Telemedicine in Psychiatry: making the dream reality

A Systematic Review of the Use of Telepsychiatry in Acute Settings

Telepsychiatry is increasingly being used in many parts of the world. We performed a systematic review of the literature on the use of telepsychiatry in acute treatment settings using MEDLINE, EMBASE, and PsycINFO from inception to June 2013 using the following key words: acute telepsychiatry, teleconsultation, teleconferencing, telemedicine, emergency telepsychiatry, and e-mental health. Only articles in English were included. All study abstracts were reviewed by both authors independently to assess whether the topic of the paper was relevant to the review. References were selected independently until no new papers were found. If there was a disagreement, a discussion between the authors took place. A leading expert in this field was contacted to check for gray literature. The review included 23 papers. No meta-analyses or systematic reviews were found. The main results are (1) that patients have a positive attitude toward the technology and show a high level of satisfaction with telepsychiatry, (2) that the use of telepsychiatry is correlated with decreased admissions to psychiatric inpatient units, (3) that the quality of clinical interaction in telepsychiatry is similar to that in face-to-face care, and (4) that telepsychiatry seems to be cost effective. The use of telepsychiatry seems to be a viable and relatively inexpensive option for use in places where access to emergency services is difficult.

Accuracy of telepsychiatric assessment of new routine outpatient referrals

BACKGROUND

Studies on the feasibility of telepsychiatry tend to concentrate only on a subset of clinical parameters. In contrast, this study utilises data from a comprehensive assessment. The main objective of this study is to compare the accuracy of findings from telepsychiatry with those from face to face interviews.

METHOD

This is a primary, cross-sectional, single-cluster, balanced crossover, blind study involving new routine psychiatric referrals. Thirty-seven out of forty cases fulfilling the selection criteria went through a complete set of independent face to face and video assessments by the researchers who were blind to each other's findings.

RESULTS

The accuracy ratio of the pooled results for DSM-IV diagnoses, risk assessment, non-drug and drug interventions were all above 0.76, and the combined overall accuracy ratio was 0.81. There were substantial intermethod agreements for Cohen's kappa on all the major components of evaluation except on the Risk Assessment Scale where there was only weak agreement.

CONCLUSION

Telepsychiatric assessment is a dependable method of assessment with a high degree of accuracy and substantial overall intermethod agreement when compared with standard face to face interview for new routine outpatient psychiatric referrals.

Videoconferencing for a Veteran’s Pain Management Follow-Up Clinic

The under treatment of pain has been well documented. Contributing to this is the limited availability of pain management specialists in many geographic areas. The use of technology to provide care to underserved areas is gaining momentum. We chose to study whether stable patients and staff in chronic pain clinic were satified with the use of a videoconferencing format in care delivery. Our goals were to determine whether patients and staff could successfully operate the extant videoconferencing equipment, was the equipment dependably functional, was the use of a videoconferencing format an acceptable method of healthcare delivery for both patients and staff, whether patients and staff were satisfied with the process, and whether this was a cost-effective mode of care delivery. Thirty-six patients were enrolled over 29 months. Questionnaires were administered to staff and patients. Routine pain clinic patient assessment tools were administered. Results showed the use of videoconferencing for this group of patients is useable and satisfactory for both patients and staff, that the patients save time and money, and that for a system where videoconferencing equipment is already in use, it is also cost effective. Staff were able to identify new patient problems. Some patients would prefer to be seen in person but find that the savings in time and money override this preference. Hearing impaired patients have difficulty using this medium. Dependable equipment and phone connections are needed. A videoconferencing clinic format is a clinically acceptable and cost effective method for follow-up of stable patients with chronic pain.

Internet application to tele-audiology--"nothin' but net"

The Telehealth program at East Carolina University has developed a system for real-time assessment of auditory thresholds using computer driven control of a remote audiometer via the Internet. The present study used 45 adult participants in a double-blind study of 2 different systems: a conventional audiometer and an audiometer operated remotely via the Internet. The audiometric thresholds assessed by these 2 systems varied by no more than 1.3 dB for air conduction and 1.2 dB for bone conduction. The results demonstrated the feasibility of this new "telehearing" audiometric system. With the rapid development of Internet-based applications, telehealth has the potential to provide important healthcare coverage for rural areas where specialized audiological services are lacking.

Telepsychiatry in the heartland: if we build it, will they come?

The quality of care provided by telemedicine and its acceptability to persons who live in rural areas is largely undetermined. In this study, service satisfaction and functional status in persons using telemedicine was compared to those receiving face-to-face services at two rural sites over a 2-year study period. Similar ratings of satisfaction and clinical status were observed in twelve patients who received services under both modalities. Although there are many obstacles to successful program implementation, telepsychiatry appears to offer an acceptable and adequate alternative mode of service delivery to persons who live in rural areas.

Evaluation of the effectiveness of portable low-bandwidth telemedical applications for postoperative followup: initial results

BACKGROUND

The idea of using telemedical applications to evaluate patients remotely is several decades old. It has already been established that x-ray images (and magnetic resonance images) can be transferred using a personal computer and a modem, and many other such applications have been implemented. Over the past 50 years the expense and technical demands of the equipment involved in telemedicine have hindered its widespread deployment. The purpose of this study is to evaluate the ability of a mobile, low-bandwidth telemedicine platform to achieve real-time postoperative visits in the home.

STUDY DESIGN

This evaluation was designed to evaluate the feasibility of performing a real-time clinical visit with computer and telecommunications hardware and software. A nurse and medical student (for information gathering only) made postoperative visits at patients' homes while the physician stayed at the office. Clinical evaluations were performed by using low-resolution and frame-rate video, high-resolution still images, and simultaneous telephony over a standard telephone line. These remote visits were followed by a standard visit in the office. Eleven patients were included, all of whom had undergone various laparoscopic procedures. They lived 5 to 240 miles from their surgeon. Efficiency was measured by recording the time required to capture and send data required by the physician to make a clinical decision. The time expense was measured at both the patients' and physician's locations. Technical issues were evaluated and patient satisfaction was assessed by standardized objective questionnaires. The accuracy of the evaluation at the remote visit was determined with a standard office visit.

RESULTS

No technical problems were observed. The mean total time of the housecall at the remote site was 86 minutes (range 60 to 160 minutes) and at the base station site was 41 minutes (range 21 to 71 minutes). After personnel became familiar with the system, the last three visits averaged 61 and 25 minutes at the two sites, respectively. This corresponds favorablywith current time requirements for visiting nurses and office visits. The patients were highly satisfied with the home visit and, on average, rated the experience as 4.8 out of a maximum of 5.

CONCLUSIONS

Followup visits in patients' homes after laparoscopic procedures can be accomplished by transmitting simultaneous voice, low-resolution video, and high-resolution still images to accurately perform postoperative evaluations over standard telephone lines, with time requirements and clinical accuracy similar to those of standard visits.

Use of mobile low-bandwith telemedical techniques for extreme telemedicine applications

BACKGROUND

Telemedicine is traditionally associated with the use of very expensive and bulky telecommunications equipment along with substantial bandwidth requirements (128 kilobytes per second [kbps] or greater). Telementoring is an educational technique that involves real-time guidance of a less experienced physician through a procedure in which he or she has limited experience. This technique has been especially dependent on the aforementioned requirements. Traditionally, telemedicine and telementoring have been restricted to technically sophisticated sites. The telemedicine applications through the existing telecommunication infrastructure has not been possible for underdeveloped parts of the world.

STUDY DESIGN

Telemedicine and telementoring were applied using low-bandwidth mobile telemedicine applications to support a mobile surgery program in rural Ecuador run by the Cinterandes Foundation and headed by Edgar Rodas, MD. A mobile operating room traveled to a remote region of Ecuador. Using a laptop computer equipped with telemedicine software, a videoconferencing system, and a digital camera, surgical patients were evaluated and operative decisions were made over low-bandwidth telephone lines. Similarly, surgeons in the mobile unit in Ecuador were telementored by an experienced surgeon located thousands of miles away at Yale University School of Medicine.

RESULTS

Five preoperative evaluations were conducted from Sucua to Cuenca, Ecuador, with excellent clinical correlation. Additionally, a laparoscopic cholecystectomy was successfully telementored from the department of surgery at Yale University School of Medicine to the mobile surgery unit in Ecuador. The telementored surgery was performed using a telephone line with a baud rate of 12 kbps.

CONCLUSIONS

Mobile, low-bandwidth telemedicine applications used in the proper technical and clinical algorithms can be very effective in supporting remote health care delivery efforts. Advantages of such applications include increased cost-effectiveness by limiting travel, expanding services to patients, and increased patient quality assurance.