Telepsychiatry: Who, What, Where, and How

Telepsychiatry is the application of telemedicine to psychiatry and is one of the most widely used telemedicine applications. Telepsychiatry uses electronic communication and various technologies to provide psychiatric care between a psychiatrist in one location and a patient in another location.

A key driver behind the growth of telepsychiatry is the national shortage of psychiatrists, particularly in specialty areas and in rural and underserviced geographical areas. This article focuses on risk management issues that may arise in telepsychiatry sessions occurring between a psychiatrist and a patient. Keep in mind, however, that telepsychiatry sessions may also occur between these individuals:

• Physicians in consultation

• A physician and another health care provider (for example, a case manager, clinical nurse practitioner, or physician assistant)

• A physician and nonphysician mental health providers (for example, social workers, therapists, or psychologists)

Here are some risk management considerations:

• Standard of Care: Using telepsychiatry does not change the standard of care—it is the same standard as when a patient is physically present in your office. There is little legal precedent on telepsychiatry. To date, the state boards of medical examiners have indicated that the standard of care rests at the patient site (local standard of care).

• Licensure: Most states require that the telepsychiatrist be licensed in both the jurisdiction where the patient is located at the time care is provided and in the telepsychiatrist’s own state (if different from the patient’s). All psychiatrists practicing telepsychiatry should familiarize themselves with state laws in both jurisdictions pertaining to providing care as laws often vary on issues such as prescribing, reporting child endangerment, participation in the civil commitment process, and supervision/collaboration with other providers.

• Privacy: Regulations under the Health Insurance Portability and Accountability Act (HIPAA) must be observed, as well as additional state regulations protecting patient privacy. Ensure the telemedicine system that you are using is HIPAA compliant. Many of the popular, free videoconferencing platforms are not HIPAA compliant (for example, Skype and Facetime). Additionally, under HIPAA, “Business Associate Agreements” may need to be in place when using third-party applications and services.

• Security: Protocols concerning network and software security to protect privacy and confidentiality and user accessibility and authentication should be in place. Measures to safeguard data against intentional and unintentional disclosure should be implemented for both storage and transmission of data.

• Safety: It is important to consider whether a patient is an appropriate candidate for telepsychiatry. Ensure that there are emergency plans in place should the patient need assistance.

• Obtain Informed Consent: Informed consent should be discussed and documented. Inform the patient of potential risks and benefits and give him or her the option of not participating in telepsychiatry. In the event that the patient elects not to participate in telepsychiatry, it is important that he is aware that care will not be withheld.

• Documentation: Be sure to thoroughly document the telepsychiatry session. Further, the medical records should be maintained in a similar manner to that of traditional psychiatric encounters. However, some additional aspects of the telepsychiatry session should be documented including the following:

• Location of psychiatrist and patient

• Who was present during the session and their roles

• Type of equipment used, including any malfunctions that may have occurred

• Poor transmission quality, if applicable

When practicing telepsychiatry, keep in mind that laws vary among states, and be aware of your jurisdiction’s laws as well as the principles of medical ethics. If you have any questions, please consult with an attorney or risk management professional.

For more information on this topic, please see the online risk management course “Risk Management: Overcoming Barriers to Implementation in Telepsychiatry” on APA’s Learning Center Risk Management page. ■