task is to ascertain the most appropriate service requirements that would assist in care for a given patient circumstance.

SUMMARY

Clear benefits of ICU-telemedicine systems remain unclear but at least the systems appear safe. Formal reviews of the impacts and contribution of ICU telemedicine to processes of care, the effects on unit staffing, hospital organization, and the healthcare region are needed. However, ICU-telemedicine is available and being embraced by some, especially to deal with the tyranny of distance.

Review of American Indian veteran telemental health

Rural American Indian veterans have unique healthcare needs and face numerous barriers to accessing healthcare services. Over the past decade, the Department of Veterans Affairs in conjunction with the University of Colorado Denver has turned to the promising field of telemental health to develop a series of videoconferencing-based clinics to reach this vulnerable population and improve mental healthcare services. The ongoing development, implementation, and expansion of these clinics have been assessed as part of a program improvement. The outcomes of these assessments have been documented in a series of published articles, controlled studies, program and case reports, and model descriptions. This article summarizes a decade of experience with the American Indian Telemental Health Clinics, the clinic model, and the literature arising from these clinics and presents lessons learned while establishing, maintaining, and evaluating these clinics. The ability to tailor the clinics to individual sites and cultures and to provide various services has been critical to the operation of the clinics. Culturally specific care through culturally knowledgeable providers, onsite tribal outreach workers, and collaboration with community services has proven essential in operating the clinics, as well as building rapport, trust, and engagement with the target patient population. It is hoped that the lessons learned and practices presented here can not only assist others working to improve the care for rural Native veterans but also serve as a model in the use of telemental health services for improving care and access to rural veteran and non-veteran populations.

Length of stay of pediatric mental health emergency department visits in the United States

OBJECTIVE

To compare pediatric mental health emergency department visits to other pediatric emergency department visits, focusing on length of stay.

METHOD

We analyzed data from the National Hospital Ambulatory Medical Care Survey, a nationally representative sample of US emergency department visits from 2001 to 2008, for patients aged ≤18 years (n = 73,015). Visits with a principal diagnosis of a mental disorder (n = 1,476) were compared to visits (n = 71,539) with regard to patient and hospital characteristics, treatment, and length of stay. Predictors of prolonged mental health visits were identified.

RESULTS

Mental health visits were more likely than other visits to arrive by ambulance (21.8% versus 6.3%, p < .001), to be triaged to rapid evaluation (27.9% versus 14.9%, p < .001), and to be admitted (16.4% versus 7.6%, p < .001) or transferred (15.7% versus 1.5%, p < .001). The median length of stay for mental health visits (169 minutes) significantly exceeded that of other visits (108 minutes). The odds of extended stay beyond 4 hours for mental health visits was almost twice that for other visits (adjusted odds ratio 1.9, 95% CI = 1.5-2.4) and was not explained by observed differences in evaluation, treatment, or disposition. Among mental health visits, advancing calendar year of study, intentional self-injury, age 6-13 years, Northeastern, Southern, and metropolitan hospital location, use of laboratory studies, and patient transfer all predicted extended stays.

CONCLUSIONS

Compared with other pediatric emergency visits, mental health visits are longer, are more frequently triaged to urgent evaluation, and more likely to result in patient admission or transfer, thereby placing distinctive burdens on US emergency departments.