The Growing Recognition of Telehealth by Dr. Pat DeLeon
The effective utilization of telehealth care is one of the Department of Veterans Affairs (VA) Secretary David Shulkin’s personal priorities. Under his leadership this spring the VA announced its top five priorities which included Suicide Prevention – Getting to Zero. The number two priority was Improving Timeliness, highlighting the potential contributions of telehealth. The VA reported having established 10 Tele-Mental health hubs and eight Tele-Primary Care hubs. Forty-five percent of telehealth services are for rural veterans. Overall, there were 2.14 million episodes of telehealth care provided to 677,000 Veterans, of which 336,000 were TeleMental health visits.
APA and the Association of State and Provincial Psychology Boards (ASPPB) have positioned psychology admirably to be responsive to this technological evolution. Within the private sector licensure mobility is critical to the effective use of telehealth services. Accordingly, we have been well served by the vision of Steve DeMers and his colleagues Alex Siegel, Janet Orwig, and Fred Millan in establishing the Interjurisdictional Compact (PSYPACT) and in gaining the support, in principle, of the APA Council of Representatives. Linda Campbell, Jana Martin, and Fred served as co-chairs of the original joint APA/ASPPB/APAIT Task Force for Telepsychology Guidelines.
During her tenure as Interim APA CEO Cynthia Belar established the position of Director of Military and Veterans Health Policy and appointed Heather O’Beirne Kelly as its first director. Heather has worked for APA for 19 years and has developed impressive relationships with the relevant Hill committees and VA and DoD psychology leadership. Several years ago, she received the VA Psychology Leadership Advocacy Award at their annual convention.
In the spring of 2010, Katherine Kolacki, who was then a psychology resident for Ray Folen at the Tripler Army Medical Center, with a jurisdiction extending over 50% of the earth’s surface, reported: “As a provider, I am excited about the future of behavioral health in the military. Like most of the other providers, I was initially cautious about participating as my training and experience up to that point had been with patients in a face-to-face encounter. I was unsure of my ability to make a reliable assessment without having my patient sitting next to me, and was fearful I might miss some nuance or non-verbal cue to signal an area of distress or discomfort. However, I found the opposite to be true. I was able to conduct a complete and thorough assessment without difficulty. I found no significant difference – web cam, videoconferencing or face-to-face – in my ability to perform a clinical interview and take in all verbal and non-verbal information. I also had a few clients tell me that they felt more comfortable admitting to experiencing difficulties by web cam or video conference. For example, after an initial few minutes of denying current distress, one soldier I observed as avoiding eye contact began to open up. He has used Skype while downrange to communicate with his family and friends and felt very comfortable using that form of communication.”
The VA is the largest employer of psychology and advance practice nursing (APRNs). As the next generation of mental (behavioral) health care providers actively utilize the unprecedented opportunities created by technology within the public sector (including the development of clinical apps), the private sector and its reimbursement systems will undoubtedly be responsive, as its beneficiary population will increasingly demand equivalent access.
For most of the past two decades, Marlene Maheu has been a telebehavioral health presenter at our APA conventions. Her focus has been to clarify the legal and ethical issues related to using a variety of technologies in clinical practice. She has trained more than 20,000 professionals from 60 countries in these issues, using both in-person and Internet-based, eLearning instructional formats. “With more than 50% of hospitals and employers already delivering telehealth in the United States, telepractice has come of age. A wide variety of evidence-based models now show efficacy on par with in-person assessment and treatment. Study after study has also clearly documented strong client/patient satisfaction with telehealth services across disciplines (e.g. cardiology, pulmonology, oncology, behavioral care). Surprisingly, the #1 barrier to telehealth currently is the uninformed, untrained practitioner. The issues for behavioral professionals to consider in 2017 then are twofold: 1. When will we as a group recognize that telehealth is safe? And, 2. When will we give serious consideration to the many legal and ethical telehealth strategies now available to better serve our client/patients through a range of technologies, and especially video conferencing. If the technology we use daily is sophisticated enough to do our banking, manage our stock portfolios and monitor our vital signs, why should we avoid using it to deliver behavioral care? Widespread training for clinicians is not only needed, but readily available.” At this year’s APA convention Marleen will be leading a full day CE Telepsychology Best Practices workshop.
The Transition Process: The House Appropriations Committee also expressed its concern regarding the transition process which military retirees often experience – an agenda which Walter Penk and Nate Ainspan have been stressing. “Military Medical Professionals and the Department of Veterans Affairs. The Committee remains concerned about the transition of separating servicemembers into civilian life, the difficulties they may face in securing employment, and the shortage of staff at the Veterans Health Administration. The Committee encourages the Assistant Secretary of Defense (Health Affairs) to work jointly with the Department of Veterans Affairs to establish a program to encourage Department of Defense medical professionals to seek employment with the Veterans Health Administration when the individual has been discharged or released from service or is contemplating separating from service.” Again, VA Secretary David Shulkin appears to be in conceptual agreement as he addressed the critical importance of DoD-VA having interoperable Electronic Medical Records. “At VA, we know where almost all of our Veteran patients are going to come from – from the DoD….” Of further interest, the Health Resources and Services Administration (HRSA) reports that over the past two years 30% of the new hires by Federally Qualified Community Health Centers (FQHCs) have been Veterans. Increasingly, health policy experts have been raising the underlying issue of the importance of addressing the unique military culture and its related health and employment consequences. They have been urging all clinicians, in the public and private sectors, to begin by asking their patients whether they have ever served in the military.
Adopting Patient-Centered Policies: Two of our colleagues who are actively engaged in the pharmacy profession have recently highlighted another intriguing evolution. Karen Pellegrin, a psychologist on the faculty of the University Of Hawaii Daniel K. Inouye College Of Pharmacy in Hilo: “One major advance by the VA is that they are now sharing data with the national prescription drug fill query systems. So when a community pharmacist or other non-VA clinician wants to know what meds a patient has (and so many patients use multiple pharmacies to fill different meds), the patient’s VA-filled meds are included in the query results. Kaiser is now the only one not participating….” Lucinda Maine, Executive Vice President and CEO of the American Association of Colleges of Pharmacy: “Having a complete and accurate medication list is essential for safe patient care. And the insights on actual patterns of medication use from an ‘all sources’ integrated Med history does literally save lives. It would be even more powerful if recommendations from an AHRQ-funded project, led by pharmacist Dr. Gordon Schiff, were fully implemented. His work addressed the benefits of and obstacles to including a Reason-for-Use indication on prescription orders. This enhancement would improve patient education and the consumer’s ability to manage their medication regimen.” Fundamental change is inevitable.