As of September 2008, 77 million residents lived in the country's 3,059 mental health professional shortage areas, or HPSAs, according to the Kaiser Family Foundation. The foundation reported that it would take an additional 5,145 mental health care providers to meet a population to practitioner ratio of 10,000 to 1.
Telemedicine often is cited as a potential solution to the country's mental health provider shortage. However, synchronous telemedicine -- which involves live, two-way interactive video -- presents its own scheduling and technological challenges.
Peter Yellowlees -- professor of psychiatry and director of the health informatics graduate program at University of California-Davis -- noted that a large barrier to live telemedicine consultations is the difficulty of coordinating "five or six people to meet together at one time in two locations."
The less-talked-about asynchronous, or store-and-forward, telemedicine approach gets around many of those issues. In asynchronous telemedicine, clinical information is collected and transmitted via e-mail or Web applications to a specialist, who later reviews the data.
Yellowlees said, "I think the barriers are significantly less for asynchronous telepsychiatry because it's more convenient for the patient to be able to simply go and have their recording done by their local doctor, rather than having to fit into a specialist's schedule, and it's more convenient for the specialist who can do the assessment [during] down time."
Study Finds Potential in Asynchronous Telepsychiatry
In the first-ever published study of asynchronous telepsychiatry, Yellowlees and his colleagues assessed the feasibility of conducting psychiatric consultations using asynchronous, video-based telemedicine.
The study, published in the August issue of the journal Psychiatric Services, was funded by the Blue Shield of California Foundation.
For the study, patient data and 20- to 30-minute video-recorded patient assessments of 60 nonemergency English-speaking adult patients in Tulare County, Calif., were uploaded to a Web-based system. Two psychiatrists later reviewed the records and provided psychiatric consultations to the referring primary care physician.
Of the patients participating in the study:
- 85% were diagnosed with mood disorders;
- 32% were diagnosed with substance use disorders;
- 53% were diagnosed with anxiety disorders; and
- 5% were given other axis I diagnoses.
The consulting psychiatrists recommended additional laboratory tests for 83% of the patients and medications changes for 95% of the patients. One patient was referred for a face-to-face consultation with a psychiatrist.
Yellowlees said, "We thought that we'd be able to do reasonable assessments on about 80% of the patients," adding, "We only referred one of the 60 patients for a face-to-face interview, and we thought there would be more than that."
The researchers are now conducting a follow-up, inter-rater reliability study using the videos and clinical histories already recorded. While the follow-up study has not yet been published, Yellowlees said that "the results are very good." He added, "What we're finding is that the psychiatrists come to very similar conclusions when they're watching the videos so that's very reassuring."
Despite the promise of the technology, Yellowlees and his colleagues stressed that asynchronous telepsychiatry should not replace face-to-face psychiatric consultations and is not appropriate for all patients.
Barriers Remain
Yellowlees said that several barriers still remain to widespread asynchronous telepsychiatry adoption.
One barrier, according to Yellowlees, is clinician resistance. He said, "This is a new approach to doing assessments," adding, "Not everyone is going to agree with it."
He said the first step to overcoming such resistance is to continue to "demonstrate that this is a very appropriate clinical process" through research.
Like most uses of telemedicine, reimbursement is a significant barrier to adoption. Yellowlees acknowledged that asynchronous telepsychiatry "does create a little more work" for primary care doctors. He said, "It seems to me that they should be paid for collecting the data at their end," adding that there could be some sort of shared payment between the primary care physicians the consulting psychiatrist.
Yellowlees is optimistic about the future of asynchronous telepsychiatry. "I think it's certainly going to increase over time," he said.
He noted that UC-Davis; the Walter Reed Army Medical Center in Washington, D.C.; and the University of Colorado are about to launch a collaborative studying using asynchronous telepsychiatry with military service members. Yellowlees said, "I think there are huge possibilities for this."