There are several things to consider when establishing a telemental health site; some of those issues are listed below. A brief discussion of the issues is provided but it is highly recommended that you utilize a TMH consultant to help you in the process. Whether the need is small and limited or whether you want to lay a good foundation to expand upon down the road, a consultant can help you with choices that will prevent squandering limited capital and ongoing resources. State and Core Service Agencies can enlist the support of Dr Grady who is funded by the Mental Hygiene Administration to consult, implement and coordinate Maryland’s telemental health initiative.
Some areas of that need to be considered:
· Client/Patient Population
· Mental Healthcare need, e.g. psychiatrist, therapist, substance counselor, etc
· Site Staffing
· Site Facilities
· Equipment
· Communication Type
· Clinical/Administrative Protocols
· Non-Clinical Uses of the technology
· Licensure, privileging and legalities
Client/Patient Population. Identifying your need(s) will be important so that you find the right provider or group of providers, choose the best facility layout for and purchase the right equipment. Telemental health is especially helpful for consumer populations with particular needs such as specialized assessment or treatment expertise, limited mobility or transportation issues and those with language barriers among many others.
Mental Healthcare Needs. Telemental health has been used for general and subspecialty psychiatry and psychotherapy. The medical/mental health literature has demonstrated for example that psychiatric evaluations and medication management and supportive and cognitive behavioral psychotherapy are effective via interactive videoconferencing. Evidence for other specific psychotherapies such as marital, EMDR, hypnosis etc are lacking in the literature. This does not mean that these therapies could not be delivered via videoconferencing or the web but rather that there has not been published scientific evidence of the outcomes using telemental health. Sites considering these and other types of treatments via telemental health that do not have evidence support should consider the risks and liabilities involved. For applications not evidence supported, clinical trials or carefully controlled pilot projects with experienced clinicians is recommended. Besides direct patient care, sites are encouraged to utilize their equipment for discharge planning, benefits consultation, family visits, health administration and staff education and training.
Site Staffing. Sites will need administrative and clinical staff involvement. Administrative staff can help with appointments, faxing/emailing of paperwork and eligibility and possibly billing for services. Electronic medical records can reduce faxing of patient information and can reduce administrative and privacy burdens tremendously. Originating site staff will also need to ensure equipment is functioning and move patients in and out of exam or counseling rooms. For Medicare patients a facility fee, indexed yearly, is provided to offset some of the originating site costs. A facility fee has been proposed in the Maryland Medicaid regulations. It will be up to individual private insurers whether a facility fee would be provided.
Site Facilities. Space is often an issue in many healthcare facilities. The ideal office space for telemental health would be an existing therapy office that is approximately 12 feet in depth so that adequate camera focal length can be obtained. The office should have adequate heating, ventilation, electrical and communication outlets to accommodate the telemental health equipment. Sound from the video system may carry a little more than normal in-person conversation so that office placement, sound proofing and or white noise machines should be considered as needed. Conference rooms are not ideal but can be used when a larger care space is needed or when the telemental health equipment will be used for other purposes.
Equipment. There are several brands of video conferencing equipment on the market, while I do not endorse any specific brand; a couple of the current manufacturing leaders in volume are Polycom and Tandberg. One size does not fit all is applicable when setting up an originating site. Considerations when selecting equipment include purpose, room size, connectivity, mobile or fixed and costs among other issues. There are also equipment options, installation and maintenance contracts to consider. It is best to discuss your individual needs, situation and plans with a consultant to select the best equipment options for you and not merely buy what your neighbor did. The major manufacturers usually distribute their equipment via resellers. Telemental health is a relatively new field and often resellers and even manufacturer representatives will make recommendations but these are often without the experience of clinical practice and may suite business clients better than healthcare clients.
Communications Connectivity. Video conferencing equipment requires access to a switched telephone network, satellite or internet to communicate. Integrated Services Digital Network (ISDN) was the major communications type used up until a few years ago when improvements in internet protocol (IP) and encryption along allowed IP to surpass ISDN for videoconferencing communication. A major benefit is the lower cost of IP as compared to ISDN. ISDN however offers a defined bandwidth that is not affected by internet usage. Types of IP connections include your facilities Local Area Network (LAN), Digital Subscriber Line (DSL), Cable modem and Fiber Optic Service (FIOS). The costs, application and availability of connections will determine what type of connection is best for your particular application.
Administrative and Clinical Protocols. Clinical protocols are necessary for safe and efficient telemental health operations. The protocols cover topics such as patient flow, client/patient inclusion/exclusion criteria, emergency procedures and record keeping among other topics. Dr Grady developed telemental health clinical protocols in 1998 that were fielded to military sites in Maryland, the Northeast United States and at one overseas location. These protocols were introduced and utilized in the Sheppard Pratt Health System state wide telepsychiatry network in July 2005. The network included one State Hospital, five general hospitals and seven clinics. The protocols were introduced at the University of Maryland, School of Medicine, Department of psychiatry and used in the School Mental Health initiative and Rural Health Care Network Development Grant Program. The protocols are also used by Veterans Services Integrated Network 5, which includes VA facilities in Maryland, West Virginia and the District of Columbia. New originating or distant sites in Maryland are encouraged to use this format for consistency throughout Maryland to mitigate clinical and administrative risks associated with care provision from a distance but primarily to ease collaboration across various telemental health networks.
Licensure, Privileging and Legalities. All sites and providers are expected to meet all applicable licensure and privileging requirements for telemental health. Until recently there has been little legal precedence for practicing telemedicine. Providers should ensure that telemedicine is covered by their insurer. Sites should work to reduce their liability through sound implementation and practice standards.
