Background: Though evidence for telepsychiatry shows good patient satisfaction, physician concerns regarding patient acceptability may impede implementation of such services. This quality improvement project improved understanding of physician attitudes toward telepsychiatry to facilitate expansion of telepsychiatry services at a large, multi-campus tertiary care health network.
Methods: A validated survey assessing family physician attitudes, beliefs, and use of telehealth was modified and emailed to all physicians in the Network’s departments of Emergency Medicine, Internal Medicine, Family Medicine, Pediatrics, and Psychiatry. “Users” were defined as those who used or referred patients for telepsychiatry in the last 12 months. Descriptive statistics compared users to nonusers and differences between departments.
Results: Fifty-three emergency physicians, 24 internists, 26 family physicians, 27 pediatricians, and 13 psychiatrists completed the survey (N=143). Overall, 29.7% of respondents identified as “users,” and 78.3% reported they would use telepsychiatry if it were available. Use was most common among emergency physicians (62.0%) and psychiatrists (61.5%). Many respondents indicated uncertainty; 32.0% of all responses regarding attitudes and beliefs were “I don’t know.” Most respondents felt telepsychiatry improves access to care (82.3%) and continuity of care (69.2%) while reducing patient travel time (50.8%). Most physicians felt that patients prefer to see their doctors in person (67.7%) and receive better quality of care in person (64.5%). Both users and nonusers identified lack of training (50.7%) as a barrier to telepsychiatry use, while the strength of telepsychiatry’s evidence base was of greater consescern for users (88.6%) compared to nonusers (22.3%). A majority of psychiatrists (71.4%) reported concern regarding potential loss of personal contact associated with telepsychiatry, but only 31.4% of all respondents using telepsychiatry reported this concern. Seventy-nine percent of physicians answered “I don’t know” regarding adequacy of Medicare reimbursement and 54.4% for potential of malpractice lawsuits.
Discussion: Though physicians may consider telepsychiatry useful in improving continuity of and access to care, most contradicted current evidence by asserting it is not better than traditional care in terms of quality or patient satisfaction. Among departments, psychiatrists seem most concerned about the impact of telepsychiatry on therapeutic rapport, although this finding should be interpreted with caution due to measurement limitations.
Conclusion: Many Network physicians lack general knowledge of telepsychiatry, indicating a need for provider education. However, Network physicians appear to be open to using telepsychiatry despite existing perceived barriers. These insights will guide the implementation of pilot programs for tele - behavioral health consultations in the Network
According to the American Psychiatric Association, telepsychiatry is the process of providing a range of mental health services, from a distance, through technology . These services may involve interaction between psychiatrists, patients, and other health care providers such that all parties can participate in psychiatric evaluation, talk therapy, medication management, provider-to-provider consult, and patient education despite barriers such as low provider availability, inadequate time or transportation, and remote physical location . Furthermore, telepsychiatry can take place through various technologies, including telephone, videoconferencing, photography, and electronic data sharing .
Several distinct telepsychiatry interventions are in use across the country. In addition to real-time interaction between patients and providers, healthcare teams may also choose “store-and-forward” technology in which sound, video, images, and other data may be recorded and sent to another location and/or stored for later review . Alternately, “remote patient monitoring” allows for the collection of patient vital signs, self-reports, and other health data, in the patient’s home or at another convenient site, for transmission to a remote psychiatrist who can respond as needed .
Available research surrounding telepsychiatry suggests that this method of mental healthcare delivery is just as, if not more, effective than traditional face-to-face care in terms of clinical outcomes and healthcare cost . For instance, a review by Hubley et al.  included seven randomized controlled trials (RCTs) analyzing the effect of in-person versus teledelivery of psychotherapy or medication management on patients with depression or Post-Traumatic Stress Disorder. Three RCTs in the review showed equal outcomes in terms of patient scores on validated symptom severity inventories [4-6], while four RCTs showed superior outcomes in patients undergoing telepsychiatry [7-10]. In terms of diagnostic reliability, the same review demonstrated high inter-rater reliability in telepsychiatry versus traditional care regardless of provider, setting, or the instrument used . The same was true even when interpreters were used .
Evidence for the cost-effectiveness of telepsychiatry is similarly strong. Per Hubley et al. , “most studies demonstrate that telepsychiatry reduces direct and indirect costs and increases the quality of life adjusted years when compared to face-to-face [care].” One study estimated that, when compared to the cost of in-person therapy, 16 sessions of cognitive behavioral therapy via telepsychiatry could save a clinic approximately $2,025 per patient . Furthermore, patients were less likely to cancel or no-show with telepsychiatry appointments than patients receiving traditional care .
In terms of patient satisfaction, both quantitative and qualitative data show high patient acceptance of telepsychiatry, particularly because of a decreased need for transportation . However, data examining provider satisfaction are less clear-cut . Evidence shows that much physician resistance to telepsychiatry use stems from concerns about therapeutic rapport and inexperience with telepsychiatry . That is, some feel that the physical and technological barriers of telepsychiatry may impede doctor-patient interaction and lead to decreased quality of care . Furthermore, many providers perceive patients to be less satisfied with telepsychiatry than has actually been reported by patients . For these reasons, a more thorough understanding of physicians’ attitudes toward telepsychiatry is needed to increase provider acceptance of the new implementation of telepsychiatry .
A major barrier to the expansion of telepsychiatry services in Pennsylvania is the inadequacy of insurance reimbursement for such services. Currently, Pennsylvania is not among the 34 states that have passed laws requiring private insurance companies to reimburse for telepsychiatry . Although Pennsylvania Medicaid will reimburse providers for some outpatient psychiatric services, the many limitations placed on these interventions greatly reduce the feasibility of providing such services. For instance, patients may receive care only from licensed psychiatrists, psychologists, and CRNPs, only via live video, for a limited number of indications . Additionally, these providers face a number of regulatory burdens before they can bill for telepsychiatry services. For example, they are required to have documented endorsement from their county mental health program in addition to the HealthChoices Behavioral Health Managed Care Organization, which must then be approved by the regional Pennsylvania Office of Mental Health and Substance Abuse Services. As a result, many providers simply do not offer telepsychiatry, despite its known benefits.
Because of these real and perceived barriers to the use of telehealth technology, we set out to survey physicians regarding its use at a large, multi-campus, tertiary-care health network. Despite its enormous therapeutic potential, telepsychiatry is currently being used only in limited formats at the Network. One major application, the Psychiatric Evaluation Service, connects patients in Network emergency departments with psychiatrists at other Network hospitals. This intervention improves patient access to timely psychiatric evaluation and reduces the transportation burden of on-call psychiatrists. Another application of telepsychiatry principles is “Telecourt,” which allows patients and providers to videoconference with judges and appropriate legal parties hearing cases for involuntary emergency evaluation and treatment. Telecourt greatly reduces the physician time and hospital resources needed for transportation to legal hearings.
Though patients are generally accepting of telepsychiatry, physician concerns may pose an obstacle to the implementation of new interventions at the surveyed Network. In gaining a more thorough understanding of physician attitudes toward telepsychiatry, this project will help foster increased physician support for this technology and facilitate the efficient roll-out of new services. It is hoped that with more awareness and education about telepsychiatry for providers, regulatory barriers may be removed to allow further expansion of telepsychiatry services
With permission, we obtained a survey created by the Robert Graham Center  to assess the beliefs and attitudes of the American Academy of Family Physicians members regarding telehealth. This previously validated survey was modified only by inserting “telepsychiatry” in place of “telehealth” and “your specialty” in place of “family medicine.” “Users” were defined as physicians who had used or referred patients for telepsychiatry in the last 12 months. Additionally, the survey provided the following definitions of telehealth and telepsychiatry.
Telehealth is the use of medical information changed from one location to another via electronic communications to improve a patient’s health. For the purpose of this project, we are defining telepsychiatry services as:
1.A physician providing care for a patient (not necessarily a patient in their practice) through the use of live interactive video; or
2. Consults between providers through the use of live interactive video; or
3. Sharing of diagnostic images, vital signs, video clips, or patient data between a primary care provider and specialist when the specialist and patient are not in the same location (sometimes referred to as store and forward). Lehigh Valley Health Network is a multi-hospital network based in sub-urban eastern Pennsylvania. Comprehensive psychiatric services consist of 145 inpatient psychiatric beds on three campuses, three partial hospital programs, five outpatient practices, and six emergency departments that provide psychiatric emergency services. The survey included 33 questions divided into five sections. After answering questions regarding physician characteristics, practice characteristics, and attitudes toward telepsychiatry, respondents were divided into “users” and “nonusers” and directed to separate sets of questions regarding their beliefs about telepsychiatry and the current use of telepsychiatry among users. Responses included open-ended, multiple choice including “other,” and level-of-agreement based on a five-point Likert scale modified to include “don’t know.” A copy of this instrument can be found in Appendix I.
The modified survey was formatted into five distinct forms using software from SurveyMonkey.com such that one form existed for each Network department to be surveyed: Emergency Medicine, Internal Medicine, Family Medicine, Pediatrics, and Psychiatry. Links to each department-specific survey form were then emailed to all physicians in the respective departments via ListServ with permission from the distinct department chairmen. In total, 114 internists, 93 family physicians, 134 emergency physicians, 116 pediatricians, and 25 psychiatrists were contacted. These providers were also sent one reminder email, and the surveys were closed after approximately six weeks. No informed consent was used, as the survey was anonymous, and this project was reviewed by the Network’s Institutional Review Board and designated “Not Human Research.”
Descriptive statistics were generated for the total sample and stratified by user status and department as appropriate. Four respondents completed only the “provider characteristics” section of the survey but no other sections and were therefore excluded from the analysis of provider attitudes and beliefs questions. Categorical variables were reported as total number of responses and percentages, while means and interquartile ranges were reported for continuous variables. Responses using the five-point Likert scale were condensed to three points to simplify data reporting given the project’s relatively small sample size.
The sample (N=143) consisted of 53 emergency physicians, 24 internists, 26 family physicians, 27 pediatricians, and 13 psychiatrists, representing a response rate of 40.0% for Emergency Medicine, 21.1% for Internal Medicine, 28.0% for Family Medicine, 23.3% for Pediatrics, and 52.0% for Psychiatry. Summary demographics are presented in Table 1. Overall, respondent gender was approximately equal, with 64 men and 78 women. Compared with other departments, Pediatrics and Family Medicine had a higher percentage of women respondents, 70.4% and 73.1%, respectively, and Internal Medicine had slightly more men respondents (62.5%). Overall physician median age was 44.5 years (IQR 36-55), and median time in practice post-residency was 13 years (IQR 4-23). Users were slightly younger (42 years old, IQR 31-55) than nonusers (46 years old, IQR 37-55) and had slightly fewer years of experience post-residency (9 years, IQR 0-20 versus 15 years, IQR 6-25).
Most respondents (70.4%) reported participating in social media. Among departments, Internal Medicine had the lowest percentage of respondents reporting social media participation (45.8%), while Emergency Medicine had the highest percentage (82.7%). Respondents reporting recent telepsychiatry use were slightly more likely to participate in social media compared with nonusers (75.6%versus 69.1%).
Table 1: Respondent characteristics stratified by users and non-users.
The majority of respondents worked in small practices of two to five physicians (38.7%) or large practices of more than 20 physicians (31.0%). Most also reported working full-time in clinical care (54.9%), defined as spending at least 33 hours per week in direct patient care. Most respondents reported that specialists (51.4%), nurse practitioners (71.1%), physician assistants (62.7%),and behavior specialists, including social workers, psychologists, and psychiatrists (56.3%), were available at their primary practice location. Fewer reported the availability of pharmacists (45.1%), physical and occupational therapists (35.2%), and community care teams (34.5%). Compared with nonusers, users reported working with a greater variety of healthcare professionals, including specialist physicians (73% vs 42%), nurse practitioners (83% vs 66%), physician assistants (88% vs 52%), pharmacists (71% vs 34%), and physical and occupational therapists (59% vs 26%) at their primary practice location. Users were no more likely to have community care teams at their primary practice location than were nonusers (34.2% versus 34.0%).
Overall, 29.7% of respondents reported telepsychiatry use in the past 12 months. Use was most common among emergency physicians (62.0%), psychiatrists (61.5%), and respondents working full time in clinical care, defined as direct patient care for 30 or more hours weekly (30.3%). The median number of telepsychiatry patients for users was 6.5 (IQR 0-22.5). Comparing departments, emergency physicians reported using telepsychiatry to care for more patients than did psychiatrists, with a median of 10 patients (IQR 0-40) versus 0.5 (IQR 0-1.5), respectively.
Table 2: Respondent attitudes and beliefs stratified by users and non-users.
Of emergency physicians, 88.9% reported referring patients for telepsychiatry consultation in the last 12 months, though only 14.8% reported personally providing patient care via real-time video telepsychiatry. No pediatricians reported recent telepsychiatry use. In terms of motivation for using telepsychiatry, only 28.6% of psychiatrists reported using the technology because their colleagues started using it, and 33.3% of emergency physicians reported the same.
General Attitudes towards Telepsychiatry Use
Overall, most respondents agreed they would use telepsychiatry, if it were available, to care for their patients (78.3%) and to connect patients to other physicians (80.4%). Pediatricians and internists were the groups least likely to report they would use telepsychiatry to care for their own patients (18.5% and 17.4%, respectively). When asked if they would consider using telepsychiatry if reimbursed for these visits, more than half of nonusers agreed (57.9%), while approximately one quarter (28.4%) did not know. Though only 22.9% of users reported using telepsychiatry for initial visits, 41.1% of nonusers said they would consider using this technology for the same. Similarly, 16.9% of users reported using telepsychiatry for follow up care, and 71.6% of nonusers said they would consider doing the same.
Many respondents indicated lack of knowledge regarding the clinical benefits and potential drawbacks of telepsychiatry use, as reflected in Table 2. Thirty-two percent of all responses to questions regarding attitudes and beliefs about telepsychiatry were “I don’t know.” For instance, 79% of physicians answered “I don’t know” regarding adequacy of Medicare reimbursement and 54.4% for potential of malpractice lawsuits. Both users and nonusers felt that telepsychiatry improves both access to care (91.4% and 79.0%, respectively) and continuity of care (65.7% and 70.5%) for their patients. One-third of Emergency Medicine users reported they did not know whether telepsychiatry improves continuity of care. Most respondents also agreed that telepsychiatry reduces patient travel time to receive care (54.3% and 49.5%), though a large portion was unsure (37.1% and 39.0%).
Attitudes Regarding Telepsychiatry Versus In-Person Visits
While most physicians disagreed that “telepsychiatry is not an efficient use of my time” (68.1%), most felt that patients prefer to see their doctors in person (68%). Interestingly, users were slightly more likely than nonusers to report this perceived patient preference (71.4% versus 66.3%, respectively). Among psychiatrists and emergency physicians, this trend was more marked, with 73.5% of users agreeing patients prefer to see their doctor in person, versus 50.0% of nonusers. In contrast, a large portion of Emergency (36.4%) and Psychiatry (60.0%) nonusers were unsure.
The majority of respondents (64.5%) also felt that patients receive better quality of care in person. Users were more uncertain than nonusers (24% versus 16%), though more nonusers felt patients would not have better care in person (19.6%, as compared to 9.8% of users). Among departments, psychiatrists were the most likely to agree that patients likely receive better quality care in person (84.6%). Users were also markedly more likely to feel that additional research on the effectiveness of telepsychiatry is needed (88.6%, compared to 22.3% of nonusers).
Many physicians indicated lack of knowledge regarding telepsychiatry reimbursement and liability, as reflected in Table 2. With regard to potentially low reimbursement rates, the vast majority of respondents (79.0%) did not know whether the current Medicare rate is adequate to cover a telepsychiatry appointment. Of the remaining respondents, 83.3% of users felt reimbursement was inadequate, compared to 94.1% of nonusers. In terms of potential liability and malpractice, just over half (54.4%) of respondents did not know whether they would be more likely to be sued because they provide telepsychiatry. Most others did
Figure 1: Barriers to telepsychiatry use.
not feel they were more likely to be sued (37.0%), though two-thirds of those who felt they would be more likely to be sued were nonusers. Among specialties, psychiatrists were most likely to agree this is a likely possibility (37.8%).
Overall, respondents did not feel that equipment cost (69.7%), reimbursement (62.7%), or potential liability (63.4%) were barriers to telepsychiatry use, though 82.4% felt that barriers do exist at the Network. Compared to users, nonusers were more likely to be concerned about reimbursement (43.3% versus 26.8%) but not about equipment cost or potential liability. The most commonly reported barriers, presented in Figure 1, included perceived patient preference (67.7%), lack of training (50.7%), and current evidence base (40.8%). In addition, nearly onethird (31.4%) of users reported they do not like the loss of personal contact associated with using telepsychiatry, while 54.3% disagreed. Nonusers were split, with 41.1% reporting concern over loss of personal contact and 41.1% disagreeing. Among departments, psychiatrists were most concerned with loss of personal contact, as 71.4% reported this as an issue, while only 22.2% of emergency physicians agreed. In fact, emergency physicians were most likely to report that no barriers exist (32.7%).
Compared with recent data regarding physician reservations about telepsychiatry use [3, 14-16], Network physicians identified fewer concerns than expected. Current evidence shows that many physicians’ resistance to using telepsychiatry stems from concerns that physical and technological barriers may impede doctor-patient interaction and therapeutic rapport [14-15]. In this survey, less than one-third of telepsychiatry users reported disliking the loss of personal contact associated with using the technology. However, this was not true of all departments. Though only 22.2% of emergency physicians identified loss of personal contact as a concern, the majority of psychiatrists reported not liking this aspect of telepsychiatry. This finding suggests that physical proximity and therapeutic rapport may be valued differently among departments and by specialty Another possible explanation for this result is the survey’s ambiguity regarding the definition of “personal contact,” which may be interpreted as physical contact, proximity, or interpersonal connection. Further, respondents’ answers may have been influenced by their specific use of telepsychiatry as it currently exists in the Network. Emergency physicians are generally in the Emergency Department with telepsychiatry patients, while psychiatrists are usually in a remote location. Thus, emergency physicians may feel they have “personal contact” due to their physical proximity to patients, while psychiatrists may not. Additionally, this survey included many forms of telemedicine in its definition of telepsychiatry, including not only direct patient-to-provider contact but also provider-to-provider consults and “store and forward” technologies, which survey respondents may be less familiar with. Depending on the form of telemedicine, concerns over “personal contact” may vary, i.e. providers may have less of a concern about losing contact for provider-to-provider consults then they would about losing contact for direct patient-to-provider consults.
Research also suggests that provider inexperience with telepsychiatry is a major barrier to its use . Indeed, fear of this unfamiliar mode of healthcare delivery may impede Network physicians’ use of telepsychiatry, as approximately half of all respondents identified “lack of training” as a barrier. Even a large portion of current users reported concern over lack of training. These results suggest the need for formal training to allow providers to become comfortable with the technology before implementing telepsychiatry into their practices, as well as regular refreshers for providers as new interventions are offered.
Two additional barriers identified through this survey are perceived patient satisfaction and quality of care. Though both quantitative and qualitative data show high patient acceptance of telepsychiatry, many providers perceive patients to be less satisfied with this mode of mental healthcare delivery that has actually been reported by patients . An overwhelming 68% of this survey’s respondents agreed that “patients prefer to see their doctor in person.” Among psychiatrists and emergency physicians, this trend was even more marked, with 73.5% of users agreeing that patients prefer to see their doctor in person, versus 50.0% of nonusers. This finding is counterintuitive, not only because evidence indicates good patient satisfaction but also because physicians using telepsychiatry were more likely than nonusers to feel patients prefer to see them in person. In addition, most respondents felt patients also receive better quality of care in person despite strong evidence to the contrary [3, 15-16]. This finding highlights the need to educate Network physicians regarding the current evidence base for telepsychiatry, including its high patient satisfaction, high quality, and cost-effectiveness .
Additional areas warranting further physician education include potential malpractice liability and reimbursement for telepsychiatry. With regard to malpractice, just over half of respondents did not know whether they would be more likely to be sued by using telepsychiatry, and the vast majority did not know whether the current Medicare rate is adequate to cover a telepsychiatry appointment. Though little objective data exist with respect to malpractice risk associated with the provision of telehealth services, medical insurance experts suggest that the incidence of claims will remain low despite increasing participation in telemedicine . In fact, Jonathan Linkous, CEO of the American Telemedicine Association, said, “People have sued hospitals because they didn’t use telemedicine . . . The claim was that this is now the standard of care.” . In terms of reimbursement, progress is being made. Though Pennsylvania is not among the 34 states that have passed laws requiring private insurance companies to reimburse for telepsychiatry , it is among 48 states whose Medicaid programs pay for some (albeit limited) telepsychiatry services .
Due to the major knowledge gaps discussed here, physician awareness of telepsychiatry, its costs, and its benefits must be addressed within the Network to facilitate efficient rollout of new services. Appropriate means for increasing awareness include Grand Rounds presentations, faculty development sessions, resident didactics, and online courses. In the future, the same groups surveyed here should also be re-engaged to assess the efficacy of these educational strategies and to track whether attitudes shift a in a more favorable direction following the interventions. Larger-scale surveys would also be helpful, as this project’s small sample size limits the ability to draw conclusive findings representative of all Network providers who may interact with telepsychiatry, including newly acquired hospital employees, Advanced Practice Clinicians, and master level therapists who were not included in this survey’s target population. Additionally, surveying and comparing local patients’ attitudes towards telepsychiatry to those of providers would be helpful. Additional barriers should also be addressed in future surveys, as lack of time and low staff availability noted by some respondents in free-response questions may pose major challenges to the effective provision of telepsychiatry services in the Network. Ideally, results of future surveys could be used to gain support for reimbursement from payers if the surveys can show adequate levels of provider and patient support for this modality.
Though Network physicians may consider telepsychiatry to be efficient in terms of clinical time, most reported that it is not better than traditional care in terms of quality and patient satisfaction. These beliefs contradict current evidence supporting this mode of psychiatric care, highlighting a lack of general knowledge regarding telepsychiatry, including its benefits to patients and providers, reimbursement, evidence base, and potential liability. This knowledge gap should be addressed for both current users and nonusers prior to implementing new telepsychiatry services in the Network, and additional surveys should be distributed to further grow Network awareness of provider attitudes toward this technology.
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