Provider Barriers to Telemental Health: Obstacles Overcome,Obstacles Remaining

Abstract

Many providers are hesitant to use telemental health technologies. When providers are queried, various barriers are presented, such as the clinician's skepticism about the effectiveness of telemental health (TMH), viewing telehealth technologies as inconvenient, or reporting difficulties with medical reimbursement. Provider support for TMH is critical to its diffusion because clinicians often serve as the initial gatekeepers to telehealth implementation and program success. In this article, we address provider concerns in three broad domains: (1) personal barriers, (2) clinical workflow and technology barriers, and (3) licensure, credentialing, and reimbursement barriers. We found evidence that, although many barriers have been discussed in the literature for years, advancements in TMH have rapidly reduced obstacles for its use. Improvements include extensive opportunities for training, a growing evidence base supporting positive TMH outcomes, and transformations in technologies that improve provider convenience and transmission quality. Recommendations for further change are discussed within each domain. In particular, it is important to grow and disseminate data underscoring the promise and effectiveness of TMH, integrate videoconferencing capabilities into electronic medical record platforms, expand TMH reimbursement, and modify licensure standards.

Introduction

The integration of technology and medicine has existed, in some capacity, for over a century. However, it was not until the last 25 years that the knowledge and use of telehealth services began to rapidly proliferate across the United States.¹ Perhaps one of the most significant factors enabling the diffusion of telehealth was the creation of several national-level organizations that were explicitly geared to educate health professionals, researchers, legislators, and the public about developing telehealth networks and to provide information about critical factors impacting the use and expansion of telehealth programs. Among the more significant players were the American Telemedicine Association (ATA) (established in 1993), the Office for the Advancement of Telehealth (established in 1998), and the Telehealth Resource Centers (established in 2006).

From the outset, telemental health (TMH) was a popular use of telehealth technologies given the high need for specialized care in rural areas and its natural integration into the existing infrastructure of many healthcare programs. Recently, the popularity of TMH has surged as more empirical research documents its ability to provide care to populations that, previously, had limited or no access to mental health services. Several developments have paved the way for broader use of TMH. In the past, equipment was often prohibitively expensive, was technologically complex, and often had unreliable performance. Third-party payer reimbursement, particularly from private payers, was unknown. Research was limited to small pilot studies, and best practices had yet to be developed. Although all of these barriers have diminished considerably in the past 25 years, several factors continue to exist that limit the utilization and growth of this healthcare delivery platform.

Materials and Methods

In this article, we discuss several obstacles that plague the diffusion of TMH. Three broad domains are discussed: (1) personal barriers, (2) clinical workflow and technology barriers, and (3) licensure, credentialing, and reimbursement barriers. Here, we focus on hurdles largely from the provider's perspective. We feel this focus is necessary largely because of the importance of provider buy-in. Providers are critical to the utilization of telehealth services and often serve as the initial gatekeepers to its implementation.² To understand recent advancements in the eradication of TMH barriers, we highlight several key examples of how TMH barriers have been successfully addressed in recent years.

Results

Provider Barriers to Telehealth

Personal barriers

Personal barriers refer to provider characteristics that influence one's acceptance and use of TMH services. Qualitative research studies have established several reasons that providers are hesitant to embrace TMH. Many providers are concerned that TMH will inhibit their ability to effectively establish rapport and cultivate a successful clinical relationship with patients.^3
–5 In turn, it is thought that patients may be less compliant with treatment recommendations and that positive clinical outcomes will be more difficult to obtain. Providers have also commented that successful treatment outcomes may be inhibited by the lack of proximity between that clinician and the provider. Because, by definition, providers are not physically located in the same room as patients, some clinicians have questioned the validity of TMH-based assessments given their diminished ability to detect some nonverbal cues such as poor hygiene habits or alcohol use.³ Still, other providers support the use of TMH, but only for certain types of care such as specialty consultations or treatment with nonpsychotic patient populations.⁴

Despite providers' initial concerns, we are finding that confidence and buy-in can be significantly improved when clinicians are given the opportunity to actually use telehealth. In the 1960s, the first formal TMH study was conducted at Harvard's Massachusetts General Hospital under the pioneering efforts of Dr. Thomas Dwyer, who reported that “after some initial reluctance, providers and patients found TMH sessions were as good as or better than traditional face to face sessions.”⁶ A study of three ongoing TMH clinics documented similar results from providers and administrators who were initially skeptical about the use of TMH; when asked which factors were instrumental for their change in attitude, respondents credited positive client feedback and improved clinical outcomes as the primary basis for change.⁷

Personal barriers for TMH also concern the clinician's training for delivering technology-based medical care. Several reports cite providers' concern about their own lack of formal instruction prior to using TMH,^5,8,9 with one survey citing that only about half of practitioners using TMH felt adequately trained.⁵ Inadequate training for providers may not only reduce their satisfaction, but may ultimately impact their use of services or willingness to make referrals, thereby limiting the growth of TMH. It is our hope, however, that inadequate training may soon be a problem of the past. In the past decade, numerous programs to orient providers to telehealth have been created, ranging from half-day programs to online beginner's courses to ongoing Webinars for more advanced users.¹⁰ Training handbooks, informational book chapters, accredited educational programs, and certificate courses can also be found.^11,12 Many universities also offer exposure to the broader field of telehealth and clinic-based educational opportunities. In addition, one of the major sites for training of mental health clinicians, the Department of Veterans Affairs, integrates clinical videoconferencing directly into its clinical care. It has formal conditions of participation and several online training venues to ensure providers are trained accordingly. Trainees are thus afforded experience in TMH as a part of routine clinical care. Since 2009, the ATA has offered accreditation for telehealth professional training programs,¹² which is critical to ensure consistency in instruction, rigor in practice, and overall quality in the telehealth workforce.

Lastly, personal barriers can be lessened when potential users are provided data about the utility of TMH.⁷ However, the evidence base for TMH outcome studies has long been identified as inadequate.^13
–15 In 1997, Baer et al.¹³ reviewed the literature to assess the effectiveness of telepsychiatry, concluding that insufficient evidence existed to support the widespread implementation of its use. Subsequently, other authors reviewed TMH or telepsychiatry literature and documented several studies showing positive outcomes—especially for patient satisfaction—but determined that additional randomized, controlled trials were needed.^14,15 To this effect, a recent literature review examined the effectiveness of randomized control trials for TMH-based videoconferencing, citing a total of 17 studies published between 2006 and 2010. The author reported that the bulk of research showed positive clinical outcomes but noted that limitations remained, namely, the relatively low number of publications discerning which interventions were indicated (or contraindicated) for specific groups.¹⁶ In the most recently published review of TMH research to date, Myers and Turvey¹⁷ concluded that the results of TMH outcomes research has been largely positive and well reviewed in several publications. Positive results were generally found for patient satisfaction, and comparable results were demonstrated between videoconferencing-based and in-person care. To this end, although requests for more research documenting the effectiveness of telehealth interventions are frequently heard, a bounty of new data has been published in the past 15 years. Although more data are certainly warranted, it seems the more salient barrier is not developing the evidence base, but rather developing ways to increase adoption.

Clinical workflow and technology barrier recommendations

Satisfaction rates for TMH—although high in general—are often lower for clinicians than patients.⁹ There are likely many reasons for this difference, but it is not all that surprising given that telehealth introduces more convenience for the patient than for the provider. Typically, the TMH consultation entails additional procedures not found in face-to-face encounters. Added processes such as traveling to a special room, making the appropriate technical arrangements, and scheduling and documenting changes can cause just enough disruption to dissuade some practitioners from adopting this practice. Consequently, some providers cite these factors as significant barriers to utilization.³

However, it is hoped that more recent technological developments may remedy this difference. Desktop videoconferencing refers to videoconferences that are generally conducted in the provider's office, using the provider's personal computer. The emergence of high-quality desktop videoconferencing technologies may improve the attractiveness of telehealth practice. If providers can conduct secure videoconferencing using their desktop computer, then they can conduct video consultations in the same room where they provide in-person care. Providers can alternate between in-person and telehealth patients, more easily integrating it into the normal workflow of their clinic. Desktop innovations would also reduce the scheduling difficulties that plagued TMH when a single dedicated room and equipment was shared between multiple providers.

With these new desktop videoconferencing technologies, the cost of providing TMH care can decrease, as much of the cost is covered by the standard budget for outfitting an office with ordinary computers and high-speed Internet connection. As an added bonus, desktop computers now make it easier for the provider to work from home, thereby offering an attractive option for those trying to balance home and work commitments.

As indicated, providers have voiced frustration with changes in medical record documentation that often occur with the utilization of telehealth technologies.¹⁸ The establishment of telehealth protocols can spiral in complexity, encompassing data sharing agreements and requiring providers to navigate several different types of electronic medical record systems. To date, there is no widely used solution to this problem. Although there are several nationwide and international forays into health information networks that aim to implement standards based the integration of multiple record systems, these networks are not widely available to most practitioners and do not have specific documentation protocols for telehealth.

While the recent desktop videoconferencing solutions address many of the barriers to clinician adoption, the issue of bandwidth difficulties and questions about network security remains.¹⁹ Sufficient bandwidth is critical to the success of videoconferencing because, in its absence, the video image is choppy, and there is a delay in signal transmission, resulting in awkward communications between the provider and the patient. As with all Internet-based information, extra security precautions must be taken to ensure safe, private transmission of patient data. Although personal and professional networks support greater activity than ever before, bandwidth demands themselves are rising and remain difficult to predict and manage. More recent technologic developments, such as the H.264 standards, improve compression of high-definition video data and reduce disrupted transmissions.

Because of the collaboration with the information technology field, state of the art encryption is available at a very low cost. This encryption allows for care to be delivered at a distance with the signal being safeguarded at the level that meets Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliance. Previously, this required expensive, virtual private networks or very expensive encryption, which generally was not affordable for most TMH programs. Most recently, HIPAA-compliant security is available to smartphones and tablets, marking a significant step in the ever-expanding TMH field.

Licensure, credentialing, and reimbursement barrier recommendations

It would be difficult, if not impossible, to provide a thorough accounting of current barriers to TMH without a significant discussion about licensing and credentialing regulations. In nonfederal settings, clinical practitioners need to be licensed in each state in which they practice telemedicine as well as a license in the state in which they physically practice medicine. This is not only a difficult and time-consuming task, but it can be expensive as well. Adding to this complication are differing laws between states. As stated by FixLicensure.Org: “…requiring health providers to obtain multiple state licenses and adhere to diverse and sometimes conflicting state medical practice rules, is a barrier to progress, quality and competition.” Provider credentialing considerations are similar to the licensing barrier. That is, TMH providers must be credentialed in each hospital or clinic in which a patient is seen. This necessitates clinicians to be credentialed in numerous facilities, all of which could have different rules and guidelines. These limitations severely restrict using TMH to its current capacity, for example, in postdisaster environments where there is a surge of mental health needs while simultaneously a reduction of mental health providers.

To address these barriers, many telehealth advocates suggest solutions such as the development of a national interstate licensure agreement, entering into entering compact agreements with other states, or creating exceptions for the telehealth-based care.²⁰ In January 2012, the ATA sponsored a briefing on Capitol Hill to discuss telehealth licensure issues and inform members of Congress about current state-based licensing systems. House Bill 6719, the Telehealth Promotion Act, was introduced recently in the 112th Congress. The bill proposed a new federal standard in which providers in all federal health plans would only need to be licensed in their physical state in order to care for eligible patients anywhere in the nation. The bill, however, died in committee, and there are no current efforts to revive it (Office of Rep. M. Thompson, pers. comm.). Clearly, although there have been positive steps to eradicate telehealth practice barriers, much work remains.

In response to the growing use of distance technologies to provide medical care, some professional organizations and third-party payers are making stipulations about care that may impede adoption of TMH. In May 2012, the American Medical Association House of Delegates drafted a document setting as a standard of care at least one in-person physical exam for all physician/patient relationships. Although on the surface this seems a reasonable requirement, telemedicine has long provided much needed care in collaboration with remote providers who are more than capable of conducting the in-person physical exam and providing the information to the consulting mental health provider. Currently, restrictions similar to these are debated by professional organizations such as the National Committee on Quality Assurance or the National Association of Boards of Pharmacy. Often concerns are allayed once the organization is made more aware of the existing research base for TMH.

Lastly, another serious barrier that deserves attention is reimbursement for services provided by TMH. Under the current system, non–federally funded health services are covered by a patchwork of third-party payers. Although some third-party payers reimburse for TMH, some do not, whereas still others reimburse for only certain procedures.²¹ Presently, two procedures frequently used in TMH practice (group therapy and family therapy) are not approved by the Centers for Medicare and Medicaid Services (CMS) as reimbursable care. Current CMS standards allow only limited TMH coverage in urban, underserved areas. The lack of reimbursement creates a major financial barrier for TMH.²² Although significant progress has been made at the national level with CMS for Medicare reimbursement, there is a great need for the state-level Medicaid and third-party payer reform. Several groups are working to address this need, notably the ATA, but because each state regulates its own Medicaid plan, the work is labor intensive and slow. However, a recent effort led by telehealth advocates demonstrates that reimbursement change is possible. In January 2013, a mandatory change in Current Procedural Terminology code reimbursement drew attention because a former code (90862) was not carried forward as a reimbursable charge using TMH. The ATA and the American Psychiatric Association teamed up and worked with the CMS to address this problem. A resolution to correct this omission was quickly found within a 2-month time period.

Discussion

The past 25 years has seen a momentous increase in the popularity and diffusion of TMH, and several obstacles that once inhibited the use of telehealth services have been significantly improved. In particular, training opportunities have increased, technological changes have made the delivery of TMH more convenient and of a better quality, and there is a growing evidence base supporting positive TMH outcomes. There remain, however, several barriers that constrain further expansion of TMH, and in order for the next 25 years to show similar evidence of success, these barriers must be addressed quickly. We conclude this article by offering our recommendations on the most important barriers that continue to need resolution.

Personal Barrier Recommendations

It seems clear that, as providers' exposure to TMH increases, their reluctance to use new technologies decreases. The ample training and educational opportunities now available to the public will likely go far in exposing providers to TMH and demonstrating the general ease of use. Providers' reluctance to use TMH is also likely to be reduced over time as new clinicians enter the field, with anecdotal data suggesting that the younger generation is less resistant, possibly because of exposure to computers and other technology in their formative years. The New Millennium Research Council found that the “digital divide' threatens the widespread implementation of telemedicine [and] that the baby-boomers generation, ages 38–59, will be better prepared to use telemedicine because of their experience and familiarity with technology.”²³

Althugh research in the field of telehealth has increased rapidly, there are still relatively low numbers of empirical studies examining the effectiveness of telehealth. As recently as 2011, approximately 78% of clinicians surveyed responded that more research on the effectiveness of telehealth was needed. To this end, it is important to secure funding to enable the execution of large-scale research studies. It is also imperative that telehealth advocates develop new and innovative ways of disseminating the results of current investigations.

Clinical Workflow and Technology Barrier Recommendations

The rapid expansion and use of reliable, accessible, and private videoconferencing technologies continue reducing one of the major barriers to adoption. Two current developments will facilitate adoption further. One development is the integration of videoconferencing capabilities into electronic medical record platforms. Integrated technologies will greatly improve workflow for clinicians. It will also reduce complexity for healthcare information support staff because they will only have to manage the privacy and bandwidth demands of one technology, instead of having to juggle the demands of three technologies.

The second development is the increasing sophistication of mobile technologies such as tablets and smartphones. Many providers already have experience with conducting videoconferencing on these devices in their personal life. Such mobility will allow TMH to be used in bedside interviews of patients, where the inpatient holds the tablet in his or her lap, or home consultations for homebound patients, such as those seen through visiting nurse associations. With this eventual use, it is critical that providers maintain clinical standards such as protecting privacy and following established clinical protocols.

Licensure, Credentialing, and Reimbursement Barrier Recommendations

It is the authors' opinion that current reimbursement rules need to be examined and updated to include coverage for all underserved populations (including all urban residents) and services that are frequently provided with TMH, such as group therapy and family therapy. It is imperative that members of Congress understand the promise of TMH to response to both everyday and crisis situations, as well as be made aware of existing data showing the effectiveness of this delivery mechanism. National legislation that enables interstate licensure and credentialing opportunities must be passed in order to grow telehealth programs.

Footnotes

Acknowledgments

This work was partially supported by the Department of Veterans Affairs, Office of Rural Health, Veteran's Rural Health Resource Center–Central Region.

Disclosure Statement

No competing financial interests exist.

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