This story was produced by The Granite State News Collaborative as part of its Granite Solutions reporting project. For more information visit www.collaborativenh.org.
While TelePsychiatry may sound futuristic, connecting with a doctor remotely isn’t new at all, and the technology has only improved since the first iteration. With tens of thousands nationwide, living in rural areas without access to psychiatric evaluations, including some in New Hampshire, this technology is becoming an important link to care.
Samir Malik, general manager of Genoa Healthcare in Manchester, says only 45 percent of the mental health needs in NH are met by the current provider base. He says telemedicine can bring together rural patients with a doctor in another city that would help alleviate wait times to see a psychiatrist in the emergency department and allow a single psychiatrist to see more patients.
Christine Finn, Dartmouth-Hitchcock’s TelePsychiatry medical director, compared the technology to other videoconferencing platforms such as Skype, and described how a general evaluation would work in the emergency department setting.
“We provide them with that equipment and the training necessary for their staff to understand how to use [the TelePsychiatry carts] and to make that connection to the appropriate tele-provider at the time of the consultation,” she explained. “So we would have availability 24/7 on-demand for an emergency department to make that connection with a telepsychiatrist who will do a full clinical assessment using the video technology and then provide written recommendations regarding diagnosis, disposition, ongoing treatment or management needs in the ED setting and would provide that back to the ED providers who can then go ahead and execute the plan or act on those recommendations.”
One of the earliest issues with telemedicine was the cost to set it up. Malik said high-definition video conferencing equipment, a dedicated internet connection, and host appliances, would cost hospitals and clinics $10,000 to $50,000. But, he added, over the past five to seven years, the technology has gotten more affordable and the requirements have become fewer.
"Today, 95 percent of our sessions that we do across the country, including all of our sessions in New Hampshire, are done over standard high-speed Internet connection,” he said. “The bandwidth offered on [standard or fiber Internet connections] is now more than adequate and video compression technology now allows for you to stream high quality video over a laptop or a desktop.”
Dartmouth-Hitchcock is one of the hospitals implementing TelePsychiatry. Finn said there can often be a long wait for psychiatric consultations, especially when it comes to involuntarily committed patients. She says having a consultation on-demand, even through telemedicine, significantly improves the number of patients accepting treatment or being sent home.
“We know about 50 percent of the patients here in our own ED at Dartmouth, who initially are held on an involuntary status. We are able to initiate treatment and either convert them to a voluntary hospitalization, which gives us a lot more options, or sometimes even to be able to discharge somebody home,” Finn said.
Despite concerns that patients may feel awkward during their consultation or that the consultation doesn’t feel personal enough, Finn said that people today have a much more positive interaction with the TelePsychiatry technology because the population has gotten used to connecting over the Internet.
Malik said that Genoa trains their physicians and nurse practitioners on how to make patients more comfortable during tele-consultations. They teach the physicians and nurses to look directly at the camera and not at the screen or the keyboard.
A potential issue for telemedicine in rural areas is the struggle to get broadband connections. Finn doesn’t see poor broadband connectivity interfering with patient consultations as most TelePsychiatry is done in a hospital setting. “Generally, we've found that the hospitals have the level of connectivity that's required. I could certainly see that being an issue if we were trying to provide services where a patient was at home and connecting with a telepsychiatrist,” she said.
Malik looked at the issue from the perspective of a small clinic. “You will find that many rural [clinics] don't have access to [broadband], but the federal government has appropriated lots of grant money to support the adoption of broadband in rural areas. So, most clinics now that are providing health care services can tap into those grant dollars to obtain broadband if they don't have it today,” he explained.
While telemedicine programs have been around since the 1900s, telemedicine technology is only in the beginning stages and has the potential to rapidly expand. Finn believes the technology could evolve to allow tele-visits with a specialist without the patient leaving their home. “Certainly, up here, patients may live quite some distance from the hospital or with the winter road conditions, not want to be driving regularly, and it really can provide excellent access to specialists that may not otherwise be accessible,” she said.
Malik says that with the right advocacy, it could become the number one solution to fixing wait times and access to specialists in rural NH. “I think that's one of the key pieces that can change in the narrative from telemedicine being like a backup, a plan B, in case I have no other option, to really being the first arrow in the quiver when it comes to addressing access challenges.”
Edward Duffy, MD, at Littleton Regional Hospital believes that TelePsychiatry and telemedicine are doing exactly what they should be, and don’t need to be improved. “I think it’s really reached its zenith, and that’s not a negative thing. This place here has a lot of capability,” he said. “We have many, many specialties here. We don’t really need tele for primary diagnosis, but we do with psychiatry. We have psychiatrists but they’re not on 24/7. The cool thing about DARPA [a federal system] is that you just press the button and they come on 24/7 pretty much. What it does is it helps coordinate care with our number one clinical partner, Dartmouth.”
However, not every hospital is implementing TelePsychiatry. Andrea Dobberstien, director of behavioral health for the Elliot Health Systems, said they partnered with Manchester Mental Health to provide initial emergency assessments for patients admitted to the hospital. This partnership also helps them maintain a strong behavioral health program in terms of providing services in the emergency department, she says.
While there are some challenges to implementing and maintaining TelePsychiatry, there are major benefits to both hospitals and patients who use it. As Malik says it’s possible for a psychiatrist on a completely different continent to connect with patients in NH and provide continuing care.