As articulated by Steve Daviss, MD, DFAPA, in the inaugural column of Techiatry, the adoption and diffusion of telepsychiatry (live two-way interactive videoconferencing) have not been as rapid and universal as expected from those of us immersed in the field.
Despite having yet to achieve its full promise, telepsychiatry has reached maturity, and is being widely deployed and used across multiple systems, settings, and applications, albeit at times in an uneven, unsystematic manner. Emerging over the past decade of development are two distinct models/approaches to telepsychiatry, which I refer to as “doc in a box” and “tele-teaming.” Those models coexist, compete, and conflict within and across organizations. The dynamic between those two models highlights a larger emergent dialogue within psychiatry around psychiatrists’ core clinical roles and functions in our evolving health care systems.
Dr. Jay H. Shore
The doc in a box model, as captured in early telepsychiatry services in the 1990s and early 2000s, focused on the virtual insertion of a solo psychiatrist into a distant setting. The services involved core psychiatric activities, such as diagnosis and assessment, with a heavy emphasis on pharmacologic management.
Not surprisingly, those services paralleled what was occurring for the rest of psychiatry at the time and were driven by the closer alignment of psychiatry with a biologic framework – and most importantly, reimbursement models that favored pharmacologic interventions and management. The subsequent rise of viable commercial telepsychiatry companies has continued offering this model driven by demands of the marketplace. While there is a legitimate place and need for such services, the phrase “doc in a box” narrows the scope of psychiatric practice, and reinforces current systems of health care structure and funding.
I proffer the phrase “tele-teaming” to denote telepsychiatric care that virtually embeds a psychiatrist as a member of a care team at a distant location. The use of telepsychiatry in integrated care is the clearest example of this. In integrated care, a psychiatrist works as part of a larger behavioral and medical team that may include case managers, social workers, psychologists, nurses, and family physicians to render care to patients in primary care clinics. The psychiatrist performs consultative, direct care, and supervisory roles in the context of the integrated care team, focusing on more holistic and population-based approaches to treatment.
Telepsychiatry, as well as other technologies (for example, electronic medical records, email, and patient registries), enables and enhances integrated care. Telepsychiatry allows smaller primary care practices, which on their own could not support a full-time psychiatrist, to create a full virtual team across multiple sites.
Tele-teaming as a concept is not limited to integrated care. Other notable examples include the use of telepsychiatry in substance rehabilitation facilities, long-term nursing homes, and psychiatric emergency services as a component of ERs. Tele-teaming and doc in a box models are not about the settings or populations to which they provide care, but the structure and philosophy of the psychiatric service.
As an illustration, imagine a rural community mental health center whose long-term psychiatric care provider retires. The center could set up a contract with a psychiatrist to provide medication management services for its patients through telepsychiatry. The psychiatrist, armed with a pen or eprescribing credentials, could provide several days a week of medication management. Treatment planning, therapy, and care coordination could be segmented off to other providers from the center (psychologists, social workers, and case managers). The psychiatrist’s time could be maximized by having the psychiatrist manage prescriptions, with communication between the patients’ various providers through a shared electronic medical record, as in the doc in a box model.
Alternatively, the center could set up a service where the psychiatrist became a virtual team member working to provide complete assessments, treatment planning, supervision, and psychiatric consultation, as well as pharmacologic management. Although in this scenario, the psychiatrist still could devote time to managing prescriptions, she/he also could spend time in team meetings, supervision, and seeing patients, often with her colleagues. In addition, the psychiatrist could work to coordinate care beyond the EMR, for example, through tele-teaming. Either of these scenarios can and do occur with in-person care as well, and the choice of which model to use would not be decided by the technology but by the underlying health care system in which it is being used.