Elsevier

Mayo Clinic Proceedings

Volume 94, Issue 12, December 2019, Pages 2510-2523
Mayo Clinic Proceedings

Review
Barriers to Use of Telepsychiatry: Clinicians as Gatekeepers

https://doi.org/10.1016/j.mayocp.2019.04.018Get rights and content

Abstract

Telepsychiatry is effective and has generated hope and promise for improved access and enhanced quality of care with reasonable cost containment. Clinicians and organizations are informed about clinical, technological, and administrative telepsychiatric barriers via guidelines, but there are many practical patient and clinician factors that have slowed implementation and undermined sustainability. Literature describing barriers to use of telepsychiatry was reviewed. PubMed search terms with date limits from January 1, 1959, to April 25, 2019, included telepsychiatry, telemedicine, telemental health, videoconferencing, video based, Internet, synchronous, real-time, two-way, limitations, restrictions, barriers, obstacles, challenges, issues, implementation, utilization, adoption, perspectives, perceptions, attitudes, beliefs, willingness, acceptability, feasibility, culture/cultural, outcomes, satisfaction, quality, effectiveness, and efficacy. Articles were selected for inclusion on the basis of relevance. Barriers are described from both patient and clinicians' perspectives. Patients and clinicians are largely satisfied with telepsychiatry, but concerns about establishing rapport, privacy, safety, and technology limitations have slowed acceptance of telepsychiatry. Clinicians are also concerned about reimbursement/financial, legal/regulatory, licensure/credentialing, and education/learning issues. These issues point to system and policy concerns, which, in combination with other administrative concerns, raise questions about system design/workflow, efficiency of clinical care, and changing organizational culture. Although telepsychiatry service is convenient for patients, the many barriers from clinicians’ perspectives are concerning, because they serve as gatekeepers for implementation and sustainability of telepsychiatry services. This suggests that solutions to overcome barriers must start by addressing the concerns of clinicians and enhancing clinical workflow.

Section snippets

Shared Concerns About Satisfaction/Alliance/Rapport/Comfort

For patients, telepsychiatry improves access to care, reduces wait times for appointments, and reduces travel time and costs.11, 13, 14, 25 For example, a recent US Department of Veterans Affairs study reported that telemedicine saves patients an average of 145 miles and 142 minutes per visit.26 These benefits seem to largely outweigh reservations patients may have, as numerous studies cite high willingness to use this mode of care and high ratings of patient satisfaction with the care they

Community/Cultural

Telepsychiatry practice often involves challenging culture gaps16, 77 and differences in values.16, 33, 38, 45, 62, 67, 69, 77, 78 Psychiatrists from elsewhere may be unfamiliar with local resources and make recommendations for services that are scarce.79 Collaborating with local clinicians provides knowledge of local resources and culture,9, 78 provides connection to the community,33, 34, 77 and may mitigate feelings of loss of control that local clinicians may feel from remote expert

Patient Privacy, Security, Boundaries, and Safety

Clinicians and patients have concerns about protecting patient privacy when using telepsychiatry.6, 9, 11, 20, 33, 44, 51, 52, 59, 67, 77, 83, 84, 85, 86, 87 They worry about others accessing telepsychiatry sessions84 or protected health information.27 Of particular concern are network security59 and encryption,67 and equipment situated outside the traditional clinical areas that could increase the risk of intercepting telemental health interactions, especially as teleconference technology

Safety

Clinicians and patients have expressed concerns about securing safety for patients in crisis or faced with the threat of self-harm.9, 16, 33, 34, 38, 46, 49, 52, 77, 78, 79, 80 Patients have voiced desire for a physical presence during a time of crisis.33 One consistent recommendation is to employ support staff where the patient is located who may intervene in case of an emergency.16, 52, 78 Given potential problems with the technology and network (lost connection), it is essential that

Technology Related

A well-functioning telepsychiatry system is essential for success.90 Fortunately, as the technology advances rapidly, technical problems become less substantial.8, 12, 47, 91 The same telepsychiatry interventions with better technologies may even improve the present results.91, 92 Unfortunately, previous studies abound with examples of technical difficulties such as sessions unable to start, spontaneous disconnections, or poor audio/visual quality, and audio/visual lag.11, 33, 38, 39, 40, 44, 51

Clinicians' Perspectives

Many more barriers to telepsychiatry practice were identified from clinicians' or health care organizations' points of view rather than from patients’ perspectives. Although many concerns are shared by patients and clinicians, usually reluctant clinicians rather than patients slow acceptance of telepsychiatry.27 Reviewing the literature, a theme of “clinician as gatekeeper” to the use of telepsychiatry became clear. Physicians are highly influential in telepsychiatry,7 and they decide about

Limited Evidence-Based Information

Although many recent studies and reviews have been published in the past 15 years, the evidence base for telepsychiatry has been considered inadequate by clinicians.31, 59, 104, 105 Although research has rapidly increased, as recently as 2011, 78% of clinicians surveyed responded that more research on the effectiveness of telehealth was needed.59 Research has been underfunded, such that projects are discontinued and findings go unpublished.3, 38 Ironically, poor research funding limits evidence

Limited Education for Clinicians/Learning Opportunities

Limited education, clinical exposure, and hands-on learning in telepsychiatry are significant barriers to expanding use.8, 11, 20, 27, 28, 31, 35, 38, 40, 47, 59, 89, 104, 105, 107, 108, 109, 110 Telepsychiatry education in medical school and residency is minimal,8, 47, 110 with only 21 of 183 US residency training programs offering any training or experience in telepsychiatry.12 The burden largely falls on individual psychiatrists to seek out the knowledge and experience required to become

Reimbursement/Financial Viability

Although improving over time, reimbursement and financial viability have been viewed as a barrier to telepsychiatry growth for more than the past decade.3, 8, 27, 38, 59, 67, 77, 78, 80, 85, 86, 89, 115, 116, 117, 118 Telepsychiatry has been largely supported by federal, internal, or grant funding, with relatively few programs with long-term commercial sustainability.3, 8, 116, 118 In one survey, nearly half of respondents indicated they did not provide telemedicine services because of lack of

Licensure and Credentialing

Most states require psychiatrists to be licensed in their home states as well as the state(s) in which their patients are physically located.27, 59, 78, 87 For 93.5% of telemental health visits in 2014, the beneficiary and clinician were in the same state,19 suggesting that the time and expense of maintaining multiple licenses, along with complicated laws that differ between states, poses a significant burden to physicians.6, 54, 59, 80, 87, 129

Only 14 states extend conditional or telemedicine

Legal/Regulatory

Legal and regulatory barriers may contribute to difficulties with telepsychiatry practice. Some states mandate conditions of clinical encounters or require that a telepsychiatrist maintain a physical practice location in that state.59, 77 The Ryan Haight Online Pharmacy Consumer Protection Act of 2008 was designed to protect against illegitimate dispensing of controlled substances online without appropriate physician oversight, but had the unintended consequence of interfering with prescribing

Liability, Litigation, and Malpractice

Clinicians have raised concerns about liability and litigation.80 Nonusers of telemedicine are more likely to believe that it would increase the risk of malpractice law suits.54 Despite literature supporting the safety and effectiveness of telepsychiatry,5 questions about liability risks remain open86, 87 because of a relative lack of case law in this area.80 The 2017 American Telemedicine Association practice guidelines for telemental health with children and adolescents recommend that

Tradition/Habit/Resistance to Change/Disruption of Routine and Workflow

Habit has been identified as an important, often overlooked factor in slow diffusion/adoption of telemedicine.54, 117 Focus groups of behavioral health clinicians identified potential benefits of telepsychiatry, but they remained reluctant to try it,20 perhaps, in part, because of habit.54 Cognitive neuroscience has established that people often act based on habit. New ways of doing things require deliberate conscious effort.130 Physicians develop efficient practice routines, and changing these

Clinician Acceptance/Clinician as Gatekeeper

Clinicians have been cited as the most significant initial gatekeepers to telemedicine use.20, 27, 35, 59, 69 Although patients and clinicians share many of the same concerns about telepsychiatry, patient satisfaction remains high. There are more barriers from the clinicians' perspective.51, 59 Low uptake rates of telepsychiatry use and survey data suggest that many clinicians remain skeptical about this mode of care,11, 49, 58, 69, 80, 132 and negative biases remain a barrier at the health

Conclusion

Telepsychiatry is an effective way to improve access, enhance quality, and provide efficient care. Clinicians’ concerns reflect a need for better system workflow integration, policy change, and shifts in organizational culture. Telepsychiatry has grown substantially in the past two decades, but further expansion is still required. By focusing on physician engagement and legislative change, the remaining barriers to acceptance may be further reduced and telepsychiatry’s full potential for

References (138)

  • C. Lauckner et al.

    The state and sustainability of telepsychiatry programs

    J Behav Health Serv Res

    (2016)
  • R.L. Caudill et al.

    Institutionally based videoconferencing

    Int Rev Psychiatry

    (2015)
  • D.M. Hilty et al.

    The effectiveness of telemental health: a 2013 review

    Telemed J E Health

    (2013)
  • M.B. Parish et al.

    Managing psychiatrist-patient relationships in the digital age: a summary review of the impact of technology-enabled care on clinical processes and rapport

    Curr Psychiatry Rep

    (2017)
  • M.L. Barnett et al.

    Trends in telemedicine use in a large commercially insured population, 2005-2017

    JAMA

    (2018)
  • S. Chan et al.

    Telepsychiatry today

    Curr Psychiatry Rep

    (2015)
  • N. Greenberg et al.

    Pediatric telepsychiatry in ontario: caregiver and service provider perspectives

    J Behav Health Serv Res

    (2006)
  • A. Mehrotra et al.

    Utilization of telemedicine among rural Medicare beneficiaries

    JAMA

    (2016)
  • L.K. Richardson et al.

    Current directions in videoconferencing tele-mental health research

    Clin Psychol (New York)

    (2009)
  • P. Yellowlees et al.

    The psychiatrist-patient relationship of the future: anytime, anywhere?

    Harv Rev Psychiatry

    (2010)
  • S.G. Simpson et al.

    Therapy via videoconferencing: a route to client empowerment?

    Clin Psychol Psychother

    (2005)
  • D.M. Hilty et al.

    Rural versus suburban primary care needs, utilization, and satisfaction with telepsychiatric consultation

    J Rural Health

    (2007)

  • Practice guidelines for videoconferencing-based telemental health

  • K. Myers et al.

    American Telemedicine Association Practice guidelines for telemental health with children and adolescents

    Telemed J E Health

    (2017)
  • J.S. Thiele et al.

    Locum tenens and telepsychiatry: trends in psychiatric care

    Telemed J E Health

    (2015)
  • J.D. Young et al.

    Telehealth: increasing access to high quality care by expanding the role of technology in correctional medicine

    J Clin Med

    (2017)
  • A. Mehrotra et al.

    Rapid growth in mental health telemedicine use among rural medicare beneficiaries, wide variation across states

    Health Aff (Millwood)

    (2017)
  • P.S. Whitten et al.

    Addressing telehealth’s foremost barrier: provider as initial gatekeeper

    Int J Technol Assess Health Care

    (2005)
  • E.A. Krupinski et al.

    Standards and guidelines in telemedicine and telehealth

    Healthcare (Basel)

    (2014)
  • A. Miles et al.

    The care of the patient and the soul of the clinic: person-centered medicine as an emergent model of modern clinical practice

    Int J Pers Cent Med

    (2011)
  • G. Frydman

    Patient-driven research: rich opportunities and real risks

    J Particip Med

    (2009)
  • A.C. Smith

    Telemedicine: challenges and opportunities

    Expert Rev Med Devices

    (2007)
  • J.E. Russo et al.

    VA telemedicine: an analysis of cost and time savings

    Telemed J E Health

    (2016)
  • S.A. Saeed et al.

    Telepsychiatry: overcoming barriers to implementation

    Curr Psychiatr

    (2012)
  • T.L. Williams et al.

    Limitations of patient satisfaction studies in telehealthcare: a systematic review of the literature

    Telemed J E Health

    (2001)
  • C.S. Kruse et al.

    Telehealth and patient satisfaction: a systematic review and narrative analysis

    BMJ Open

    (2017)
  • S. Chakrabarti

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

    World J Psychiatry

    (2015)
  • D.M. Hilty et al.

    Clinical and educational telepsychiatry applications: a review

    Can J Psychiatry

    (2004)
  • J.E. Brick et al.

    Public knowledge, perception, and expressed choice of telemedicine in rural West Virginia

    Telemed J

    (1997)
  • K.L. Gibson et al.

    Conversations on telemental health: listening to remote and rural First Nations communities

    Rural Remote Health

    (2011)
  • J.H. Shore et al.

    Telepsychiatry with rural American Indians: issues in civil commitments

    Behav Sci Law

    (2008)
  • P. Whitten et al.

    A multi-phase telepsychiatry programme in Michigan: organizational factors affecting utilization and user perceptions

    J Telemed Telecare

    (2004)
  • C.J. Miller et al.

    Interest in use of technology for healthcare among veterans receiving treatment for mental health

    Telemed J E Health

    (2016)
  • E. Brooks et al.

    The diffusion of telehealth in rural American Indian communities: a retrospective survey of key stakeholders

    Telemed J E Health

    (2012)
  • K. Gibson et al.

    Mental health professionals’ perspectives of telemental health with remote and rural First Nations communities

    J Telemed Telecare

    (2011)
  • D.L. Cunningham et al.

    Providers’ perspectives: utilizing telepsychiatry in schools

    Telemed J E Health

    (2013)
  • V. Germain et al.

    Assessment of the therapeutic alliance in face-to-face or videoconference treatment for posttraumatic stress disorder

    Cyberpsychol Behav Soc Netw

    (2010)
  • C. Montani et al.

    Psychological impact of a remote psychometric consultation with hospitalized elderly people

    J Telemed Telecare

    (1997)
  • R.E. Scott et al.

    Telehealth outcomes: a synthesis of the literature and recommendations for outcome indicators

    J Telemed Telecare

    (2007)
  • E. Salomone et al.

    Parental attitudes to a telehealth parent coaching intervention for autism spectrum disorder

    J Telemed Telecare

    (2017)

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    Potential Competing Interests: Dr Cowan was previously a child psychiatry fellow at Mayo Clinic, but is no longer affiliated with Mayo Clinic. Drs McKean and Gentry is employed as a consultant in the Department of Psychiatry and Psychology, Mayo Clinic (outside the submitted work). Dr Hilty reports no competing interests.

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