In Telepsychiatry, Access Is Everything

Jay H. Shore, MD, MPH


April 06, 2021

It's undisputable that digital health technologies have been vital to the delivery of behavioral health services during the pandemic. They have allowed us to quickly pivot in order to maintain treatment of our patients during this tumultuous period. But it's also true that COVID-19 has accentuated and widened an already troubling digital divide.

"Digital divide" refers to the gap between those who do have access to digital technologies and those who do not. Focused attention on expanding access to telecommunication technologies dates back to the 1950s. The rise of the internet in the 1990s and the increasing digitalization of services, information, entertainment, and social interactions in subsequent decades further crystalized the need for individuals to access such technologies in order to participate and benefit from the growing digital economy.

The digital divide plays out in numerous ways in psychiatry. Below is a rubric drawn from a variety of models, offering six key requirements for a patient to be able to access digital psychiatric services.

  1. Adequate and stable bandwidth and broadband to take advantage of the full complement of digital services (eg, videoconferencing, patient portals, apps, streaming education)

  2. Up-to-date technology platforms (eg, computer, tablet, mobile phone) that can fully operate digital healthcare apps

  3. Sufficient overall comfort with and understanding of technology (often called "digital literacy") to engage in digital health, as well as knowledge of and comfort with specific technologies that a patient is using

  4. Ongoing and available technical support

  5. A secure, private, and safe location from which to engage in digital psychiatric care

  6. Appropriate financial resources to pay for digital healthcare, including health insurance coverage or an individual patient having adequate resources to cover the cost themselves at the time a service is required

A missing or incomplete component of these requirements can create significant barriers to participating in digital psychiatric care.

The Pandemic's Digital Toll

Even prior to pandemic videoconferencing (often termed telepsychiatry), a wide array of digital behavioral health options had become increasingly important as a means to deliver and receive mental health care. This was particularly true in efforts to extend care to patients in remote, rural settings.

Ability to access digital psychiatric services can mean life and death for some patients…

The COVID-19 pandemic, by necessity, ushered in rapid virtualization of all behavioral health services and associated business operations. Since the beginning of the pandemic, psychiatric providers and organizations have had to deliver the majority of care through digital means. Ability to access digital psychiatric services can mean life and death for some patients, in terms of receiving necessary psychiatric care as well as limiting potential exposure to the coronavirus.

Fortunately, COVID-19 occurred when technology had matured enough to support more-robust remote applications. If the pandemic had struck 10-15 years ago, there would have been significantly greater challenges in the virtualization of psychiatric care.

Despite this benefit, COVID-19 has also exposed pre-existing individual and structural digital disparities in healthcare and other areas, such as education (ie, difficulties with remote-learning models). Most psychiatric providers have examples of this, ranging from poor connectivity interfering with a clinical session to being unable to connect with a patient during a critical time.

The American Psychiatric Association's 2020 Telehealth Survey, although positive overall about telehealth from both patient and provider perspectives, reported that most psychiatric providers said that up to 25% of their patients were only able to use the phone for a telehealth session during the pandemic. A recent study comparing April and May 2020 visits in a geriatric clinic found that half of older patients did not use video visits, and that minority and Medicaid patients were even less likely to do so.

Prior to COVID-19, most federal, state, and private insurance plans did not provide reimbursement for telephone sessions. Reimbursement has been expanded for the telephone during the pandemic, but many of these new policies are set to expire when the COVID emergency declaration ends.

Comparative data assessing whether telephone or video yields better treatment, and for which circumstances and patients, do not yet exist. This is an example of a potential double disparity, the first for patients without access to the full range of available technologies beyond their telephone, and the second being the precarious long-term status of telephone reimbursement which could further jeopardize access to care in vulnerable populations.

How Do We Bridge the Divide?

There are several ways that behavioral health providers can address digital divide issues in their practices. They can begin by developing basic competency and knowledge of the technologies used in their practice, and being comfortable providing guidance and troubleshooting.

Providers should also share their awareness of resources and best practices with their patients. For example, they can let patients know about the availability of discounted calling plans for veterans.

Providers also can work with patients to develop individual plans to manage these challenges and be prepared to offer creative solutions. One example is helping identify free Wi-Fi hot spots (eg, a local library parking lot) where a patient can access and connect to broadband for sessions from their cars.

Recent examples of best practices that organizations can employ include a Veterans Affairs program using peer technical support and consultation to aid rural veterans' access to home-based telehealth programs. Another published report describes how digital healthcare navigators can help support patients and providers in connecting to and successfully using technology.

There are also several steps that our behavioral healthcare organizations should consider making to tackle the digital divide, beginning with acting as a dedicated source of relevant information, resources, and guidance for patients and providers alike.

They could provide equipment (eg, tablets) and/or broadband to patients on the basis of needs assessment. Large healthcare organizations, including insurance providers, should weigh the cost to their systems of providing access in this manner vs the cost of untreated patients (eg, increased service utilization).

These organizations are well placed to provide dedicated staff to troubleshoot and support IT issues. For example, they can train front administrative staff to perform test calls with all patients prior to an initial clinical session, and then offer advice and resources as warranted.

To make significant progress going forward, psychiatrists and behavioral health organizations need to advocate for and support local, state, and federal policy changes that target digital access barriers. These include increased funding for public broadband and Wi-Fi, campaigns to boost health technology literacy, healthcare payment models that promote the use of digital technologies, and resources for programs that can support expanded care, such as supplementing patient equipment costs or incentives to healthcare systems to provide digital healthcare navigation.

If there is a silver lining in the current situation, it is that COVID-19 has more clearly revealed the digital divide in psychiatry and delineated the current challenges. These clear disparities provide the opportunity to develop strategic and direct efforts to address the issues. To quote singer-songwriter Leonard Cohen, "There is a crack in everything; that's how the light gets in." Let us endeavor to fix the divide that this pandemic has exacerbated.

Dr Shore is director of telemedicine at the Helen and Arthur E. Johnson Depression Center at the University of Colorado at Denver, Aurora. He also directs telemedicine programming at the medical center's department of psychiatry.

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