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Barriers to Use of Telepsychiatry: Clinicians as Gatekeepers

      Abstract

      Telepsychiatry is effective and has generated hope and promise for improved access and enhanced quality of care with reasonable cost containment. Clinicians and organizations are informed about clinical, technological, and administrative telepsychiatric barriers via guidelines, but there are many practical patient and clinician factors that have slowed implementation and undermined sustainability. Literature describing barriers to use of telepsychiatry was reviewed. PubMed search terms with date limits from January 1, 1959, to April 25, 2019, included telepsychiatry, telemedicine, telemental health, videoconferencing, video based, Internet, synchronous, real-time, two-way, limitations, restrictions, barriers, obstacles, challenges, issues, implementation, utilization, adoption, perspectives, perceptions, attitudes, beliefs, willingness, acceptability, feasibility, culture/cultural, outcomes, satisfaction, quality, effectiveness, and efficacy. Articles were selected for inclusion on the basis of relevance. Barriers are described from both patient and clinicians' perspectives. Patients and clinicians are largely satisfied with telepsychiatry, but concerns about establishing rapport, privacy, safety, and technology limitations have slowed acceptance of telepsychiatry. Clinicians are also concerned about reimbursement/financial, legal/regulatory, licensure/credentialing, and education/learning issues. These issues point to system and policy concerns, which, in combination with other administrative concerns, raise questions about system design/workflow, efficiency of clinical care, and changing organizational culture. Although telepsychiatry service is convenient for patients, the many barriers from clinicians’ perspectives are concerning, because they serve as gatekeepers for implementation and sustainability of telepsychiatry services. This suggests that solutions to overcome barriers must start by addressing the concerns of clinicians and enhancing clinical workflow.
      Article Highlights
      • Although telemedicine care has substantially increased in the past decade, telepsychiatry expansion has been hampered by multiple barriers, resulting in slower than expected growth and uneven distribution of services. Telepsychiatry may now be at a tipping point and is poised to be widely used.
      • Many more barriers to telepsychiatry practice were identified from clinicians' or health care organizations' points of view rather than from patients’ perspectives. Although many concerns are shared by patients and clinicians, usually a reluctant clinician rather than the patient hampers acceptance of telepsychiatry.
      • Telepsychiatry is an effective way to improve access, enhance quality, and provide efficient care. Clinicians’ concerns reflect a need for better system workflow integration, policy change, and shifts in organizational culture if telepsychiatry’s full potential is to be realized.
      Lack of access to psychiatry is a well-documented problem.
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      The state and sustainability of telepsychiatry programs.
      Telepsychiatry (ie, 2-way video) provides access to psychiatric care, enhanced quality of care, and reduced health care costs.
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      Managing psychiatrist-patient relationships in the digital age: a summary review of the impact of technology-enabled care on clinical processes and rapport.
      An increasing body of literature reports effectiveness and outcomes equivalent to in-person care across a broad range of mental health disorders and patient populations.
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      Institutionally based videoconferencing.
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      The effectiveness of telemental health: a 2013 review.
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      • Yellowlees P.M.
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      In some situations (such as working with children and teens), telepsychiatry may even be preferable to in-person care.
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      Utilization of telemedicine among rural Medicare beneficiaries.
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      Current directions in videoconferencing tele-mental health research.
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      The psychiatrist-patient relationship of the future: anytime, anywhere?.
      Despite many studies reporting positive clinician and patient satisfaction with telepsychiatry,
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      Telepsychiatry today.
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      • Boydell K.M.
      • Volpe T.
      Pediatric telepsychiatry in ontario: caregiver and service provider perspectives.
      • Richardson L.K.
      • Frueh B.C.
      • Grubaugh A.L.
      • Egede L.
      • Elhai J.D.
      Current directions in videoconferencing tele-mental health research.
      • Simpson S.G.
      • Bell L.
      • Knox J.
      • Mitchell D.
      Therapy via videoconferencing: a route to client empowerment?.
      • Hilty D.M.
      • Nesbitt T.S.
      • Kuenneth C.A.
      • Cruz G.M.
      • Hales R.E.
      Rural versus suburban primary care needs, utilization, and satisfaction with telepsychiatric consultation.
      implementation has not been rapid, easy, or widespread.
      Practice guidelines for videoconferencing-based telemental health.
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      • Nelson E.L.
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      American Telemedicine Association Practice guidelines for telemental health with children and adolescents.
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      In 2009, only about 2% of psychiatrists had used telepsychiatry in the United States.
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      • Nafiz N.
      The psychiatrist-patient relationship of the future: anytime, anywhere?.
      Although the numbers of Medicare telemedicine visits have been increasing, less than 1% of rural Medicare beneficiaries received a telemedicine visit as of 2016.
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      • Jena A.B.
      • Busch A.B.
      • Souza J.
      • Uscher-Pines L.
      • Landon B.E.
      Utilization of telemedicine among rural Medicare beneficiaries.
      A recent article examining a large commercially insured population concluded that although telemedicine care substantially increased from 2005 to 2017, use was still uncommon by 2017.
      • Barnett M.L.
      • Ray K.N.
      • Souza J.
      • Mehrotra A.
      Trends in telemedicine use in a large commercially insured population, 2005-2017.
      In addition, in 2014, only 100 clinicians accounted for more than half of all telemental health visits that year,
      • Mehrotra A.
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      • Souza J.
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      Rapid growth in mental health telemedicine use among rural medicare beneficiaries, wide variation across states.
      suggesting that telepsychiatry practice has been undertaken by a select few clinicians and/or private companies
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      • Mackert M.S.
      Addressing telehealth’s foremost barrier: provider as initial gatekeeper.
      with dramatically uneven distribution across states.
      • Mehrotra A.
      • Huskamp H.A.
      • Souza J.
      • et al.
      Rapid growth in mental health telemedicine use among rural medicare beneficiaries, wide variation across states.
      Despite its slow start, telepsychiatry may now be at a tipping point and is poised to be widely used.
      • Hilty D.
      • Yellowlees P.M.
      • Parrish M.B.
      • Chan S.
      Telepsychiatry: effective, evidence-based, and at a tipping point in health care delivery?.
      We reviewed the telepsychiatry literature to identify barriers to the implementation and use of telepsychiatry. The American Telemedicine Association practice guidelines outline important clinical, technological, and administrative barriers.
      Practice guidelines for videoconferencing-based telemental health.
      • Myers K.
      • Nelson E.L.
      • Rabinowitz T.
      • et al.
      American Telemedicine Association Practice guidelines for telemental health with children and adolescents.
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      Standards and guidelines in telemedicine and telehealth.
      In addition, there are many practical patient and clinician factors that have slowed implementation and undermined sustainability. Indeed, patient-centered health care, in which patients are drivers, not just participants, suggests that barriers need to be described from their perspective and the perspectives of clinicians who are directly helping them.
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      PubMed search terms with date limits from January 1, 1959, to April 25, 2019, included telepsychiatry, telemedicine, telemental health, videoconferencing, video based, Internet, synchronous, real-time, two-way, limitations, restrictions, barriers, obstacles, challenges, issues, implementation, utilization, adoption, perspectives, perceptions, attitudes, beliefs, willingness, acceptability, feasibility, culture/cultural, outcomes, satisfaction, quality, effectiveness, and efficacy. Articles were selected for inclusion on the basis of relevance. This review comprehensively describes barriers that have impeded telepsychiatry’s expansion, with an eye toward solutions to these challenges.

      Shared Concerns About Satisfaction/Alliance/Rapport/Comfort

      For patients, telepsychiatry improves access to care, reduces wait times for appointments, and reduces travel time and costs.
      • Richardson L.K.
      • Frueh B.C.
      • Grubaugh A.L.
      • Egede L.
      • Elhai J.D.
      Current directions in videoconferencing tele-mental health research.
      • Simpson S.G.
      • Bell L.
      • Knox J.
      • Mitchell D.
      Therapy via videoconferencing: a route to client empowerment?.
      • Hilty D.M.
      • Nesbitt T.S.
      • Kuenneth C.A.
      • Cruz G.M.
      • Hales R.E.
      Rural versus suburban primary care needs, utilization, and satisfaction with telepsychiatric consultation.
      • Smith A.C.
      Telemedicine: challenges and opportunities.
      For example, a recent US Department of Veterans Affairs study reported that telemedicine saves patients an average of 145 miles and 142 minutes per visit.
      • Russo J.E.
      • McCool R.R.
      • Davies L.
      VA telemedicine: an analysis of cost and time savings.
      These benefits seem to largely outweigh reservations patients may have, as numerous studies cite high willingness to use this mode of care and high ratings of patient satisfaction with the care they receive via telepsychiatry.
      • Hilty D.M.
      • Ferrer D.C.
      • Parish M.B.
      • Johnston B.
      • Callahan E.J.
      • Yellowlees P.M.
      The effectiveness of telemental health: a 2013 review.
      • Chan S.
      • Parish M.
      • Yellowlees P.
      Telepsychiatry today.
      • Greenberg N.
      • Boydell K.M.
      • Volpe T.
      Pediatric telepsychiatry in ontario: caregiver and service provider perspectives.
      • Richardson L.K.
      • Frueh B.C.
      • Grubaugh A.L.
      • Egede L.
      • Elhai J.D.
      Current directions in videoconferencing tele-mental health research.
      • Simpson S.G.
      • Bell L.
      • Knox J.
      • Mitchell D.
      Therapy via videoconferencing: a route to client empowerment?.
      • Hilty D.M.
      • Nesbitt T.S.
      • Kuenneth C.A.
      • Cruz G.M.
      • Hales R.E.
      Rural versus suburban primary care needs, utilization, and satisfaction with telepsychiatric consultation.
      • Whitten P.S.
      • Mackert M.S.
      Addressing telehealth’s foremost barrier: provider as initial gatekeeper.
      • Saeed S.A.
      • Bloch R.M.
      • Diamond J.M.
      Telepsychiatry: overcoming barriers to implementation.
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      Limitations of patient satisfaction studies in telehealthcare: a systematic review of the literature.
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      Telehealth and patient satisfaction: a systematic review and narrative analysis.
      To some extent, acceptability of telepsychiatry to patients may be mediated by cost and distance.
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      Limitations of patient satisfaction studies in telehealthcare: a systematic review of the literature.
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      Usefulness of telepsychiatry: a critical evaluation of videoconferencing-based approaches.
      Satisfaction is higher if the alternative is no care or higher cost, with more travel time for in-person care.
      • Hilty D.M.
      • Nesbitt T.S.
      • Kuenneth C.A.
      • Cruz G.M.
      • Hales R.E.
      Rural versus suburban primary care needs, utilization, and satisfaction with telepsychiatric consultation.
      • Hilty D.M.
      • Marks S.L.
      • Urness D.
      • Yellowlees P.M.
      • Nesbitt T.S.
      Clinical and educational telepsychiatry applications: a review.
      Despite access and potentially saving money, they may remain skeptical of telemedicine’s efficacy and quality.
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      Public knowledge, perception, and expressed choice of telemedicine in rural West Virginia.
      Even in resource scarce areas, some patients still voice a preference for in-person encounters.
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      Conversations on telemental health: listening to remote and rural First Nations communities.
      • Shore J.H.
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      Telepsychiatry with rural American Indians: issues in civil commitments.
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      A multi-phase telepsychiatry programme in Michigan: organizational factors affecting utilization and user perceptions.
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      Interest in use of technology for healthcare among veterans receiving treatment for mental health.
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      The diffusion of telehealth in rural American Indian communities: a retrospective survey of key stakeholders.
      Negative perceptions and expectations should not be ignored, as they may predict actual use and satisfaction.
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      Mental health professionals’ perspectives of telemental health with remote and rural First Nations communities.
      Patients generally report increasing comfort and satisfaction once they have used telepsychiatry
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      • Diamond J.M.
      Telepsychiatry: overcoming barriers to implementation.
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      • Stephan S.H.
      Providers’ perspectives: utilizing telepsychiatry in schools.
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      Assessment of the therapeutic alliance in face-to-face or videoconference treatment for posttraumatic stress disorder.
      after initial apprehension, discomfort, and fear.
      • Myers K.
      • Nelson E.L.
      • Rabinowitz T.
      • et al.
      American Telemedicine Association Practice guidelines for telemental health with children and adolescents.
      • Whitten P.S.
      • Mackert M.S.
      Addressing telehealth’s foremost barrier: provider as initial gatekeeper.
      • Williams T.L.
      • May C.R.
      • Esmail A.
      Limitations of patient satisfaction studies in telehealthcare: a systematic review of the literature.
      • Hilty D.M.
      • Marks S.L.
      • Urness D.
      • Yellowlees P.M.
      • Nesbitt T.S.
      Clinical and educational telepsychiatry applications: a review.
      • Brick J.E.
      • Bashshur R.L.
      • Brick J.F.
      • D’Alessandri R.M.
      Public knowledge, perception, and expressed choice of telemedicine in rural West Virginia.
      • Gibson K.L.
      • Coulson H.
      • Miles R.
      • Kakekakekung C.
      • Daniels E.
      • O’Donnell S.
      Conversations on telemental health: listening to remote and rural First Nations communities.
      • Whitten P.
      • Kuwahara E.
      A multi-phase telepsychiatry programme in Michigan: organizational factors affecting utilization and user perceptions.
      • Miller C.J.
      • McInnes D.K.
      • Stolzmann K.
      • Bauer M.S.
      Interest in use of technology for healthcare among veterans receiving treatment for mental health.
      • Gibson K.
      • O’Donnell S.
      • Coulson H.
      • Kakepetum-Schultz T.
      Mental health professionals’ perspectives of telemental health with remote and rural First Nations communities.
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      Psychological impact of a remote psychometric consultation with hospitalized elderly people.
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      • et al.
      Telehealth outcomes: a synthesis of the literature and recommendations for outcome indicators.
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      Parental attitudes to a telehealth parent coaching intervention for autism spectrum disorder.
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      • Grigsby J.
      • Manson S.M.
      Acceptability of telepsychiatry in American Indians.
      Clinicians, who often come to the profession because they desire contact with patients, may share these concerns.
      • Whitten P.S.
      • Mackert M.S.
      Addressing telehealth’s foremost barrier: provider as initial gatekeeper.
      • Gibson K.
      • O’Donnell S.
      • Coulson H.
      • Kakepetum-Schultz T.
      Mental health professionals’ perspectives of telemental health with remote and rural First Nations communities.
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      • Atkinson T.
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      • Esmail A.
      Resisting and promoting new technologies in clinical practice: the case of telepsychiatry.
      Like patients, clinicians also report improved attitudes toward telepsychiatry after trying it, suggesting that increased exposure for clinicians may be important to alleviate their concerns about rapport.
      • Whitten P.
      • Kuwahara E.
      A multi-phase telepsychiatry programme in Michigan: organizational factors affecting utilization and user perceptions.
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      The evolution and history of telepsychiatry and its impact on psychiatric care: current implications for psychiatrists and psychiatric organizations.
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      Child and adolescent telepsychiatry: variations in utilization, referral patterns and practice trends.
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      Attracting child psychiatrists to a televideo consultation service: the telelink experience.
      Where organization level barriers have been eliminated, the most frequent barrier was a view that telepsychiatry was less personal and that it was more difficult to establish rapport.
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      Psychiatrists’ satisfaction with telepsychiatry.
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      Telepsychiatry: videoconferencing in the delivery of psychiatric care.
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      • Anderson H.
      • et al.
      Characteristics of telemental health service use by American Indian veterans.
      Both users and particularly nonusers of telemedicine reported disliking the loss of personal patient contact.
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      • et al.
      Specialist physicians’ knowledge and beliefs about telemedicine: a comparison of users and nonusers of the technology.
      Decreased ability to detect nonverbal cues during videoconferencing may limit rapport building,
      • Hilty D.M.
      • Marks S.L.
      • Urness D.
      • Yellowlees P.M.
      • Nesbitt T.S.
      Clinical and educational telepsychiatry applications: a review.
      • McLaren P.
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      An evaluation of the use of interactive television in an acute psychiatric service.
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      The Social Psychology of Telecommunications.
      with clinicians noting difficulty picking up nuances and emotions.
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      • Ellis N.
      • Mair F.
      • Esmail A.
      Resisting and promoting new technologies in clinical practice: the case of telepsychiatry.
      • Wagnild G.
      • Leenknecht C.
      • Zauher J.
      Psychiatrists’ satisfaction with telepsychiatry.
      Some clinicians may feel and look stiff or uncomfortable or have difficulty engaging patients.
      • Cunningham D.L.
      • Connors E.H.
      • Lever N.
      • Stephan S.H.
      Providers’ perspectives: utilizing telepsychiatry in schools.
      • May C.
      • Gask L.
      • Atkinson T.
      • Ellis N.
      • Mair F.
      • Esmail A.
      Resisting and promoting new technologies in clinical practice: the case of telepsychiatry.
      They have reported discomfort due to focus on staying in view and that fear of making the screen jerky impeded note taking.
      • Wagnild G.
      • Leenknecht C.
      • Zauher J.
      Psychiatrists’ satisfaction with telepsychiatry.
      • Maheu M.M.
      • Drude K.P.
      • Hertlein K.M.
      • Lipschutz R.
      • Wall K.
      • Hilty D.M.
      Correction to: an interprofessional framework for telebehavioral health competencies.
      Eye contact can also feel artificial across technology.
      • May C.
      • Gask L.
      • Atkinson T.
      • Ellis N.
      • Mair F.
      • Esmail A.
      Resisting and promoting new technologies in clinical practice: the case of telepsychiatry.
      Clinicians have also expressed discomfort in being unable to take physical steps to reassure or comfort. Gestures such as handing tissues to a tearful patient, moving a chair closer in support, or walking someone in and out may carry emotional significance.
      • May C.
      • Gask L.
      • Atkinson T.
      • Ellis N.
      • Mair F.
      • Esmail A.
      Resisting and promoting new technologies in clinical practice: the case of telepsychiatry.
      Specific educational core competencies have been suggested to teach telepsychiatry clinicians how to facilitate the therapeutic relationship by adjusting clinical interview skills, attending to rooms and furnishings, and preventing distractions.
      • Maheu M.M.
      • Drude K.P.
      • Hertlein K.M.
      • Lipschutz R.
      • Wall K.
      • Hilty D.M.
      Correction to: an interprofessional framework for telebehavioral health competencies.
      In one highly experienced center, they note that rapport was quickly established by exhibiting use of the equipment and allowing youth and their parents to become familiar with screen controls.
      • Myers K.M.
      • Vander Stoep A.
      • McCarty C.A.
      • et al.
      Child and adolescent telepsychiatry: variations in utilization, referral patterns and practice trends.
      Clinicians reported lower therapeutic alliance in telemental health conditions when randomly assigned to evaluate in-person or videoconference therapy sessions
      • Rees C.
      • Stone S.
      Therapeutic alliance in face-to-face versus videoconferenced psychotherapy.
      and remain hesitant to use video conference therapy sessions because they believed that the therapeutic alliance was at risk.
      • Germain V.
      • Marchand A.
      • Bouchard S.
      • Guay S.
      • Drouin M.S.
      Assessment of the therapeutic alliance in face-to-face or videoconference treatment for posttraumatic stress disorder.
      • Rees C.
      • Stone S.
      Therapeutic alliance in face-to-face versus videoconferenced psychotherapy.
      They are understandably concerned about the quality of therapeutic relationships and ability to establish rapport,
      • Parish M.B.
      • Fazio S.
      • Chan S.
      • Yellowlees P.M.
      Managing psychiatrist-patient relationships in the digital age: a summary review of the impact of technology-enabled care on clinical processes and rapport.
      • Whitten P.S.
      • Mackert M.S.
      Addressing telehealth’s foremost barrier: provider as initial gatekeeper.
      • Gibson K.
      • O’Donnell S.
      • Coulson H.
      • Kakepetum-Schultz T.
      Mental health professionals’ perspectives of telemental health with remote and rural First Nations communities.
      • May C.
      • Gask L.
      • Atkinson T.
      • Ellis N.
      • Mair F.
      • Esmail A.
      Resisting and promoting new technologies in clinical practice: the case of telepsychiatry.
      • Brooks E.
      • Turvey C.
      • Augusterfer E.F.
      Provider barriers to telemental health: obstacles overcome, obstacles remaining.
      • Horvath A.O.
      • Del Re A.C.
      • Flückiger C.
      • Symonds D.
      Alliance in individual psychotherapy.
      given that psychotherapy outcome research has found therapeutic alliance to account for nearly 30% of the variance in treatment outcomes independent of moderating factors.
      • Parish M.B.
      • Fazio S.
      • Chan S.
      • Yellowlees P.M.
      Managing psychiatrist-patient relationships in the digital age: a summary review of the impact of technology-enabled care on clinical processes and rapport.
      • Wagnild G.
      • Leenknecht C.
      • Zauher J.
      Psychiatrists’ satisfaction with telepsychiatry.
      • Horvath A.O.
      • Del Re A.C.
      • Flückiger C.
      • Symonds D.
      Alliance in individual psychotherapy.
      Accordingly, clinicians may fear if rapport suffers, positive clinical outcomes will not be forthcoming.
      • Brooks E.
      • Turvey C.
      • Augusterfer E.F.
      Provider barriers to telemental health: obstacles overcome, obstacles remaining.
      • Olden M.
      • Cukor J.
      • Rizzo A.S.
      • Rothbaum B.
      • Difede J.
      House calls revisited: leveraging technology to overcome obstacles to veteran psychiatric care and improve treatment outcomes.
      In addition to their own feelings about telepsychiatry, clinicians worry that patients will feel self-conscious, uncomfortable, or unsatisfied with videoconference encounters.
      • May C.
      • Gask L.
      • Atkinson T.
      • Ellis N.
      • Mair F.
      • Esmail A.
      Resisting and promoting new technologies in clinical practice: the case of telepsychiatry.
      • Wagnild G.
      • Leenknecht C.
      • Zauher J.
      Psychiatrists’ satisfaction with telepsychiatry.
      They have expressed concerns about some patients or circumstances being inappropriate for telepsychiatry, including the elderly, patients experiencing psychotic symptoms or who are in crisis, patients with hearing or vision impairment, or patients with cognitive impairments.
      • Richardson L.K.
      • Frueh B.C.
      • Grubaugh A.L.
      • Egede L.
      • Elhai J.D.
      Current directions in videoconferencing tele-mental health research.
      • Myers K.
      • Nelson E.L.
      • Rabinowitz T.
      • et al.
      American Telemedicine Association Practice guidelines for telemental health with children and adolescents.
      • Whitten P.S.
      • Mackert M.S.
      Addressing telehealth’s foremost barrier: provider as initial gatekeeper.
      • Gibson K.L.
      • Coulson H.
      • Miles R.
      • Kakekakekung C.
      • Daniels E.
      • O’Donnell S.
      Conversations on telemental health: listening to remote and rural First Nations communities.
      • Whitten P.
      • Kuwahara E.
      A multi-phase telepsychiatry programme in Michigan: organizational factors affecting utilization and user perceptions.
      • Gibson K.
      • O’Donnell S.
      • Coulson H.
      • Kakepetum-Schultz T.
      Mental health professionals’ perspectives of telemental health with remote and rural First Nations communities.
      • Montani C.
      • Billaud N.
      • Tyrrell J.
      • et al.
      Psychological impact of a remote psychometric consultation with hospitalized elderly people.
      • Bratton R.L.
      • Cody C.
      Telemedicine applications in primary care: a geriatric patient pilot project.
      • Salomone E.
      • Maurizio Arduino G.
      Parental attitudes to a telehealth parent coaching intervention for autism spectrum disorder.
      • Shore J.H.
      • Brooks E.
      • Savin D.
      • Orton H.
      • Grigsby J.
      • Manson S.M.
      Acceptability of telepsychiatry in American Indians.
      • Werner P.
      Willingness to use telemedicine for psychiatric care.
      • Rabinowitz T.
      • Murphy K.M.
      • Amour J.L.
      • Ricci M.A.
      • Caputo M.P.
      • Newhouse P.A.
      Benefits of a telepsychiatry consultation service for rural nursing home residents.
      Unfamiliarity with technology may also play a role in patients’ comfort and willingness to try telepsychiatry.
      • Richardson L.K.
      • Frueh B.C.
      • Grubaugh A.L.
      • Egede L.
      • Elhai J.D.
      Current directions in videoconferencing tele-mental health research.
      • Gibson K.L.
      • Coulson H.
      • Miles R.
      • Kakekakekung C.
      • Daniels E.
      • O’Donnell S.
      Conversations on telemental health: listening to remote and rural First Nations communities.
      • Salomone E.
      • Maurizio Arduino G.
      Parental attitudes to a telehealth parent coaching intervention for autism spectrum disorder.
      • Werner P.
      Willingness to use telemedicine for psychiatric care.
      • Alverson D.C.
      • Shannon S.
      • Sullivan E.
      • et al.
      Telehealth in the trenches: reporting back from the frontlines in rural America.
      • Shore J.H.
      • Savin D.M.
      • Novins D.
      • Manson S.M.
      Cultural aspects of telepsychiatry.
      • Jean S.
      • Sue F.
      From pilot to permanent service: ten years of paediatric telepsychiatry.
      • Morland L.A.
      • Poizner J.M.
      • Williams K.E.
      • Masino T.T.
      • Thorp S.R.
      Home-based clinical video teleconferencing care: clinical considerations and future directions.
      However, clinicians rate patients’ comfort and satisfaction with telepsychiatry encounters less highly than do patients
      • Shore J.H.
      • Brooks E.
      • Savin D.
      • Orton H.
      • Grigsby J.
      • Manson S.M.
      Acceptability of telepsychiatry in American Indians.
      and they rate patients’ levels of comfort as lower than their own.
      • Cunningham D.L.
      • Connors E.H.
      • Lever N.
      • Stephan S.H.
      Providers’ perspectives: utilizing telepsychiatry in schools.
      In one such study, patients assessed videoconference meetings as being more meaningful than therapists did, and patients evaluated the therapists more positively than the therapists did themselves. The overall results suggested that telepsychotherapy did not negatively affect the development of therapeutic alliance.
      • Germain V.
      • Marchand A.
      • Bouchard S.
      • Guay S.
      • Drouin M.S.
      Assessment of the therapeutic alliance in face-to-face or videoconference treatment for posttraumatic stress disorder.
      Although much has been written about difficulties establishing therapeutic relationships through videoconferencing, there may actually be some distinct advantages in building psychotherapeutic relationships in a “virtual space.” For instance, some patients actually report feeling more comfortable and are able to be more open and honest when discussing difficult subjects because of the “protection” or distance afforded by the virtual space of the session.
      • Kocsis B.J.
      • Yellowlees P.
      Telepsychotherapy and the therapeutic relationship: principles, advantages, and case examples.
      • Yellowlees P.
      • Shore J.H.
      Telepsychiatry and Health Technologies: A Guide For Mental Health Professionals.
      Clinicians, too, may feel safer evaluating patients with risk of aggression.
      • Yellowlees P.
      • Shore J.H.
      Telepsychiatry and Health Technologies: A Guide For Mental Health Professionals.
      As the vignette in Table 1 highlights, rapport can even be established under acute and challenging circumstances. Children, brought up in the era of the Internet, find telepsychiatry to be fairly natural
      • Chan S.
      • Parish M.
      • Yellowlees P.
      Telepsychiatry today.
      and perhaps even preferable.
      • Boydell K.M.
      • Hodgins M.
      • Pignatiello A.
      • Teshima J.
      • Edwards H.
      • Willis D.
      Using technology to deliver mental health services to children and youth: a scoping review.
      • Pakyurek M.
      • Yellowlees P.
      • Hilty D.
      The child and adolescent telepsychiatry consultation: can it be a more effective clinical process for certain patients than conventional practice?.
      Another unique advantage of telepsychiatry in terms of rapport building is the possibility for patients (especially immigrants, refugees, and asylum seekers) to receive care in their native language without the assistance of an interpreter.
      • Yellowlees P.
      • Shore J.H.
      Telepsychiatry and Health Technologies: A Guide For Mental Health Professionals.
      • Mucic D.
      International telepsychiatry: a study of patient acceptability.
      Exposure to these advantages may help mitigate clinician’s concerns, as successful therapeutic relationships have been established using telepsychiatry across multiple patient populations and psychiatric symptoms.
      • Kocsis B.J.
      • Yellowlees P.
      Telepsychotherapy and the therapeutic relationship: principles, advantages, and case examples.
      • Pakyurek M.
      • Yellowlees P.
      • Hilty D.
      The child and adolescent telepsychiatry consultation: can it be a more effective clinical process for certain patients than conventional practice?.
      • Myers K.
      Telepsychiatry: time to connect.
      • Fortney J.C.
      • Pyne J.M.
      • Kimbrell T.A.
      • et al.
      Telemedicine-based collaborative care for posttraumatic stress disorder: a randomized clinical trial [published correction appears in JAMA Psychiatry. 2015;72(1):96].
      • Grady B.J.
      • Melcer T.
      A retrospective evaluation of TeleMental Healthcare services for remote military populations.
      • Tuerk P.W.
      • Yoder M.
      • Ruggiero K.J.
      • Gros D.F.
      • Acierno R.
      A pilot study of prolonged exposure therapy for posttraumatic stress disorder delivered via telehealth technology.
      Table 1Establishing Rapport and Safety in an Acute Setting
      Case example: Telepsychiatry was provided to an inpatient hospital to cover for physician illness. A 43-year-old man with depression was hospitalized after a suicide attempt. At the beginning of the telepsychiatry encounter, he minimized events leading to hospitalization and became frustrated after learning he would not be discharged and abruptly left the room. He was able to calm down, returned to finish the evaluation, and was agreeable to treatment recommendations, including medication for depression. He worked with the telepsychiatrist daily. At discharge, he voiced a preference for telehealth rather than seeing on-site psychiatrists he had worked with before.
      Take home points: The patient was initially willing to participate, but abruptly left the first session and then returned. Despite the acuity of the situation and initial frustration, rapport was successfully established, and the patient reported being satisfied overall, even voicing preference for telehealth. The telepsychiatrist was able to successfully perform the suicide risk assessment, manage medications and treatment, and oversee discharge planning.

      Community/Cultural

      Telepsychiatry practice often involves challenging culture gaps
      • Myers K.
      • Nelson E.L.
      • Rabinowitz T.
      • et al.
      American Telemedicine Association Practice guidelines for telemental health with children and adolescents.
      American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Telepsychiatry and AACAP Committee on Quality Issues
      Clinical update: telepsychiatry with children and adolescents.
      and differences in values.
      • Myers K.
      • Nelson E.L.
      • Rabinowitz T.
      • et al.
      American Telemedicine Association Practice guidelines for telemental health with children and adolescents.
      • Gibson K.L.
      • Coulson H.
      • Miles R.
      • Kakekakekung C.
      • Daniels E.
      • O’Donnell S.
      Conversations on telemental health: listening to remote and rural First Nations communities.
      • Gibson K.
      • O’Donnell S.
      • Coulson H.
      • Kakepetum-Schultz T.
      Mental health professionals’ perspectives of telemental health with remote and rural First Nations communities.
      • Shore J.H.
      • Brooks E.
      • Savin D.
      • Orton H.
      • Grigsby J.
      • Manson S.M.
      Acceptability of telepsychiatry in American Indians.
      • Werner P.
      Willingness to use telemedicine for psychiatric care.
      • Morland L.A.
      • Poizner J.M.
      • Williams K.E.
      • Masino T.T.
      • Thorp S.R.
      Home-based clinical video teleconferencing care: clinical considerations and future directions.
      • Yellowlees P.
      • Shore J.H.
      Telepsychiatry and Health Technologies: A Guide For Mental Health Professionals.
      American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Telepsychiatry and AACAP Committee on Quality Issues
      Clinical update: telepsychiatry with children and adolescents.
      • Myers K.
      • Cain S.
      Work Group on Quality Issues; American Academy of Child and Adolescent Psychiatry Staff
      Practice parameter for telepsychiatry with children and adolescents.
      Psychiatrists from elsewhere may be unfamiliar with local resources and make recommendations for services that are scarce.
      • Boydell K.M.
      • Volpe T.
      • Kertes A.
      • Greenberg N.
      A review of the outcomes of the recommendations made during paediatric telepsychiatry consultations.
      Collaborating with local clinicians provides knowledge of local resources and culture,
      • Greenberg N.
      • Boydell K.M.
      • Volpe T.
      Pediatric telepsychiatry in ontario: caregiver and service provider perspectives.
      • Myers K.
      • Cain S.
      Work Group on Quality Issues; American Academy of Child and Adolescent Psychiatry Staff
      Practice parameter for telepsychiatry with children and adolescents.
      provides connection to the community,
      • Gibson K.L.
      • Coulson H.
      • Miles R.
      • Kakekakekung C.
      • Daniels E.
      • O’Donnell S.
      Conversations on telemental health: listening to remote and rural First Nations communities.
      • Shore J.H.
      • Bloom J.D.
      • Manson S.M.
      • Whitener R.J.
      Telepsychiatry with rural American Indians: issues in civil commitments.
      American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Telepsychiatry and AACAP Committee on Quality Issues
      Clinical update: telepsychiatry with children and adolescents.
      and may mitigate feelings of loss of control that local clinicians may feel from remote expert consultations.
      • Whitten P.S.
      • Mackert M.S.
      Addressing telehealth’s foremost barrier: provider as initial gatekeeper.
      • Volpe T.
      • Boydell K.M.
      • Pignatiello A.
      Attracting child psychiatrists to a televideo consultation service: the telelink experience.
      • Rogove H.J.
      • McArthur D.
      • Demaerschalk B.M.
      • Vespa P.M.
      Barriers to telemedicine: survey of current users in acute care units.
      • Dansky K.H.
      • Bowles K.H.
      Lessons learned from a telehomecare project.
      • Valenta A.L.
      • Wigger U.
      Early results of user profiles: physicians' opinions on the use of information technology.
      Connection with local clinicians also enhances feedback on the effectiveness of recommendations (the lack of which has been of concern to remote telepsychiatrists).
      • Volpe T.
      • Boydell K.M.
      • Pignatiello A.
      Attracting child psychiatrists to a televideo consultation service: the telelink experience.
      In addition, the investment of community stakeholders and the support of telepsychiatry champions have been cited as key to telepsychiatry program success and sustainability.
      • Myers K.M.
      • Vander Stoep A.
      • McCarty C.A.
      • et al.
      Child and adolescent telepsychiatry: variations in utilization, referral patterns and practice trends.

      Patient Privacy, Security, Boundaries, and Safety

      Clinicians and patients have concerns about protecting patient privacy when using telepsychiatry.
      • Parish M.B.
      • Fazio S.
      • Chan S.
      • Yellowlees P.M.
      Managing psychiatrist-patient relationships in the digital age: a summary review of the impact of technology-enabled care on clinical processes and rapport.
      • Greenberg N.
      • Boydell K.M.
      • Volpe T.
      Pediatric telepsychiatry in ontario: caregiver and service provider perspectives.
      • Richardson L.K.
      • Frueh B.C.
      • Grubaugh A.L.
      • Egede L.
      • Elhai J.D.
      Current directions in videoconferencing tele-mental health research.
      • Whitten P.S.
      • Mackert M.S.
      Addressing telehealth’s foremost barrier: provider as initial gatekeeper.
      • Gibson K.L.
      • Coulson H.
      • Miles R.
      • Kakekakekung C.
      • Daniels E.
      • O’Donnell S.
      Conversations on telemental health: listening to remote and rural First Nations communities.
      • Salomone E.
      • Maurizio Arduino G.
      Parental attitudes to a telehealth parent coaching intervention for autism spectrum disorder.
      • Wagnild G.
      • Leenknecht C.
      • Zauher J.
      Psychiatrists’ satisfaction with telepsychiatry.
      • Shore J.H.
      Telepsychiatry: videoconferencing in the delivery of psychiatric care.
      • Brooks E.
      • Turvey C.
      • Augusterfer E.F.
      Provider barriers to telemental health: obstacles overcome, obstacles remaining.
      • Morland L.A.
      • Poizner J.M.
      • Williams K.E.
      • Masino T.T.
      • Thorp S.R.
      Home-based clinical video teleconferencing care: clinical considerations and future directions.
      American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Telepsychiatry and AACAP Committee on Quality Issues
      Clinical update: telepsychiatry with children and adolescents.
      • Myers K.
      • Valentine J.
      • Morganthaler R.
      • Melzer S.
      Telepsychiatry with incarcerated youth.
      • Kumekawa J.K.
      Health information privacy protection: crisis or common sense?.
      • Brown N.A.
      State Medicaid and private payer reimbursement for telemedicine: an overview.
      • Sanders J.H.
      • Bashshur R.L.
      Challenges to the implementation of telemedicine.
      • Kramer G.M.
      • Kinn J.T.
      • Mishkind M.C.
      Legal, regulatory, and risk management issues in the use of technology to deliver mental health care.
      They worry about others accessing telepsychiatry sessions
      • Kumekawa J.K.
      Health information privacy protection: crisis or common sense?.
      or protected health information.
      • Saeed S.A.
      • Bloch R.M.
      • Diamond J.M.
      Telepsychiatry: overcoming barriers to implementation.
      Of particular concern are network security
      • Brooks E.
      • Turvey C.
      • Augusterfer E.F.
      Provider barriers to telemental health: obstacles overcome, obstacles remaining.
      and encryption,
      • Morland L.A.
      • Poizner J.M.
      • Williams K.E.
      • Masino T.T.
      • Thorp S.R.
      Home-based clinical video teleconferencing care: clinical considerations and future directions.
      and equipment situated outside the traditional clinical areas that could increase the risk of intercepting telemental health interactions, especially as teleconference technology becomes ever more mobile.
      • Richardson L.K.
      • Frueh B.C.
      • Grubaugh A.L.
      • Egede L.
      • Elhai J.D.
      Current directions in videoconferencing tele-mental health research.
      • Whitten P.S.
      • Mackert M.S.
      Addressing telehealth’s foremost barrier: provider as initial gatekeeper.
      • Saeed S.A.
      • Bloch R.M.
      • Diamond J.M.
      Telepsychiatry: overcoming barriers to implementation.
      American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Telepsychiatry and AACAP Committee on Quality Issues
      Clinical update: telepsychiatry with children and adolescents.
      • Myers K.
      • Valentine J.
      • Morganthaler R.
      • Melzer S.
      Telepsychiatry with incarcerated youth.
      • Kramer G.M.
      • Kinn J.T.
      • Mishkind M.C.
      Legal, regulatory, and risk management issues in the use of technology to deliver mental health care.
      Although technically possible to videoconference over mobile devices, lack of information security on these devices may not meet clinical standards.
      • Morland L.A.
      • Poizner J.M.
      • Williams K.E.
      • Masino T.T.
      • Thorp S.R.
      Home-based clinical video teleconferencing care: clinical considerations and future directions.
      Patients have attempted to create cell phone hotspots for connectivity and called in from restaurants, libraries, and their cars, creating obvious privacy and security problems.
      • Morland L.A.
      • Poizner J.M.
      • Williams K.E.
      • Masino T.T.
      • Thorp S.R.
      Home-based clinical video teleconferencing care: clinical considerations and future directions.
      There are, however, a growing number of Health Insurance Portability and Accountability Act of 1996–adherent technologies available for telepsychiatry.
      • Ostrowski J.
      Telemental Health Comparisons.
      Telepsychiatry clinicians need particular training in the use of approved technologies, privacy requirements, and potential liability issues related to the use of technology.
      • Kramer G.M.
      • Kinn J.T.
      • Mishkind M.C.
      Legal, regulatory, and risk management issues in the use of technology to deliver mental health care.
      Although telepsychiatry parallels in-person care in these requirements, the issues are even more important when social media, smartphone applications across mobile health platforms, or a range of other technologies are used.
      In addition, for in-home sessions, a quiet secluded space is essential, yet challenging to ensure in shared living environments.
      • Kocsis B.J.
      • Yellowlees P.
      Telepsychotherapy and the therapeutic relationship: principles, advantages, and case examples.
      American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Telepsychiatry and AACAP Committee on Quality Issues
      Clinical update: telepsychiatry with children and adolescents.
      Moreover, the home environment pushes limits of traditional therapeutic boundaries. Patients eager to share may introduce clinicians to partners and children and invite clinicians remotely into their living spaces in ways not possible from traditional office-based settings.
      American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Telepsychiatry and AACAP Committee on Quality Issues
      Clinical update: telepsychiatry with children and adolescents.
      Firm boundaries must be established from the outset, as patients have been noted to multitask during appointments by eating and preparing food, doing laundry, and smoking. It is also possible for the patient to literally “switch off” the therapist.
      • Yellowlees P.
      • Shore J.H.
      Telepsychiatry and Health Technologies: A Guide For Mental Health Professionals.
      American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Telepsychiatry and AACAP Committee on Quality Issues
      Clinical update: telepsychiatry with children and adolescents.
      • Cloutier P.
      • Cappelli M.
      • Glennie J.E.
      • Keresztes C.
      Mental health services for children and youth: a survey of physicians’ knowledge, attitudes and use of telehealth services.

      Safety

      Clinicians and patients have expressed concerns about securing safety for patients in crisis or faced with the threat of self-harm.
      • Greenberg N.
      • Boydell K.M.
      • Volpe T.
      Pediatric telepsychiatry in ontario: caregiver and service provider perspectives.
      • Myers K.
      • Nelson E.L.
      • Rabinowitz T.
      • et al.
      American Telemedicine Association Practice guidelines for telemental health with children and adolescents.
      • Gibson K.L.
      • Coulson H.
      • Miles R.
      • Kakekakekung C.
      • Daniels E.
      • O’Donnell S.
      Conversations on telemental health: listening to remote and rural First Nations communities.
      • Shore J.H.
      • Bloom J.D.
      • Manson S.M.
      • Whitener R.J.
      Telepsychiatry with rural American Indians: issues in civil commitments.
      • Gibson K.
      • O’Donnell S.
      • Coulson H.
      • Kakepetum-Schultz T.
      Mental health professionals’ perspectives of telemental health with remote and rural First Nations communities.
      • May C.
      • Gask L.
      • Atkinson T.
      • Ellis N.
      • Mair F.
      • Esmail A.
      Resisting and promoting new technologies in clinical practice: the case of telepsychiatry.
      • Serhal E.
      • Crawford A.
      • Cheng J.
      • Kurdyak P.
      Implementation and utilisation of telepsychiatry in ontario: a population-based study.
      • Shore J.H.
      Telepsychiatry: videoconferencing in the delivery of psychiatric care.
      American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Telepsychiatry and AACAP Committee on Quality Issues
      Clinical update: telepsychiatry with children and adolescents.
      • Myers K.
      • Cain S.
      Work Group on Quality Issues; American Academy of Child and Adolescent Psychiatry Staff
      Practice parameter for telepsychiatry with children and adolescents.
      • Boydell K.M.
      • Volpe T.
      • Kertes A.
      • Greenberg N.
      A review of the outcomes of the recommendations made during paediatric telepsychiatry consultations.
      • Rogove H.J.
      • McArthur D.
      • Demaerschalk B.M.
      • Vespa P.M.
      Barriers to telemedicine: survey of current users in acute care units.
      Patients have voiced desire for a physical presence during a time of crisis.
      • Gibson K.L.
      • Coulson H.
      • Miles R.
      • Kakekakekung C.
      • Daniels E.
      • O’Donnell S.
      Conversations on telemental health: listening to remote and rural First Nations communities.
      One consistent recommendation is to employ support staff where the patient is located who may intervene in case of an emergency.
      • Myers K.
      • Nelson E.L.
      • Rabinowitz T.
      • et al.
      American Telemedicine Association Practice guidelines for telemental health with children and adolescents.
      • Shore J.H.
      Telepsychiatry: videoconferencing in the delivery of psychiatric care.
      • Myers K.
      • Cain S.
      Work Group on Quality Issues; American Academy of Child and Adolescent Psychiatry Staff
      Practice parameter for telepsychiatry with children and adolescents.
      Given potential problems with the technology and network (lost connection), it is essential that clinicians know the patient’s location and have a local collaborator or secondary method for immediately contacting the patient or staff at the patient site.
      • Kramer G.M.
      • Kinn J.T.
      • Mishkind M.C.
      Legal, regulatory, and risk management issues in the use of technology to deliver mental health care.

      Technology Related

      A well-functioning telepsychiatry system is essential for success.
      • Wade V.A.
      • Eliott J.A.
      • Hiller J.E.
      Clinician acceptance is the key factor for sustainable telehealth services.
      Fortunately, as the technology advances rapidly, technical problems become less substantial.
      • Chan S.
      • Parish M.
      • Yellowlees P.
      Telepsychiatry today.
      • Yellowlees P.
      • Nafiz N.
      The psychiatrist-patient relationship of the future: anytime, anywhere?.
      • Shore J.
      The evolution and history of telepsychiatry and its impact on psychiatric care: current implications for psychiatrists and psychiatric organizations.
      • Deslich S.
      • Stec B.
      • Tomblin S.
      • Coustasse A.
      Telepsychiatry in the 21(st) century: transforming healthcare with technology.
      The same telepsychiatry interventions with better technologies may even improve the present results.
      • Deslich S.
      • Stec B.
      • Tomblin S.
      • Coustasse A.
      Telepsychiatry in the 21(st) century: transforming healthcare with technology.
      • García-Lizana F.
      • Muñoz-Mayorga I.
      What about telepsychiatry? A systematic review.
      Unfortunately, previous studies abound with examples of technical difficulties such as sessions unable to start, spontaneous disconnections, or poor audio/visual quality, and audio/visual lag.
      • Richardson L.K.
      • Frueh B.C.
      • Grubaugh A.L.
      • Egede L.
      • Elhai J.D.
      Current directions in videoconferencing tele-mental health research.
      • Gibson K.L.
      • Coulson H.
      • Miles R.
      • Kakekakekung C.
      • Daniels E.
      • O’Donnell S.
      Conversations on telemental health: listening to remote and rural First Nations communities.
      • Gibson K.
      • O’Donnell S.
      • Coulson H.
      • Kakepetum-Schultz T.
      Mental health professionals’ perspectives of telemental health with remote and rural First Nations communities.
      • Cunningham D.L.
      • Connors E.H.
      • Lever N.
      • Stephan S.H.
      Providers’ perspectives: utilizing telepsychiatry in schools.
      • Germain V.
      • Marchand A.
      • Bouchard S.
      • Guay S.
      • Drouin M.S.
      Assessment of the therapeutic alliance in face-to-face or videoconference treatment for posttraumatic stress disorder.
      • Salomone E.
      • Maurizio Arduino G.
      Parental attitudes to a telehealth parent coaching intervention for autism spectrum disorder.
      • Wagnild G.
      • Leenknecht C.
      • Zauher J.
      Psychiatrists’ satisfaction with telepsychiatry.
      • Barton P.L.
      • Brega A.G.
      • Devore P.A.
      • et al.
      Specialist physicians’ knowledge and beliefs about telemedicine: a comparison of users and nonusers of the technology.
      • Alverson D.C.
      • Shannon S.
      • Sullivan E.
      • et al.
      Telehealth in the trenches: reporting back from the frontlines in rural America.
      • Shore J.H.
      • Savin D.M.
      • Novins D.
      • Manson S.M.
      Cultural aspects of telepsychiatry.
      • Jean S.
      • Sue F.
      From pilot to permanent service: ten years of paediatric telepsychiatry.
      • Morland L.A.
      • Poizner J.M.
      • Williams K.E.
      • Masino T.T.
      • Thorp S.R.
      Home-based clinical video teleconferencing care: clinical considerations and future directions.
      • Cloutier P.
      • Cappelli M.
      • Glennie J.E.
      • Keresztes C.
      Mental health services for children and youth: a survey of physicians’ knowledge, attitudes and use of telehealth services.
      • Marchand A.
      • Beaulieu-Prévost D.
      • Guay S.
      • Bouchard S.
      • Drouin M.S.
      • Germain V.
      Relative efficacy of cognitive-behavioral therapy administered by videoconference for posttraumatic stress disorder: a six-month follow-up.
      • Luxton D.D.
      • Pruitt L.D.
      • O’Brien K.
      • Kramer G.
      An evaluation of the feasibility and safety of a home-based telemental health treatment for posttraumatic stress in the U.S. Military.
      • Detweiler M.B.
      • Arif S.
      • Candelario J.
      • et al.
      A telepsychiatry transition clinic: the first 12 months experience.
      When technology works poorly, technical support becomes an additional factor deserving consideration.
      • Whitten P.S.
      • Mackert M.S.
      Addressing telehealth’s foremost barrier: provider as initial gatekeeper.
      • Hilty D.
      • Yellowlees P.M.
      • Parrish M.B.
      • Chan S.
      Telepsychiatry: effective, evidence-based, and at a tipping point in health care delivery?.
      • Hilty D.M.
      • Marks S.L.
      • Urness D.
      • Yellowlees P.M.
      • Nesbitt T.S.
      Clinical and educational telepsychiatry applications: a review.
      • Wagnild G.
      • Leenknecht C.
      • Zauher J.
      Psychiatrists’ satisfaction with telepsychiatry.
      Adequate transmission speed (at least 384 kbps) and adequate bandwidth are needed to support ability to detect facial cues, and without lag that can result in a jerky video.
      • Wagnild G.
      • Leenknecht C.
      • Zauher J.
      Psychiatrists’ satisfaction with telepsychiatry.
      • Brooks E.
      • Turvey C.
      • Augusterfer E.F.
      Provider barriers to telemental health: obstacles overcome, obstacles remaining.
      • O’Malley C.
      • Langton S.
      • Anderson A.H.
      • Doherty-Sneddon G.
      • Bruce V.
      Comparison of face-to-face and video-mediated interaction.
      • Kim T.
      • Biocca F.
      Telepresence via television: two dimensions of telepresence may have different connections to memory and persuasion.
      Unfortunately, according to the US Federal Communications Commission’s broadband progress report in 2015, the United States is failing to keep pace in rural areas, which are often areas with targeted need for telepsychiatry.
      • Myers K.
      • Nelson E.L.
      • Rabinowitz T.
      • et al.
      American Telemedicine Association Practice guidelines for telemental health with children and adolescents.
      • Gibson K.L.
      • Coulson H.
      • Miles R.
      • Kakekakekung C.
      • Daniels E.
      • O’Donnell S.
      Conversations on telemental health: listening to remote and rural First Nations communities.
      • Gibson K.
      • O’Donnell S.
      • Coulson H.
      • Kakepetum-Schultz T.
      Mental health professionals’ perspectives of telemental health with remote and rural First Nations communities.
      • Morland L.A.
      • Poizner J.M.
      • Williams K.E.
      • Masino T.T.
      • Thorp S.R.
      Home-based clinical video teleconferencing care: clinical considerations and future directions.
      • Luxton D.D.
      • Pruitt L.D.
      • O’Brien K.
      • Kramer G.
      An evaluation of the feasibility and safety of a home-based telemental health treatment for posttraumatic stress in the U.S. Military.
      The US Federal Communications Commission’s Universal Service Fund has subsidies that can reduce the cost of bringing bandwidth to support telepsychiatry network connections. This resource is underutilized in part because of a cumbersome application and limitations on eligible facilities.
      • Saeed S.A.
      • Bloch R.M.
      • Diamond J.M.
      Telepsychiatry: overcoming barriers to implementation.
      • Puskin D.S.
      Telemedicine: follow the money modalities.
      Sound quality may affect psychiatrist satisfaction more than video quality. In fact, psychiatrists indicated that they would be willing to sacrifice video quality to have or maintain high-quality audio,
      • Elford R.
      • White H.
      • Bowering R.
      • Ghandi A.
      • Maddiggan B.
      • John K.S.
      A randomized, controlled trial of child psychiatric assessments conducted using videoconferencing.
      making prioritizing sensitive and well-placed microphones essential.
      • Myers K.
      • Nelson E.L.
      • Rabinowitz T.
      • et al.
      American Telemedicine Association Practice guidelines for telemental health with children and adolescents.
      • Wagnild G.
      • Leenknecht C.
      • Zauher J.
      Psychiatrists’ satisfaction with telepsychiatry.
      Although audio quality may be prioritized, poor visual transmission resulting in decreased ability to detect nonverbal cues remains concerning.
      • McLaren P.
      • Ball C.J.
      • Summerfield A.B.
      • Watson J.P.
      • Lipsedge M.
      An evaluation of the use of interactive television in an acute psychiatric service.
      Poor visual transmission may limit mutual connection and understanding
      • Short J.
      • Williams E.
      • Christie B.
      The Social Psychology of Telecommunications.
      and impair ability to detect physical examination findings
      • Parish M.B.
      • Fazio S.
      • Chan S.
      • Yellowlees P.M.
      Managing psychiatrist-patient relationships in the digital age: a summary review of the impact of technology-enabled care on clinical processes and rapport.
      • Myers K.
      • Nelson E.L.
      • Rabinowitz T.
      • et al.
      American Telemedicine Association Practice guidelines for telemental health with children and adolescents.
      • Whitten P.S.
      • Mackert M.S.
      Addressing telehealth’s foremost barrier: provider as initial gatekeeper.
      • Hilty D.M.
      • Marks S.L.
      • Urness D.
      • Yellowlees P.M.
      • Nesbitt T.S.
      Clinical and educational telepsychiatry applications: a review.
      • Miller C.J.
      • McInnes D.K.
      • Stolzmann K.
      • Bauer M.S.
      Interest in use of technology for healthcare among veterans receiving treatment for mental health.
      • Gibson K.
      • O’Donnell S.
      • Coulson H.
      • Kakepetum-Schultz T.
      Mental health professionals’ perspectives of telemental health with remote and rural First Nations communities.
      • Cunningham D.L.
      • Connors E.H.
      • Lever N.
      • Stephan S.H.
      Providers’ perspectives: utilizing telepsychiatry in schools.
      • Germain V.
      • Marchand A.
      • Bouchard S.
      • Guay S.
      • Drouin M.S.
      Assessment of the therapeutic alliance in face-to-face or videoconference treatment for posttraumatic stress disorder.
      • Shore J.H.
      • Brooks E.
      • Savin D.
      • Orton H.
      • Grigsby J.
      • Manson S.M.
      Acceptability of telepsychiatry in American Indians.
      • May C.
      • Gask L.
      • Atkinson T.
      • Ellis N.
      • Mair F.
      • Esmail A.
      Resisting and promoting new technologies in clinical practice: the case of telepsychiatry.
      • Wagnild G.
      • Leenknecht C.
      • Zauher J.
      Psychiatrists’ satisfaction with telepsychiatry.
      • Shore J.H.
      Telepsychiatry: videoconferencing in the delivery of psychiatric care.
      • Shore J.H.
      • Brooks E.
      • Anderson H.
      • et al.
      Characteristics of telemental health service use by American Indian veterans.
      • Barton P.L.
      • Brega A.G.
      • Devore P.A.
      • et al.
      Specialist physicians’ knowledge and beliefs about telemedicine: a comparison of users and nonusers of the technology.
      • McLaren P.
      • Ball C.J.
      • Summerfield A.B.
      • Watson J.P.
      • Lipsedge M.
      An evaluation of the use of interactive television in an acute psychiatric service.
      • Short J.
      • Williams E.
      • Christie B.
      The Social Psychology of Telecommunications.
      • Rees C.
      • Stone S.
      Therapeutic alliance in face-to-face versus videoconferenced psychotherapy.
      • Horvath A.O.
      • Del Re A.C.
      • Flückiger C.
      • Symonds D.
      Alliance in individual psychotherapy.
      • Olden M.
      • Cukor J.
      • Rizzo A.S.
      • Rothbaum B.
      • Difede J.
      House calls revisited: leveraging technology to overcome obstacles to veteran psychiatric care and improve treatment outcomes.
      • Rabinowitz T.
      • Murphy K.M.
      • Amour J.L.
      • Ricci M.A.
      • Caputo M.P.
      • Newhouse P.A.
      Benefits of a telepsychiatry consultation service for rural nursing home residents.
      • Brown N.A.
      State Medicaid and private payer reimbursement for telemedicine: an overview.
      • Greene C.J.
      • Morland L.A.
      • Macdonald A.
      • Frueh B.C.
      • Grubbs K.M.
      • Rosen C.S.
      How does tele-mental health affect group therapy process? Secondary analysis of a noninferiority trial.
      such as tics, tremors, and subtle facial expressions.
      • Wagnild G.
      • Leenknecht C.
      • Zauher J.
      Psychiatrists’ satisfaction with telepsychiatry.
      • Brooks E.
      • Turvey C.
      • Augusterfer E.F.
      Provider barriers to telemental health: obstacles overcome, obstacles remaining.
      In one survey, only about one-third of respondents felt they could conduct a thorough physical examination using telemedicine.
      • Barton P.L.
      • Brega A.G.
      • Devore P.A.
      • et al.
      Specialist physicians’ knowledge and beliefs about telemedicine: a comparison of users and nonusers of the technology.
      Local collaborators at the patient’s location may be able to supply on the ground observations and physical examination findings to mitigate lost data.
      • Myers K.
      • Nelson E.L.
      • Rabinowitz T.
      • et al.
      American Telemedicine Association Practice guidelines for telemental health with children and adolescents.
      • Shore J.H.
      Telepsychiatry: videoconferencing in the delivery of psychiatric care.
      • Myers K.
      • Cain S.
      Work Group on Quality Issues; American Academy of Child and Adolescent Psychiatry Staff
      Practice parameter for telepsychiatry with children and adolescents.
      • Kramer G.M.
      • Kinn J.T.
      • Mishkind M.C.
      Legal, regulatory, and risk management issues in the use of technology to deliver mental health care.

      Clinicians' Perspectives

      Many more barriers to telepsychiatry practice were identified from clinicians' or health care organizations' points of view rather than from patients’ perspectives. Although many concerns are shared by patients and clinicians, usually reluctant clinicians rather than patients slow acceptance of telepsychiatry.
      • Saeed S.A.
      • Bloch R.M.
      • Diamond J.M.
      Telepsychiatry: overcoming barriers to implementation.
      Reviewing the literature, a theme of “clinician as gatekeeper” to the use of telepsychiatry became clear. Physicians are highly influential in telepsychiatry,
      • Barnett M.L.
      • Ray K.N.
      • Souza J.
      • Mehrotra A.
      Trends in telemedicine use in a large commercially insured population, 2005-2017.
      and they decide about telemedicine use for more than 90% of patients.
      • Lauckner C.
      • Whitten P.
      The state and sustainability of telepsychiatry programs.
      • Whitten P.
      • Kuwahara E.
      A multi-phase telepsychiatry programme in Michigan: organizational factors affecting utilization and user perceptions.
      • Smith G.E.
      • Lunde A.M.
      • Hathaway J.C.
      • Vickers K.S.
      Telehealth home monitoring of solitary persons with mild dementia.
      This critical finding suggests that encouraging growth of telepsychiatry must start by first addressing clinician concerns,
      • Whitten P.
      • Kuwahara E.
      A multi-phase telepsychiatry programme in Michigan: organizational factors affecting utilization and user perceptions.
      which are further reviewed below (also see Table 2
      • Hilty D.M.
      • Evangelatos G.
      • Valasquez G.A.
      • Le C.
      • Sosa J.
      Telehealth for rural diverse populations: cultural and telebehavioral competencies and practical approaches for clinical services.
      • Vogt E.L.
      • Mahmoud H.
      • Elhaj O.
      Telepsychiatry: implications for psychiatrist burnout and well-being.
      ).
      Table 2Additional Factors Affecting Clinician Satisfaction With Telehealth
      • Hilty D.M.
      • Evangelatos G.
      • Valasquez G.A.
      • Le C.
      • Sosa J.
      Telehealth for rural diverse populations: cultural and telebehavioral competencies and practical approaches for clinical services.
      • Vogt E.L.
      • Mahmoud H.
      • Elhaj O.
      Telepsychiatry: implications for psychiatrist burnout and well-being.
      • Ratio of negatives and positives regarding the modality
      • Sense of efficacy as a clinician
      • Positive vs negative endorsement of patients’ experiences (ie, that patients like or dislike the telehealth modality)
      • Ease of physical transition between in-person and telehealth modes of care during workday
      • Degree of valuing telehealth encounters when interacting with patients
      • Aspects of in-person care missed in virtual encounters
      • Satisfaction with plan for handling clinical emergencies at a distance
      • Clinical and technical competency
      • Perceived value of improving care to remote site (eg, diagnosis, treatment, and/or disease management)
      • Wagnild G.
      • Leenknecht C.
      • Zauher J.
      Psychiatrists’ satisfaction with telepsychiatry.
      • Sense of isolation during workday
      • Hailey D.
      • Roine R.
      • Ohinmaa A.
      The effectiveness of telemental health applications: a review.
      • Reports of telehealth/technology burnout (eg, increased “screen time”)

      Limited Evidence-Based Information

      Although many recent studies and reviews have been published in the past 15 years, the evidence base for telepsychiatry has been considered inadequate by clinicians.
      • Hilty D.M.
      • Marks S.L.
      • Urness D.
      • Yellowlees P.M.
      • Nesbitt T.S.
      Clinical and educational telepsychiatry applications: a review.
      • Brooks E.
      • Turvey C.
      • Augusterfer E.F.
      Provider barriers to telemental health: obstacles overcome, obstacles remaining.
      • Baer L.
      • Elford D.R.
      • Cukor P.
      Telepsychiatry at forty: what have we learned?.
      • Hailey D.
      • Roine R.
      • Ohinmaa A.
      The effectiveness of telemental health applications: a review.
      Although research has rapidly increased, as recently as 2011, 78% of clinicians surveyed responded that more research on the effectiveness of telehealth was needed.
      • Brooks E.
      • Turvey C.
      • Augusterfer E.F.
      Provider barriers to telemental health: obstacles overcome, obstacles remaining.
      Research has been underfunded, such that projects are discontinued and findings go unpublished.
      • Lauckner C.
      • Whitten P.
      The state and sustainability of telepsychiatry programs.
      • Gibson K.
      • O’Donnell S.
      • Coulson H.
      • Kakepetum-Schultz T.
      Mental health professionals’ perspectives of telemental health with remote and rural First Nations communities.
      Ironically, poor research funding limits evidence to support telemedicine, the lack of which may be a reason organizations are reluctant to provide long-term funding for telemedicine.
      • Smith A.C.
      Telemedicine: challenges and opportunities.
      More high-quality research and data are desired
      • Hailey D.
      • Roine R.
      • Ohinmaa A.
      The effectiveness of telemental health applications: a review.
      about referring and consulting clinician satisfaction, the characteristics of the technology used, the cost (preferably through cost-benefit analyses), and longitudinal evaluation.
      • Hilty D.M.
      • Marks S.L.
      • Urness D.
      • Yellowlees P.M.
      • Nesbitt T.S.
      Clinical and educational telepsychiatry applications: a review.
      Satisfaction studies need to be more specific,
      • Hilty D.M.
      • Marks S.L.
      • Urness D.
      • Yellowlees P.M.
      • Nesbitt T.S.
      Clinical and educational telepsychiatry applications: a review.
      and further study is needed on therapeutic alliance and specific variables involved in videoconferencing that could affect the therapeutic relationship.
      • Germain V.
      • Marchand A.
      • Bouchard S.
      • Guay S.
      • Drouin M.S.
      Assessment of the therapeutic alliance in face-to-face or videoconference treatment for posttraumatic stress disorder.
      Research has provided few insights into how telemental health is being used in most real-world settings,
      • Mehrotra A.
      • Jena A.B.
      • Busch A.B.
      • Souza J.
      • Uscher-Pines L.
      • Landon B.E.
      Utilization of telemedicine among rural Medicare beneficiaries.
      • Mehrotra A.
      • Huskamp H.A.
      • Souza J.
      • et al.
      Rapid growth in mental health telemedicine use among rural medicare beneficiaries, wide variation across states.
      something the Congressional Budget Office has recently emphasized need for.
      • Mehrotra A.
      • Huskamp H.A.
      • Souza J.
      • et al.
      Rapid growth in mental health telemedicine use among rural medicare beneficiaries, wide variation across states.
      Congressional Budget Office
      Answers to Questions for the Record Following a Hearing on the 2015 Long-Term Budget Outlook Conducted by the Senate Committee on the Budget.
      In addition, the understanding of how technology affects patient-doctor relationships, practice, and clinical outcomes has not kept pace with the rapidly changing technologies.
      • Yellowlees P.
      • Nafiz N.
      The psychiatrist-patient relationship of the future: anytime, anywhere?.
      • Shore J.
      The evolution and history of telepsychiatry and its impact on psychiatric care: current implications for psychiatrists and psychiatric organizations.
      Additional studies to address these concerns would strengthen the literature and mitigate clinician skepticism.

      Limited Education for Clinicians/Learning Opportunities

      Limited education, clinical exposure, and hands-on learning in telepsychiatry are significant barriers to expanding use.
      • Chan S.
      • Parish M.
      • Yellowlees P.
      Telepsychiatry today.
      • Richardson L.K.
      • Frueh B.C.
      • Grubaugh A.L.
      • Egede L.
      • Elhai J.D.
      Current directions in videoconferencing tele-mental health research.
      • Whitten P.S.
      • Mackert M.S.
      Addressing telehealth’s foremost barrier: provider as initial gatekeeper.
      • Saeed S.A.
      • Bloch R.M.
      • Diamond J.M.
      Telepsychiatry: overcoming barriers to implementation.
      • Williams T.L.
      • May C.R.
      • Esmail A.
      Limitations of patient satisfaction studies in telehealthcare: a systematic review of the literature.
      • Hilty D.M.
      • Marks S.L.
      • Urness D.
      • Yellowlees P.M.
      • Nesbitt T.S.
      Clinical and educational telepsychiatry applications: a review.
      • Whitten P.
      • Kuwahara E.
      A multi-phase telepsychiatry programme in Michigan: organizational factors affecting utilization and user perceptions.
      • Gibson K.
      • O’Donnell S.
      • Coulson H.
      • Kakepetum-Schultz T.
      Mental health professionals’ perspectives of telemental health with remote and rural First Nations communities.
      • Germain V.
      • Marchand A.
      • Bouchard S.
      • Guay S.
      • Drouin M.S.
      Assessment of the therapeutic alliance in face-to-face or videoconference treatment for posttraumatic stress disorder.
      • Shore J.
      The evolution and history of telepsychiatry and its impact on psychiatric care: current implications for psychiatrists and psychiatric organizations.
      • Brooks E.
      • Turvey C.
      • Augusterfer E.F.
      Provider barriers to telemental health: obstacles overcome, obstacles remaining.
      • Cloutier P.
      • Cappelli M.
      • Glennie J.E.
      • Keresztes C.
      Mental health services for children and youth: a survey of physicians’ knowledge, attitudes and use of telehealth services.
      • Baer L.
      • Elford D.R.
      • Cukor P.
      Telepsychiatry at forty: what have we learned?.
      • Hailey D.
      • Roine R.
      • Ohinmaa A.
      The effectiveness of telemental health applications: a review.
      • Maieritsch K.P.
      • Smith T.L.
      • Hessinger J.D.
      • Ahearn E.P.
      • Eickhoff J.C.
      • Zhao Q.
      Randomized controlled equivalence trial comparing videoconference and in person delivery of cognitive processing therapy for PTSD.
      • Jameson J.P.
      • Farmer M.S.
      • Head K.J.
      • Fortney J.
      • Teal C.R.
      VA community mental health service providers’ utilization of and attitudes toward telemental health care: the gatekeeper’s perspective.
      • Karlinsky H.
      Psychiatry, technology, and the corn fields of Iowa.
      • Sunderji N.
      • Crawford A.
      • Jovanovic M.
      Telepsychiatry in graduate medical education: a narrative review.
      Telepsychiatry education in medical school and residency is minimal,
      • Chan S.
      • Parish M.
      • Yellowlees P.
      Telepsychiatry today.
      • Shore J.
      The evolution and history of telepsychiatry and its impact on psychiatric care: current implications for psychiatrists and psychiatric organizations.
      • Sunderji N.
      • Crawford A.
      • Jovanovic M.
      Telepsychiatry in graduate medical education: a narrative review.
      with only 21 of 183 US residency training programs offering any training or experience in telepsychiatry.
      • Yellowlees P.
      • Nafiz N.
      The psychiatrist-patient relationship of the future: anytime, anywhere?.
      The burden largely falls on individual psychiatrists to seek out the knowledge and experience required to become competent in telepsychiatry.
      • Shore J.
      The evolution and history of telepsychiatry and its impact on psychiatric care: current implications for psychiatrists and psychiatric organizations.
      Many telemental health clinicians have reported feeling inadequately trained,
      • Richardson L.K.
      • Frueh B.C.
      • Grubaugh A.L.
      • Egede L.
      • Elhai J.D.
      Current directions in videoconferencing tele-mental health research.
      • Brooks E.
      • Turvey C.
      • Augusterfer E.F.
      Provider barriers to telemental health: obstacles overcome, obstacles remaining.
      • Jameson J.P.
      • Farmer M.S.
      • Head K.J.
      • Fortney J.
      • Teal C.R.
      VA community mental health service providers’ utilization of and attitudes toward telemental health care: the gatekeeper’s perspective.
      which, in turn, may affect their use and may reduce their satisfaction.
      • Brooks E.
      • Turvey C.
      • Augusterfer E.F.
      Provider barriers to telemental health: obstacles overcome, obstacles remaining.
      Those who received training were likely to use telepsychiatry more often,
      • Gibson K.
      • O’Donnell S.
      • Coulson H.
      • Kakepetum-Schultz T.
      Mental health professionals’ perspectives of telemental health with remote and rural First Nations communities.
      and clinicians reported increased positive attitudes toward telemedicine after using it,
      • Whitten P.
      • Kuwahara E.
      A multi-phase telepsychiatry programme in Michigan: organizational factors affecting utilization and user perceptions.
      suggesting that education and training in telepsychiatry is an important strategy to increase use.
      • Shore J.
      The evolution and history of telepsychiatry and its impact on psychiatric care: current implications for psychiatrists and psychiatric organizations.
      • Myers K.M.
      • Vander Stoep A.
      • McCarty C.A.
      • et al.
      Child and adolescent telepsychiatry: variations in utilization, referral patterns and practice trends.
      • Serhal E.
      • Crawford A.
      • Cheng J.
      • Kurdyak P.
      Implementation and utilisation of telepsychiatry in ontario: a population-based study.
      • Volpe T.
      • Boydell K.M.
      • Pignatiello A.
      Attracting child psychiatrists to a televideo consultation service: the telelink experience.
      A leading expert has even recommended that training become a mandated requirement for telepsychiatry clinicians.
      • Shore J.
      The evolution and history of telepsychiatry and its impact on psychiatric care: current implications for psychiatrists and psychiatric organizations.
      Telehealth competencies have been developed in recent years, which align targeted clinical outcomes with teaching and supervisory methods, evaluation, and feedback. One article provides an overview of needed telepsychiatric competencies and also telebehavioral health competencies across mental health specialties.
      • Hilty D.M.
      • Crawford A.
      • Teshima J.
      • et al.
      A framework for telepsychiatric training and e-health: competency-based education, evaluation and implications.
      • Hilty D.M.
      • Maheu M.M.
      • Drude K.P.
      • et al.
      Telebehavioral health, telemental health, e-therapy and e-health competencies: the need for an interdisciplinary framework.
      Other guidelines have outlined clinical evaluation and care; administration; cultural competence and diversity; legal and regulatory issues; evidence-based and ethical practice; and mobile health, smartphone, and apps.
      • Maheu M.M.
      • Drude K.P.
      • Hertlein K.M.
      • Lipschutz R.
      • Wall K.
      • Hilty D.M.
      Correction to: an interprofessional framework for telebehavioral health competencies.
      • Hilty D.M.
      • Crawford A.
      • Teshima J.
      • et al.
      A framework for telepsychiatric training and e-health: competency-based education, evaluation and implications.
      The American Telemedicine Association now offers accreditation and webinars.
      • Chan S.
      • Parish M.
      • Yellowlees P.
      Telepsychiatry today.
      Training handbooks and book chapters
      • Vanderpool D.
      An overview of practicing high quality telepsychiatry.
      as well as online courses are also available to help train and educate interested clinicians.
      • Yellowlees P.
      • Shore J.H.
      Telepsychiatry and Health Technologies: A Guide For Mental Health Professionals.
      American Telemedicine Association Learning Center

      Reimbursement/Financial Viability

      Although improving over time, reimbursement and financial viability have been viewed as a barrier to telepsychiatry growth for more than the past decade.
      • Lauckner C.
      • Whitten P.
      The state and sustainability of telepsychiatry programs.
      • Chan S.
      • Parish M.
      • Yellowlees P.
      Telepsychiatry today.
      • Saeed S.A.
      • Bloch R.M.
      • Diamond J.M.
      Telepsychiatry: overcoming barriers to implementation.
      • Gibson K.
      • O’Donnell S.
      • Coulson H.
      • Kakepetum-Schultz T.
      Mental health professionals’ perspectives of telemental health with remote and rural First Nations communities.
      • Brooks E.
      • Turvey C.
      • Augusterfer E.F.
      Provider barriers to telemental health: obstacles overcome, obstacles remaining.
      • Morland L.A.
      • Poizner J.M.
      • Williams K.E.
      • Masino T.T.
      • Thorp S.R.
      Home-based clinical video teleconferencing care: clinical considerations and future directions.
      American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Telepsychiatry and AACAP Committee on Quality Issues
      Clinical update: telepsychiatry with children and adolescents.
      • Myers K.
      • Cain S.
      Work Group on Quality Issues; American Academy of Child and Adolescent Psychiatry Staff
      Practice parameter for telepsychiatry with children and adolescents.
      • Rogove H.J.
      • McArthur D.
      • Demaerschalk B.M.
      • Vespa P.M.
      Barriers to telemedicine: survey of current users in acute care units.
      • Brown N.A.
      State Medicaid and private payer reimbursement for telemedicine: an overview.
      • Sanders J.H.
      • Bashshur R.L.
      Challenges to the implementation of telemedicine.
      • Cloutier P.
      • Cappelli M.
      • Glennie J.E.
      • Keresztes C.
      Mental health services for children and youth: a survey of physicians’ knowledge, attitudes and use of telehealth services.
      • Antoniotti N.M.
      • Drude K.P.
      • Rowe N.
      Private payer telehealth reimbursement in the United States.
      • Bashshur R.L.
      • Shannon G.
      • Krupinski E.A.
      • Grigsby J.
      Sustaining and realizing the promise of telemedicine.
      • Grigsby B.
      • Brega A.G.
      • Bennett R.E.
      • et al.
      The slow pace of interactive video telemedicine adoption: the perspective of telemedicine program administrators on physician participation.
      • Meyer B.C.
      • Clarke C.A.
      • Troke T.M.
      • Friedman L.S.
      Essential telemedicine elements (tele-ments) for connecting the academic health center and remote community providers to enhance patient care.
      Telepsychiatry has been largely supported by federal, internal, or grant funding, with relatively few programs with long-term commercial sustainability.
      • Lauckner C.
      • Whitten P.
      The state and sustainability of telepsychiatry programs.
      • Chan S.
      • Parish M.
      • Yellowlees P.
      Telepsychiatry today.
      • Bashshur R.L.
      • Shannon G.
      • Krupinski E.A.
      • Grigsby J.
      Sustaining and realizing the promise of telemedicine.
      • Meyer B.C.
      • Clarke C.A.
      • Troke T.M.
      • Friedman L.S.
      Essential telemedicine elements (tele-ments) for connecting the academic health center and remote community providers to enhance patient care.
      In one survey, nearly half of respondents indicated they did not provide telemedicine services because of lack of payment.
      • Antoniotti N.M.
      • Drude K.P.
      • Rowe N.
      Private payer telehealth reimbursement in the United States.
      Billing clinicians reported lack of reimbursement and related problems including denials as well as previous authorization/case reviews required.
      • Barton P.L.
      • Brega A.G.
      • Devore P.A.
      • et al.
      Specialist physicians’ knowledge and beliefs about telemedicine: a comparison of users and nonusers of the technology.
      • Antoniotti N.M.
      • Drude K.P.
      • Rowe N.
      Private payer telehealth reimbursement in the United States.
      Medicare coverage only for rural areas (with limited exceptions) poses a barrier to expansion.
      • Mehrotra A.
      • Huskamp H.A.
      • Souza J.
      • et al.
      Rapid growth in mental health telemedicine use among rural medicare beneficiaries, wide variation across states.
      Furthermore, for clinicians starting out, videoconferencing/infrastructure costs may not be covered.
      • Saeed S.A.
      • Bloch R.M.
      • Diamond J.M.
      Telepsychiatry: overcoming barriers to implementation.
      • Myers K.
      • Cain S.
      Work Group on Quality Issues; American Academy of Child and Adolescent Psychiatry Staff
      Practice parameter for telepsychiatry with children and adolescents.
      • Glueck D.A.
      Telepsychiatry in private practice.
      Inconsistent reimbursement across payers for telepsychiatry services poses another barrier.
      • Saeed S.A.
      • Bloch R.M.
      • Diamond J.M.
      Telepsychiatry: overcoming barriers to implementation.
      • Brooks E.
      • Turvey C.
      • Augusterfer E.F.
      Provider barriers to telemental health: obstacles overcome, obstacles remaining.
      • Morland L.A.
      • Poizner J.M.
      • Williams K.E.
      • Masino T.T.
      • Thorp S.R.
      Home-based clinical video teleconferencing care: clinical considerations and future directions.
      American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Telepsychiatry and AACAP Committee on Quality Issues
      Clinical update: telepsychiatry with children and adolescents.
      • Rogove H.J.
      • McArthur D.
      • Demaerschalk B.M.
      • Vespa P.M.
      Barriers to telemedicine: survey of current users in acute care units.
      • Brown N.A.
      State Medicaid and private payer reimbursement for telemedicine: an overview.
      • Sanders J.H.
      • Bashshur R.L.
      Challenges to the implementation of telemedicine.
      • Bashshur R.L.
      • Shannon G.
      • Krupinski E.A.
      • Grigsby J.
      Sustaining and realizing the promise of telemedicine.
      With a constantly changing and complicated insurance market, clinicians understandably report lacking knowledge in this area. Many respondents did not know which private payers paid for telepsychiatry and frequently erroneously identified the insurance companies most frequently reimbursing as the companies that do not pay.
      • Antoniotti N.M.
      • Drude K.P.
      • Rowe N.
      Private payer telehealth reimbursement in the United States.
      Clinicians also report not knowing how to bill for telepsychiatry services (different billing codes and modifiers), though some new practice parameters address this concern.
      American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Telepsychiatry and AACAP Committee on Quality Issues
      Clinical update: telepsychiatry with children and adolescents.
      • Antoniotti N.M.
      • Drude K.P.
      • Rowe N.
      Private payer telehealth reimbursement in the United States.
      Because inadequate reimbursement can limit telemedicine use, many states have passed telemedicine parity laws mandating reimbursement for telemedicine visits.
      • Barnett M.L.
      • Ray K.N.
      • Souza J.
      • Mehrotra A.
      Trends in telemedicine use in a large commercially insured population, 2005-2017.
      • Mehrotra A.
      • Jena A.B.
      • Busch A.B.
      • Souza J.
      • Uscher-Pines L.
      • Landon B.E.
      Utilization of telemedicine among rural Medicare beneficiaries.
      • Mehrotra A.
      • Huskamp H.A.
      • Souza J.
      • et al.
      Rapid growth in mental health telemedicine use among rural medicare beneficiaries, wide variation across states.
      • Puskin D.S.
      Telemedicine: follow the money modalities.
      Congressional Budget Office
      Answers to Questions for the Record Following a Hearing on the 2015 Long-Term Budget Outlook Conducted by the Senate Committee on the Budget.
      • Thomas L.
      • Capistrant G.
      50 State Telemedicine Gaps Analysis: Coverage & Reimbursement.
      Cost-effectiveness studies warrant further investigation.
      • Deslich S.
      • Stec B.
      • Tomblin S.
      • Coustasse A.
      Telepsychiatry in the 21(st) century: transforming healthcare with technology.
      One study found that telepsychiatry costs more than in-person treatment per hour,
      • Modai I.
      • Jabarin M.
      • Kurs R.
      • Barak P.
      • Hanan I.
      • Kitain L.
      Cost effectiveness, safety, and satisfaction with video telepsychiatry versus face-to-face care in ambulatory settings.
      whereas others have found a 40%
      • Rabinowitz T.
      • Murphy K.M.
      • Amour J.L.
      • Ricci M.A.
      • Caputo M.P.
      • Newhouse P.A.
      Benefits of a telepsychiatry consultation service for rural nursing home residents.
      or even 70% cost reduction.
      • Spaulding R.
      • Belz N.
      • DeLurgio S.
      • Williams A.R.
      Cost savings of telemedicine utilization for child psychiatry in a rural Kansas community.
      A recent study involving a multistate telepsychiatry intervention serving rural American Indian/Alaska Native populations noted that telepsychiatry session costs were estimated to be $93.90 as compared with $183.34 per session cost for psychiatrist travel and $268.23 for patient travel.
      • Yilmaz S.K.
      • Horn B.P.
      • Fore C.
      • Bonham C.A.
      An economic cost analysis of an expanding, multi-state behavioural telehealth intervention.
      Several other studies support cost-effectiveness.
      • O’Reilly R.
      • Bishop J.
      • Maddox K.
      • Hutchinson L.
      • Fisman M.
      • Takhar J.
      Is telepsychiatry equivalent to face-to-face psychiatry? Results from a randomized controlled equivalence trial.
      • Narasimhan M.
      • Druss B.G.
      • Hockenberry J.M.
      • et al.
      Impact of a telepsychiatry program at emergency departments statewide on the quality, utilization, and costs of mental health services.
      • Hilt R.J.
      • Barclay R.P.
      • Bush J.
      • Stout B.
      • Anderson N.
      • Wignall J.R.
      A statewide child telepsychiatry consult system yields desired health system changes and savings.
      • Shore J.H.
      • Brooks E.
      • Savin D.M.
      • Manson S.M.
      • Libby A.M.
      An economic evaluation of telehealth data collection with rural populations.
      Further cost-benefit analyses could ease financial concerns.
      • Russo J.E.
      • McCool R.R.
      • Davies L.
      VA telemedicine: an analysis of cost and time savings.
      • Glueck D.A.
      Telepsychiatry in private practice.
      • Yilmaz S.K.
      • Horn B.P.
      • Fore C.
      • Bonham C.A.
      An economic cost analysis of an expanding, multi-state behavioural telehealth intervention.
      • Rojas S.V.
      • Gagnon M.P.
      A systematic review of the key indicators for assessing telehomecare cost-effectiveness.

      Licensure and Credentialing

      Most states require psychiatrists to be licensed in their home states as well as the state(s) in which their patients are physically located.
      • Saeed S.A.
      • Bloch R.M.
      • Diamond J.M.
      Telepsychiatry: overcoming barriers to implementation.
      • Brooks E.
      • Turvey C.
      • Augusterfer E.F.
      Provider barriers to telemental health: obstacles overcome, obstacles remaining.
      • Myers K.
      • Cain S.
      Work Group on Quality Issues; American Academy of Child and Adolescent Psychiatry Staff
      Practice parameter for telepsychiatry with children and adolescents.
      • Kramer G.M.
      • Kinn J.T.
      • Mishkind M.C.
      Legal, regulatory, and risk management issues in the use of technology to deliver mental health care.
      For 93.5% of telemental health visits in 2014, the beneficiary and clinician were in the same state,
      • Mehrotra A.
      • Huskamp H.A.
      • Souza J.
      • et al.
      Rapid growth in mental health telemedicine use among rural medicare beneficiaries, wide variation across states.
      suggesting that the time and expense of maintaining multiple licenses, along with complicated laws that differ between states, poses a significant burden to physicians.
      • Parish M.B.
      • Fazio S.
      • Chan S.
      • Yellowlees P.M.
      Managing psychiatrist-patient relationships in the digital age: a summary review of the impact of technology-enabled care on clinical processes and rapport.
      • Barton P.L.
      • Brega A.G.
      • Devore P.A.
      • et al.
      Specialist physicians’ knowledge and beliefs about telemedicine: a comparison of users and nonusers of the technology.
      • Brooks E.
      • Turvey C.
      • Augusterfer E.F.
      Provider barriers to telemental health: obstacles overcome, obstacles remaining.
      • Rogove H.J.
      • McArthur D.
      • Demaerschalk B.M.
      • Vespa P.M.
      Barriers to telemedicine: survey of current users in acute care units.
      • Kramer G.M.
      • Kinn J.T.
      • Mishkind M.C.
      Legal, regulatory, and risk management issues in the use of technology to deliver mental health care.
      • Rogove H.J.
      • Amoateng B.
      • Binner J.
      • Demaerschalk B.M.
      • Sanders R.B.
      A survey and review of telemedicine license portability.
      Only 14 states extend conditional or telemedicine licenses to out-of-state physicians.
      • Mehrotra A.
      • Huskamp H.A.
      • Souza J.
      • et al.
      Rapid growth in mental health telemedicine use among rural medicare beneficiaries, wide variation across states.
      • Thomas L.
      • Capistrant G.
      50 State Telemedicine Gaps Analysis: Coverage & Reimbursement.
      A recent bill proposing that clinicians in federal health plans would need to license only in their physical state to care for eligible patients anywhere in the nation died in committee.
      • Brooks E.
      • Turvey C.
      • Augusterfer E.F.
      Provider barriers to telemental health: obstacles overcome, obstacles remaining.
      Many bills have been proposed to expand telemedicine services in Medicare, none of which have become law.
      • Mehrotra A.
      • Huskamp H.A.
      • Souza J.
      • et al.
      Rapid growth in mental health telemedicine use among rural medicare beneficiaries, wide variation across states.
      There has, however, been a recent launch of the Interstate Medical Licensure Compact, which will streamline medical licensure process across states and support expanded use of telemedicine. At least 18 states have adopted the compact as of 2017.
      American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Telepsychiatry and AACAP Committee on Quality Issues
      Clinical update: telepsychiatry with children and adolescents.
      Licensure solutions suggested include establishing national licensure, assigning responsibility to the referring physician with the consulting telepsychiatrist’s opinion serving as a recommendation, or determining that the patient is being “electronically transmitted” to the consultant’s state, eliminating the need to license in the patient’s state.
      • Mehrotra A.
      • Huskamp H.A.
      • Souza J.
      • et al.
      Rapid growth in mental health telemedicine use among rural medicare beneficiaries, wide variation across states.
      • Saeed S.A.
      • Bloch R.M.
      • Diamond J.M.
      Telepsychiatry: overcoming barriers to implementation.
      The considerable administrative burden required to be credentialed and privileged at all facilities a telepsychiatrist would work with poses another barrier.
      • Brooks E.
      • Turvey C.
      • Augusterfer E.F.
      Provider barriers to telemental health: obstacles overcome, obstacles remaining.
      • Sanders J.H.
      • Bashshur R.L.
      Challenges to the implementation of telemedicine.
      More recently, the Centers for Medicare and Medicaid Services released a new rule that streamlines telepsychiatry credentialing and privileging by allowing the decision to rely on the distant site facility, helping to mitigate this barrier.
      • Kramer G.M.
      • Kinn J.T.
      • Mishkind M.C.
      Legal, regulatory, and risk management issues in the use of technology to deliver mental health care.

      Legal/Regulatory

      Legal and regulatory barriers may contribute to difficulties with telepsychiatry practice. Some states mandate conditions of clinical encounters or require that a telepsychiatrist maintain a physical practice location in that state.
      • Brooks E.
      • Turvey C.
      • Augusterfer E.F.
      Provider barriers to telemental health: obstacles overcome, obstacles remaining.
      American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Telepsychiatry and AACAP Committee on Quality Issues
      Clinical update: telepsychiatry with children and adolescents.
      The Ryan Haight Online Pharmacy Consumer Protection Act of 2008 was designed to protect against illegitimate dispensing of controlled substances online without appropriate physician oversight, but had the unintended consequence of interfering with prescribing through telepsychiatry encounters, as revealed by the case presented in Table 3. Although it stated that telemedicine is an exception, it technically requires at least one in-person evaluation before prescribing a controlled substance.
      • Brooks E.
      • Turvey C.
      • Augusterfer E.F.
      Provider barriers to telemental health: obstacles overcome, obstacles remaining.
      • Kramer G.M.
      • Kinn J.T.
      • Mishkind M.C.
      Legal, regulatory, and risk management issues in the use of technology to deliver mental health care.
      Although the Drug Enforcement Administration noted that it does not intend to interfere with the legitimate prescribing of controlled substances, the legislation is difficult to follow.
      Table 3Regulatory Barriers After Successful Adoption of Telepsychiatry
      Case example: Sam, a 10-year-old boy with a history of attention deficit hyperactivity disorder treated with a stimulant, was referred by his school to a telepsychiatry clinic after moving into a rural area. After a videoconference visit, a thoughtful plan was made to increase his stimulant dose and add psychosocial treatments. Although telepsychiatry succeeded in providing convenient access to psychiatry in a resource scarce area and provided an accurate diagnosis with valuable treatment recommendations, the stimulant medication was unable to be prescribed by the telepsychiatrist because of limitations imposed by the Ryan Haight Act. The telepsychiatrist attempted to liaise with rural primary care clinicians in the area. Challenges included no pediatricians within the county or adjacent counties. Sam did not regularly meet with a physician, and the nurse practitioner he had seen previously was not open to assuming the attention deficit hyperactivity disorder care or comanagement with the telepsychiatrist. This left the patient and guardian no option other than traveling a long distance to see a psychiatrist in person, defeating the purpose of telepsychiatry. The guardian did not have the resources to travel 4 hours to the academic health center for an on-site appointment and the travel was not supported through the child’s insurance.
      Take home points: The outcome was that Sam (and other patients like him) may not have access to beneficial medication, leading to increased symptoms and a lower quality of life for him and his family. Regulatory barriers, such as the Ryan Haight Act, remain problematic, even where telepsychiatry has otherwise been successfully adopted.
      Other legal and regulatory barriers include the fact that some state laws may prohibit telepsychiatrists from participating in the civil commitment process.
      • Myers K.
      • Cain S.
      Work Group on Quality Issues; American Academy of Child and Adolescent Psychiatry Staff
      Practice parameter for telepsychiatry with children and adolescents.
      Regulatory and procedural guidelines vary by jurisdiction.
      American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Telepsychiatry and AACAP Committee on Quality Issues
      Clinical update: telepsychiatry with children and adolescents.
      Clinicians need to learn local civil commitment laws and duty to report/warn/protect requirements.
      • Kramer G.M.
      • Kinn J.T.
      • Mishkind M.C.
      Legal, regulatory, and risk management issues in the use of technology to deliver mental health care.
      States also vary in the requirement for specific written consent to deliver care via videoconference
      • Myers K.
      • Nelson E.L.
      • Rabinowitz T.
      • et al.
      American Telemedicine Association Practice guidelines for telemental health with children and adolescents.
      as well as insurance requirements and regulations.
      • Kramer G.M.
      • Kinn J.T.
      • Mishkind M.C.
      Legal, regulatory, and risk management issues in the use of technology to deliver mental health care.
      There is a marked variation in telemedicine use across states.
      • Deslich S.
      • Stec B.
      • Tomblin S.
      • Coustasse A.
      Telepsychiatry in the 21(st) century: transforming healthcare with technology.
      States with a telemedicine parity law and a pro-telemental health regulatory environment had notably higher rates of telemental health use than those that did not, suggesting that addressing the legal and regulatory environment may substantially affect the use and growth of telepsychiatry.
      • Mehrotra A.
      • Huskamp H.A.
      • Souza J.
      • et al.
      Rapid growth in mental health telemedicine use among rural medicare beneficiaries, wide variation across states.
      There was a roughly 2-fold higher rate of telemental health use in states with a more favorable regulatory environment
      • Mehrotra A.
      • Huskamp H.A.
      • Souza J.
      • et al.
      Rapid growth in mental health telemedicine use among rural medicare beneficiaries, wide variation across states.
      and use increased considerably faster in states with parity mandates.
      • Barnett M.L.
      • Ray K.N.
      • Souza J.
      • Mehrotra A.
      Trends in telemedicine use in a large commercially insured population, 2005-2017.

      Liability, Litigation, and Malpractice

      Clinicians have raised concerns about liability and litigation.
      • Rogove H.J.
      • McArthur D.
      • Demaerschalk B.M.
      • Vespa P.M.
      Barriers to telemedicine: survey of current users in acute care units.
      Nonusers of telemedicine are more likely to believe that it would increase the risk of malpractice law suits.
      • Barton P.L.
      • Brega A.G.
      • Devore P.A.
      • et al.
      Specialist physicians’ knowledge and beliefs about telemedicine: a comparison of users and nonusers of the technology.
      Despite literature supporting the safety and effectiveness of telepsychiatry,
      • Hilty D.M.
      • Ferrer D.C.
      • Parish M.B.
      • Johnston B.
      • Callahan E.J.
      • Yellowlees P.M.
      The effectiveness of telemental health: a 2013 review.
      questions about liability risks remain open
      • Sanders J.H.
      • Bashshur R.L.
      Challenges to the implementation of telemedicine.
      • Kramer G.M.
      • Kinn J.T.
      • Mishkind M.C.
      Legal, regulatory, and risk management issues in the use of technology to deliver mental health care.
      because of a relative lack of case law in this area.
      • Rogove H.J.
      • McArthur D.
      • Demaerschalk B.M.
      • Vespa P.M.
      Barriers to telemedicine: survey of current users in acute care units.
      The 2017 American Telemedicine Association practice guidelines for telemental health with children and adolescents recommend that clinicians verify that their liability insurance covers activities in all sites of telepsychiatry practice.
      • Myers K.
      • Nelson E.L.
      • Rabinowitz T.
      • et al.
      American Telemedicine Association Practice guidelines for telemental health with children and adolescents.
      For many clinicians, risk management can be one of the most anxiety-laden factors of home-based clinical videoconferencing in particular, which could deter them from providing services to patient in their homes
      • Morland L.A.
      • Poizner J.M.
      • Williams K.E.
      • Masino T.T.
      • Thorp S.R.
      Home-based clinical video teleconferencing care: clinical considerations and future directions.
      or from pursuing telepsychiatry in general.

      Tradition/Habit/Resistance to Change/Disruption of Routine and Workflow

      Habit has been identified as an important, often overlooked factor in slow diffusion/adoption of telemedicine.
      • Barton P.L.
      • Brega A.G.
      • Devore P.A.
      • et al.
      Specialist physicians’ knowledge and beliefs about telemedicine: a comparison of users and nonusers of the technology.
      • Grigsby B.
      • Brega A.G.
      • Bennett R.E.
      • et al.
      The slow pace of interactive video telemedicine adoption: the perspective of telemedicine program administrators on physician participation.
      Focus groups of behavioral health clinicians identified potential benefits of telepsychiatry, but they remained reluctant to try it,
      • Whitten P.S.
      • Mackert M.S.
      Addressing telehealth’s foremost barrier: provider as initial gatekeeper.
      perhaps, in part, because of habit.
      • Barton P.L.
      • Brega A.G.
      • Devore P.A.
      • et al.
      Specialist physicians’ knowledge and beliefs about telemedicine: a comparison of users and nonusers of the technology.
      Cognitive neuroscience has established that people often act based on habit. New ways of doing things require deliberate conscious effort.
      • Grigsby J.
      • Rigby M.
      • Hiemstra A.
      • House M.
      • Olsson S.
      • Whitten P.
      Telemedicine/telehealth: an international perspective. The diffusion of telemedicine.
      Physicians develop efficient practice routines, and changing these habitual routines involves a temporary loss of efficiency.
      • Grigsby J.
      • Rigby M.
      • Hiemstra A.
      • House M.
      • Olsson S.
      • Whitten P.
      Telemedicine/telehealth: an international perspective. The diffusion of telemedicine.
      In the moment, doing things differently requires too great an investment of time and energy, especially if there is a steep learning curve or low intrinsic motivation.
      • Whitten P.S.
      • Mackert M.S.
      Addressing telehealth’s foremost barrier: provider as initial gatekeeper.
      • Barton P.L.
      • Brega A.G.
      • Devore P.A.
      • et al.
      Specialist physicians’ knowledge and beliefs about telemedicine: a comparison of users and nonusers of the technology.
      • Dansky K.H.
      • Bowles K.H.
      Lessons learned from a telehomecare project.
      • Valenta A.L.
      • Wigger U.
      Early results of user profiles: physicians' opinions on the use of information technology.
      • Grigsby B.
      • Brega A.G.
      • Bennett R.E.
      • et al.
      The slow pace of interactive video telemedicine adoption: the perspective of telemedicine program administrators on physician participation.
      • Grigsby J.
      • Rigby M.
      • Hiemstra A.
      • House M.
      • Olsson S.
      • Whitten P.
      Telemedicine/telehealth: an international perspective. The diffusion of telemedicine.
      In short, clinician’s habits represent a strong inertial force.
      • Grigsby J.
      • Rigby M.
      • Hiemstra A.
      • House M.
      • Olsson S.
      • Whitten P.
      Telemedicine/telehealth: an international perspective. The diffusion of telemedicine.
      Practicing telepsychiatry may involve traveling to a special room, making appropriate technical arrangements, and scheduling and documentation changes, complex data sharing agreements, and navigating several types of electronic medical records. This amount of inconvenience and disruption of routine may dissuade clinicians from participating in telepsychiatry.
      • Wagnild G.
      • Leenknecht C.
      • Zauher J.
      Psychiatrists’ satisfaction with telepsychiatry.
      • Brooks E.
      • Turvey C.
      • Augusterfer E.F.
      Provider barriers to telemental health: obstacles overcome, obstacles remaining.
      • Sanders J.H.
      • Bashshur R.L.
      Challenges to the implementation of telemedicine.
      Portability and ease of use have been highlighted as priorities to clinicians.
      • Lauckner C.
      • Whitten P.
      The state and sustainability of telepsychiatry programs.
      • Whitten P.S.
      • Mackert M.S.
      Addressing telehealth’s foremost barrier: provider as initial gatekeeper.
      • Sanders J.H.
      • Bashshur R.L.
      Challenges to the implementation of telemedicine.
      The need for frontline clinician input in designing telepsychiatry systems is particularly important.
      • Saeed S.A.
      • Bloch R.M.
      • Diamond J.M.
      Telepsychiatry: overcoming barriers to implementation.
      Top-down approaches may contribute to frustration with and subsequent failure of telemedicine systems.
      • Hilty D.M.
      • Marks S.L.
      • Urness D.
      • Yellowlees P.M.
      • Nesbitt T.S.
      Clinical and educational telepsychiatry applications: a review.
      • Barton P.L.
      • Brega A.G.
      • Devore P.A.
      • et al.
      Specialist physicians’ knowledge and beliefs about telemedicine: a comparison of users and nonusers of the technology.
      • Yellowlees P.
      How not to develop telemedicine systems.
      Clinical office space is often a barrier.
      • Maieritsch K.P.
      • Smith T.L.
      • Hessinger J.D.
      • Ahearn E.P.
      • Eickhoff J.C.
      • Zhao Q.
      Randomized controlled equivalence trial comparing videoconference and in person delivery of cognitive processing therapy for PTSD.
      • Jameson J.P.
      • Farmer M.S.
      • Head K.J.
      • Fortney J.
      • Teal C.R.
      VA community mental health service providers’ utilization of and attitudes toward telemental health care: the gatekeeper’s perspective.
      For basic setup, one needs an appropriate room (well lit; with the ability of the camera to pan, tilt/zoom, and see all who are present; toys that are not noisy for children; well-placed microphones; rooms large enough for several people, but not too large that younger kids will wander; a dark background; diffuse lighting to reduce glare; and heavy chairs to reduce movement on screen).
      • Myers K.
      • Nelson E.L.
      • Rabinowitz T.
      • et al.
      American Telemedicine Association Practice guidelines for telemental health with children and adolescents.
      • Wagnild G.
      • Leenknecht C.
      • Zauher J.
      Psychiatrists’ satisfaction with telepsychiatry.
      American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Telepsychiatry and AACAP Committee on Quality Issues
      Clinical update: telepsychiatry with children and adolescents.
      In some care models, it may also be necessary to employ staff to physically be present to aid in support activities such as physical examination and vital signs, maintaining medical records, obtaining consent, registering and scheduling patients, fielding calls from families, solving technical and equipment problems, intervening in case of emergency or crisis, coordinating care with local clinicians and services, and coordinating laboratory results and prescriptions.
      • Myers K.
      • Nelson E.L.
      • Rabinowitz T.
      • et al.
      American Telemedicine Association Practice guidelines for telemental health with children and adolescents.
      • Gibson K.L.
      • Coulson H.
      • Miles R.
      • Kakekakekung C.
      • Daniels E.
      • O’Donnell S.
      Conversations on telemental health: listening to remote and rural First Nations communities.
      • Shore J.H.
      • Bloom J.D.
      • Manson S.M.
      • Whitener R.J.
      Telepsychiatry with rural American Indians: issues in civil commitments.
      • Wagnild G.
      • Leenknecht C.
      • Zauher J.
      Psychiatrists’ satisfaction with telepsychiatry.
      • Shore J.H.
      Telepsychiatry: videoconferencing in the delivery of psychiatric care.
      • Barton P.L.
      • Brega A.G.
      • Devore P.A.
      • et al.
      Specialist physicians’ knowledge and beliefs about telemedicine: a comparison of users and nonusers of the technology.
      • Myers K.
      • Cain S.
      Work Group on Quality Issues; American Academy of Child and Adolescent Psychiatry Staff
      Practice parameter for telepsychiatry with children and adolescents.
      Pharmacotherapy is one of the most frequently requested services for telepsychiatry, so clearly outlining who prescribes and monitors medications in adherence with state and federal regulations is important as well.
      • Myers K.
      • Nelson E.L.
      • Rabinowitz T.
      • et al.
      American Telemedicine Association Practice guidelines for telemental health with children and adolescents.
      In addition to temporary loss of efficiency in deviation from habit, there are deep-seated cultural traditions in medicine that hamper expansion of telepsychiatry. Physical colocation is a maxim of clinical practice with enormous culture significance. Over the course of two millennia, the physical presence of the doctor has been regarded as necessary for clinical work.
      • May C.
      • Gask L.
      • Atkinson T.
      • Ellis N.
      • Mair F.
      • Esmail A.
      Resisting and promoting new technologies in clinical practice: the case of telepsychiatry.
      Although the technology on which telemedicine is founded itself is subject to rapid development, tradition and culture change slowly.
      • May C.
      • Gask L.
      • Atkinson T.
      • Ellis N.
      • Mair F.
      • Esmail A.
      Resisting and promoting new technologies in clinical practice: the case of telepsychiatry.
      • Shore J.
      The evolution and history of telepsychiatry and its impact on psychiatric care: current implications for psychiatrists and psychiatric organizations.
      A survey to clinicians considering telemedicine revealed lack of desire or unwillingness to change clinical paradigms through use of telemedicine as the third rank ordered barrier.
      • Rogove H.J.
      • McArthur D.
      • Demaerschalk B.M.
      • Vespa P.M.
      Barriers to telemedicine: survey of current users in acute care units.
      The results of another survey suggest that demographic characteristics (such as age) do not fully explain participation patterns in telemedicine.
      • Barton P.L.
      • Brega A.G.
      • Devore P.A.
      • et al.
      Specialist physicians’ knowledge and beliefs about telemedicine: a comparison of users and nonusers of the technology.
      Rather, it seems physicians express a range of typologies in terms of adoption of new technologies in their practices, ranging from the so-called early adopter to the unwilling-uneasy participant.
      • Barton P.L.
      • Brega A.G.
      • Devore P.A.
      • et al.
      Specialist physicians’ knowledge and beliefs about telemedicine: a comparison of users and nonusers of the technology.
      • Valenta A.L.
      • Wigger U.
      Early results of user profiles: physicians' opinions on the use of information technology.
      • Grigsby J.
      • Rigby M.
      • Hiemstra A.
      • House M.
      • Olsson S.
      • Whitten P.
      Telemedicine/telehealth: an international perspective. The diffusion of telemedicine.
      Most telehealth projects were initiated by champions who also played a critical role in translating projects to ongoing services. Champions support clinician acceptance by legitimizing telepsychiatry as effective, safe, and normal and by promoting relationships between telepsychiatrists and remote sites.
      • Wade V.A.
      • Eliott J.A.
      • Hiller J.E.
      Clinician acceptance is the key factor for sustainable telehealth services.
      Culture change may be increasing in speed, with a growing acceptance of integration of technology into health care,
      • Yellowlees P.
      • Nafiz N.
      The psychiatrist-patient relationship of the future: anytime, anywhere?.
      especially in “digital natives” who grew up using technology.
      • Shore J.
      The evolution and history of telepsychiatry and its impact on psychiatric care: current implications for psychiatrists and psychiatric organizations.
      Growing numbers of psychiatrists are signing for telepsychiatry positions.
      • Thiele J.S.
      • Doarn C.R.
      • Shore J.H.
      Locum tenens and telepsychiatry: trends in psychiatric care.
      Although little has yet to be published about their reasons for doing so, citied factors include desire to bring care to support resource scarce areas,
      • Volpe T.
      • Boydell K.M.
      • Pignatiello A.
      Attracting child psychiatrists to a televideo consultation service: the telelink experience.
      flexibility/control over schedules, ability to diversify practice, desire to work part-time, and the opportunity to work from home.
      • Thiele J.S.
      • Doarn C.R.
      • Shore J.H.
      Locum tenens and telepsychiatry: trends in psychiatric care.
      • Shore J.
      The evolution and history of telepsychiatry and its impact on psychiatric care: current implications for psychiatrists and psychiatric organizations.
      As a growing number of clinicians accept telepsychiatry practice, there will be new challenges to adapt to, including risk of social and professional isolation, difficulty separating work from home, and possibly a more sedentary lifestyle.
      • Vogt E.L.
      • Mahmoud H.
      • Elhaj O.
      Telepsychiatry: implications for psychiatrist burnout and well-being.
      How telepsychiatry practice affects clinician well-being warrants further study. Recommendations to improve well-being in telepsychiatry practice include establishing clear work and personal life boundaries, scheduling exercise and social activities, building relationships with staff via telepsychiatry, and diversifying work experiences or perhaps practicing a combination of telepsychiatry and in-person care.
      • Vogt E.L.
      • Mahmoud H.
      • Elhaj O.
      Telepsychiatry: implications for psychiatrist burnout and well-being.

      Clinician Acceptance/Clinician as Gatekeeper

      Clinicians have been cited as the most significant initial gatekeepers to telemedicine use.
      • Whitten P.S.
      • Mackert M.S.
      Addressing telehealth’s foremost barrier: provider as initial gatekeeper.
      • Saeed S.A.
      • Bloch R.M.
      • Diamond J.M.
      Telepsychiatry: overcoming barriers to implementation.
      • Whitten P.
      • Kuwahara E.
      A multi-phase telepsychiatry programme in Michigan: organizational factors affecting utilization and user perceptions.
      • Brooks E.
      • Turvey C.
      • Augusterfer E.F.
      Provider barriers to telemental health: obstacles overcome, obstacles remaining.
      • Yellowlees P.
      • Shore J.H.
      Telepsychiatry and Health Technologies: A Guide For Mental Health Professionals.
      Although patients and clinicians share many of the same concerns about telepsychiatry, patient satisfaction remains high. There are more barriers from the clinicians' perspective.
      • Wagnild G.
      • Leenknecht C.
      • Zauher J.
      Psychiatrists’ satisfaction with telepsychiatry.
      • Brooks E.
      • Turvey C.
      • Augusterfer E.F.
      Provider barriers to telemental health: obstacles overcome, obstacles remaining.
      Low uptake rates of telepsychiatry use and survey data suggest that many clinicians remain skeptical about this mode of care,
      • Richardson L.K.
      • Frueh B.C.
      • Grubaugh A.L.
      • Egede L.
      • Elhai J.D.
      Current directions in videoconferencing tele-mental health research.
      • Serhal E.
      • Crawford A.
      • Cheng J.
      • Kurdyak P.
      Implementation and utilisation of telepsychiatry in ontario: a population-based study.
      • Rees C.
      • Stone S.
      Therapeutic alliance in face-to-face versus videoconferenced psychotherapy.
      • Yellowlees P.
      • Shore J.H.
      Telepsychiatry and Health Technologies: A Guide For Mental Health Professionals.
      • Rogove H.J.
      • McArthur D.
      • Demaerschalk B.M.
      • Vespa P.M.
      Barriers to telemedicine: survey of current users in acute care units.
      • Austen S.
      • McGrath M.
      Attitudes to the use of videoconferencing in general and specialist psychiatric services.
      and negative biases remain a barrier at the health system leadership and clinician level.
      • Chan S.
      • Parish M.
      • Yellowlees P.
      Telepsychiatry today.