The U.S. Drug Enforcement Administration’s stance on prescribing via telehealth has been evolving, with hints toward an appetite for lasting flexibilities. This, among other policy shifts, has a direct impact on healthcare provider organizations and telemedicine companies delivering care virtually.
On another front, telepsychiatry keeps gaining ground in the post-public health emergency landscape. But there are many issues to be aware of here, beyond remote prescribing, that require foresight and creativity on the parts of provider organizations and virtual care companies.
Healthcare IT News sat down with Geoffrey Boyce, CEO and cofounder of Array Behavioral Care, a telemedicine provider that specializes in behavioral health, to discuss the DEA, telepsychiatry challenges and much more.
Q. Given the recent evolution of the DEA’s stance on prescribing via telemedicine, what has that experience been like as your company works to navigate these impending changes, and how do you see this impacting the industry in the years to come?
A. For countless healthcare providers and groups, the last several months were a scramble to get compliant with what felt like overly restrictive regulations being implemented under unrealistic deadlines. That scramble ended with a very anticlimactic false start when the DEA decided to postpone action and extend the current flexibilities.
On a relative basis, we were fortunate compared to many others in that our basic clinical and operational models for telepsychiatry existed well before the PHE, and we continued to operate during COVID-19 without relying heavily on many of the PHE’s specific telehealth flexibilities.
Some parts of our practice do leverage telemedicine prescribing flexibilities, and we were part of that scramble to align with DEA’s original proposed rules. We were busy updating workflows, educating and retraining our prescribers, working with our partners to help facilitate in-person examinations, and in some instances winding down our care of certain individuals under the assumption that the DEA’s proposed rules would become final.
All that transitional effort proved to be wasteful and certainly resulted in care unnecessarily terminating for some individuals. But in the end, we are glad the DEA is taking the matter seriously. We hope they review the 38,000 public comments in detail and come back to the industry with a revised set of regulations that is more nuanced for different disciplines and clinical presentations.
We also hope they look forward and craft regulation that is flexible enough to apply to the next 10-plus years, because it sure seems that a lot more innovation and change is not far out on the horizon.
Q. All eyes are on the DEA currently, but when you think beyond telehealth prescribing, what other aspects of telepsychiatry are you keeping an eye on?
A. Thinking about the question from the perspective of unnecessary regulatory barriers to telemedicine, we spend a lot of time and effort in an area we call medical affairs. For our practice, medical affairs includes clinical licensure, primary source credentialing, facility privileging and payer enrollment.
These functions are well-intended stopgaps and safety measures in healthcare 1.0. However, in today’s environment of huge health disparities, imbalanced supply and demand, and the awesome potential of telehealth to break down geography, these medical affairs functions have become antiquated barriers to care.
The redundancy and inefficiency that exist in medical affairs processes and systems are the most misunderstood and underappreciated barriers to doing telemedicine at scale, and this is one of the industry’s most significant opportunities for improvement over the next several years.
There has been a lot of discussion about state licensure and the fact that our system of healthcare is divided up on a state-by-state basis, where local medical boards hold the authority to grant licensure, when our nation would obviously benefit from a single, universal license or a system of reciprocity.
And that is certainly true and a significant issue. Today, a telemedicine physician does need to be licensed by the board in the state where the patient is sitting. There were some temporary flexibilities granted during COVID, and more states agreed to join the Interstate Medical Licensure Compact to make it somewhat easier to obtain new state licenses.
But the system is still broken, and it is more complex than most people realize.
People probably do not fully appreciate that the system of healthcare licensure is not just an issue of 50 state licensing boards, it is actually an issue of hundreds and hundreds of different fiefdoms of licensing bodies when you account for state-by-state licensure of multiple levels of professionals like medical doctors, doctors of osteopathic medicine, advance practice nurses, nurses, pharmacists, psychologists, clinical social workers, counselors, therapists and more.
Nearly every healthcare professional has its own licensing body, sometimes with multiple different licensing boards per state, each acting with high levels of independence and autonomy. There is tremendous redundancy in our system of licensure, and in its current design, the onus is placed on the applicant to manage through that redundancy and across multiple states and boards.
When healthcare professionals are in short supply, filling out redundant licensure paperwork is not the highest and best use of their time.
To make it even more complex, we should also look at the realities of hospital privileging. When seeing a patient in a hospital via telehealth, the clinician not only has to be licensed in the state, they also have to be credentialed by the hospital and be granted privileges to operate as part of the medical staff of that hospital.
For a physician practicing telemedicine into a hospital, this means that before they can start, the hospital medical staff office will do an extensive background check on the physician that will verify: medical education, residency training, test scores, fellowship training, board certification status, medical malpractice claims, all state licenses, criminal background checks, all employment history, all privileges held at other hospitals, case logs of clinical competency, multiple clinical references and more.
In many instances, hospitals conduct primary source verification of each of these elements, which often means things like placing a phone call or asking for a letter of recommendation from a physician’s residency training director, who may have retired 20 years ago.
After all this diligence is collected, an extensive file is put together on the applicant, and a medical executive committee reviews each application in monthly meetings. On a good day, the process of obtaining privileges at a hospital regularly takes four months or more. It can sometimes take upwards of a year and costs thousands of dollars in fees and time.
In an analogue 1:1 world, this sort of privileging diligence made sense, and I think that we all wanted to know that the clinicians working inside our hospital were thoroughly vetted. But in today’s world, all that information is now digitized, and it should be centrally verifiable without redundancy or a major onus on the physician as the applicant and the medical affairs staff as the reviewers, who presently have no choice but to push a lot of paper around between one another.
The power of telemedicine is not only in making clinicians available to any state where there is need, but also to any facility or individual in need. Unfortunately, given how hospital credentialing and privileging still works today, when a physician wants to serve multiple sites simultaneously, they often need to go through the painful process I described multiple times.
This is really significant for on-demand telemedicine applications like tele-stroke or telepsychiatry where telehealth technology can make a single clinician’s expertise available as needed for simultaneous coverage across 1-50 sites.
In today’s medical affairs world, each of those 50 sites would likely do their own full primary source diligence of exactly the same material from the clinician’s background. Literally thousands of the same pieces of credentialing information on the single clinician can be redundantly requested and verified over and over to obtain the privilege to provide on-demand telemedicine where it is needed most within hospitals.
I’ll spare you all the expansion of my point to payer enrollment, but please take my word for it that there is similar redundancy as with licensure and privileging, and remember that before a telemedicine clinician can see a patient, they need to be primary source credentialed, licensed in the state, privileged by the facility and vetted for enrollment with all of the right payers.
Getting all those things to align requires a mind-blowing amount of paperwork for the clinician to produce and for large medical staff offices to process.
While some systems and industry groups are increasingly embracing mechanisms like delegation to entrust the onus of primary source verification to others – the overall system of medical affairs is downright silly, and overdue for a regulatory, system and process overhaul before telehealth can realize its true potential.
Q. There’s much discussion around the dangers and concerns of AI. However, what do you see as the potential benefits or use cases of AI to improve mental healthcare, be it operationally, clinically or in other areas?
A. AI’s application to mental healthcare is another mind-blowing topic around our organization that I think we are only just beginning to get our head around.
We are starting our first pilot with AI where we will be running an AI program to scan patient intake stories, categorize and highlight significant phrases, recommend certain paths and cadences of treatment, and offer some statistical analysis to our clinicians about the likelihood of certain diagnoses.
Another application that is likely to capture the hearts and minds of mental health clinicians quickly, particularly those practicing telehealth, is the potential to use the natural language processing models to unobtrusively transcribe video sessions and to draft suggested clinical notes for the session.
AI can draft the note, and the clinician can review, edit and finalize it. Clinicians consistently communicate their frustration with capturing proper clinical documentation from sessions within the EHR as one of the most challenging and disheartening parts of their role, and with these new AI virtual scribe applications it seems likely that frustration level is likely to change substantially in the next couple of years.
With the foundation of a transcribed session and AI models, our clinical leadership team will be better enabled to monitor techniques, skills and tools used by our clinicians and will be able to more directly map clinical outcomes measures to the interventions and methods deployed by our clinicians.
We will have new tools to measure empathy, patient engagement and adherence to treatment plans. AI-enhanced models will allow us to give clinicians more information about how their interventions are benefiting their patients and will enable us to give more meaningful information about how our clinicians are working relative to their peers, which will help foster a culture of learning and improvement.
Administratively, once a session is transcribed and notes are captured, AI is going to open up new administrative efficiencies for our practice as we can use AI to support records requests and to share properly reviewed and formatted clinical information with different interested parties and other members of the treatment team, like our colleagues in primary care.
Of course, the list goes on and on. There are chatbots for patient engagement and machine learning to quickly identify trends in patient data and develop more personalized treatment plans. The industry is already seeing early success in AI-enabled telehealth medication monitoring.
With the appropriate safeguards in place, and clinicians at the helm driving decisions that require reasoning, judgment and empathy, AI is going to have a very big place in mental healthcare.
Q. Mental health patients are waiting hours, days and, in some cases, weeks in emergency departments to receive care. What’s causing this “boarding” crisis? How can telebehavioral health help?
A. With a mental health crisis in our country, largely inadequate and inaccessible resources, and general confusion about where and how to manage mental health concerns, many individuals needing evaluation and care revert to the old staple of a trip to the emergency department.
Our country’s behavioral health workforce shortage is a significant part of the problem. Given the redundancy of medical affairs and the challenges working inside hospitals, the scarcity of mental health professionals hits hospitals and emergency departments hard.
These are very tough environments to cover on a 24/7 basis with a scarce resource like a psychiatrist, and so many EDs do not have a psychiatrist available for psychiatric emergencies. The American College of Emergency Physicians has estimated that only 17% of emergency physicians report they had a psychiatrist on call.
Due to their different training, ED physicians are more likely to admit an individual in psychiatric crisis to an inpatient bed than a psychiatrist.
Boarding is the natural consequence of that supply/demand imbalance within the ED, combined with an overall shortage of qualified inpatient beds to receive mental health patients from the ED.
When there is rarely anyone to see the patient in a timely manner and/or when admitted patients have no options for inpatient beds, they wait or “board” in the ED. On average, mental health patients in hospitals often wait three times longer for care than other patients.
Today, there is not a panacea to this boarding crisis, but there are several paths forward. With EDs increasingly becoming the primary treatment center for many patients with mental health concerns, telebehavioral health is a proven and effective model of care that serves as a pressure valve for our emergency care teams.
By using video, hospitals can access licensed psychiatrists, nurse practitioners, LCSWs or other behavioral health professionals in the ED via telehealth to tremendous benefits for patients and ED staff alike.
Remote mental health professionals can use on-demand telepsychiatry to evaluate patients, review collateral information, speak with family members, and consult with other caregivers. In doing so, they can get a more complete picture of the individual and their situation and can leverage their unique mental health expertise to craft a thoughtful and actionable treatment plan for the ED.
This detailed disposition plan can help move the individual on to the right next level of care, which in the majority of cases is not one of those scarce inpatient beds.
On-demand telepsychiatry done well can route individuals into less restrictive levels of care like partial hospitalization programs, intensive outpatient programs, and other outpatient programs, making better use of our scarce mental health resources.
Today, telehealth is a fundamental component of the healthcare system, and its positive impact is undeniable. On-site care teams and remote psychiatrists working as one will be essential to resolve these converging crises of increased mental health demand and a shortage of psychiatrists to treat them.
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