Dr. Jason Cafer, MD

Integrating Telepsychiatry with Electronic Medical Record Technology for Improved Rural Mental Health Care

Abstract

IconoPsych Care, LLC is working toward commercialization of web-based mental health services which integrate the practice of video telepsychiatry with electronic medical record keeping. This research and development effort is in response to three problems:

1. the shortage of mental health providers available in rural areas
2. the stigma related to seeking mental health services, and
3. the need for medical recordkeeping technology that is useful for both patients and mental health practitioners

IconoPsych has developed an innovative solution to the problems listed above that addresses the limitations of the competitors in the field. IconoPsych is positioned as the first company to offer video telepsychiatry services through an online clinic format. A patent pending information management system is included in the online software suite, customized to increase quality and efficiency of mental health services.

In IconoPsych Care LLC’s Phase I SBIR project, the overall objective was to explore the technical feasibility of producing and marketing high quality mental health delivery software and teleportal based communications technologies.  All Phase I objectives were met. The Phase II objective is to further develop the system and bring the product to market. Specific objectives include:

1. Establish safety and quality of the current product from a technical standpoint.
2. Develop a marketable system for improving quality and efficiency of mental health services through secure online video conferencing and innovations in information management.
3. Revise preliminary cost and revenue projections based on a detailed analysis of target market(s), expenses and pricing.
4. Ensure adequate availability of capital for launch.
5. Launch the product to market.

Responsiveness to USDA SBIR Program Priorities

IconoPsych Care, LLC received a Phase I SBIR grant under the research topic area of “Rural Development” for a project with significant positive implications for rural development. The company seeks to improve the efficiency and quality of mental health care services in rural communities as a means of contributing to rural development. Contributions to the rural economy include improving fiscal viability among rural mental health practitioners and agencies, improving service provisions by rural health clinics, and enabling rural residents to improve productivity through access to much needed mental health services.

Prior USDA support

IconoPsych Care, LLC, received a Phase I SBIR grant through USDA SBIR. The title of the application was “Research and Development to Improve Rural Mental Health Care.” The Principal Investigator on this project was Dr. Jason Cafer, MD, President of IconoPsych Care, LLC.

Identification and Significance of the Problem or Opportunity

IconoPsych Care, LLC is working toward commercialization of a web-based mental health product which integrates telepsychiatry with electronic medical recordkeeping in response to three major problems. First and foremost is the considerable shortage of mental health providers available in rural areas. There is a particularly acute shortage of psychiatrists. Secondly, stigma is associated with seeking mental health care, which may be a more prominent issue in small communities. Thirdly, there is a need for medical recordkeeping technology that is useful for both mental health practitioners and patients, and which will reduce costs while improving quality of care.

Research in the field of rural health care delivery has documented significant need for improved quality-of-care. Dr. L. L. Hicks summed up the research by describing the following characteristics related to rural health care delivery concerns.

• Rural communities have much fewer health care providers per capita than do urban communities.
• Rural residents travel much longer distances to obtain health care services.
• Rural communities have higher levels of alcoholism, smoking and infant mortality resulting in a greater need for health care services.

These problems are particularly acute for rural mental health provision. Many rural communities have higher levels of child abuse, child neglect, divorce, suicide and youth delinquency, possibly due to the social factors of higher-than-average poverty, unemployment and financial stress.

Despite large rural mental health needs, very few rural communities have access to mental health services in their area. Over half of the counties in the United States have no psychiatrists, psychologists or social workers. Due to this shortage, many rural communities must pay high costs for mental health professionals to travel to their local clinics. Common practice is to pay psychiatrists travel expenses to drive from urban centers to outlying rural hospitals, clinics or community centers.

To add to the difficulty in providing adequate mental health services in rural areas, rural residents face a greater stigma for the pursuit of mental health care, as compared to urban residents. This stems in part from the lack of anonymity in rural areas and strong beliefs concerning self-reliance4.

To further complicate the provision of adequate mental health care in rural areas, rural caregivers may face ethical dilemmas due to the lack of qualified rural mental healthcare providers.  For example, rural caregivers may be put in the position of providing  mental health care without proper training, support or safeguards.  They may also have to ration care, provide services outside of their areas of expertise, deal with patients who are unable to comply with recommendations because of access problems, and respond to a host of complaints and issues without the benefit of trained specialists5.

Rural Americans feel the same cost squeeze and have similar concerns about health care quality as their urban counterparts. Healthcare costs have inflated over the last 20 years, far in excess of the consumer price index. According to the Bureau of Labor Statistics, outpatient medical care cost inflated 174% from 1986-2006, far in excess of the consumer price index, which inflated by 84% over the past 20 years. Americans now spend $2.25 trillion/year on healthcare, and inefficiencies and impaired processes abound in the healthcare system.

In order to meet concerns about cost and quality, one of the top priorities of the Bush Administration and the health care industry is to improve the quality of and access to patient information through the adoption of electronic medical records (EMRs). In his last four State of the Union addresses, President Bush specifically referred to the priority of full adoption of EMRs.  In 2004 he set 2014 as a goal for full adoption of electronic health records throughout the healthcare system. A few key quotes from the four addresses are listed below:

• 2004: “By computerizing health records, we can avoid dangerous medical mistakes reduce costs, and improve care.”
• 2005: “To make our economy stronger and more productive, we must make healthcare more affordable with improved information technology to prevent medical error and needless costs.”
• 2006: “We will make wider use of electronic records and other health information technology to help control costs and reduce dangerous medical errors.”
• 2007: “We need to reduce costs and medical errors with better information technology”.

This issue enjoys bipartisan support in the US Congress and among candidates in the current Presidential race.  Senator Clinton has stated, “A move toward electronic medical records would help tackle the cost of poor quality, inefficiency and redundancy.”  Senator Obama successfully advocated legislation in the Senate to force the Pentagon to work towards an efficient electronic medical records system that will help the nation’s troops. Based on this recent history in the political scene, it is anticipated that there will be continuing regulatory pressure for the adoption of EMRs.

IconoPsych Care, LLC, is positioned to address the need for mental health practitioners in rural areas as well as the demand for high quality electronic medical recordkeeping technologies customized for mental health. Through innovative research and development funded in part by their Phase I USDA SBIR grant, IconoPsych determined the technical feasibility and commercial applicability of two web-based solutions that can contribute to rural development. First is an online telepsychiatry “clinic” that creates greater access to mental health care in rural areas through webcam  videoconferencing. This product is capable of linking mental health care providers with patients in rural areas while eliminating transportation costs and providing the option for patients to seek mental health treatment from their own homes and avoid the stigma faced in public waiting rooms. The second product is an advanced, efficient electronic medical recordkeeping software customized for mental health providers. Phase I USDA SBIR funds also helped determine that it is technically feasible to integrate both solutions into one product suite to be offered to rural health clinics and private practioners. Phase II USDA SBIR funds will be used to refine the product suite and commercialize this online software suite for utilization by doctors, counselors and patients alike.

Background and Rationale

Rural America has seen a critical shortage of mental health professionals for more than thirty years. The vast majority of mental health professionals, including over 90% of all psychologists and psychiatrists, and 80% of Licensed Clinical Social Workers, work in urban areas. This is despite the fact that rural Americans suffer from mental illness at rates similar to their urban peers 6. According to the US Department of Health and Human Services, more than 60% of rural Americans live in mental health professional shortage areas (MHPSAs). As previously noted, over half of the counties in the United States have no psychiatrists, psychologists or social workers at all7. These shortages in rural areas lead more than 65% of rural Americans to get their mental health care from their primary care providers8.

Due to this shortage, many rural communities must pay high costs for mental health professionals to travel to their local clinics. Common practice is to pay psychiatrists’ travel expenses to drive from urban centers to outlying rural hospitals and mental health care service clinics, typically in excess of $120 per hour. This raises the costs of providing rural mental health services and decreases the number of hours that doctors are available on-site.

When patients commute to urban centers for mental health services, a large proportion of their work day is missed for driving and, often, time spent in the waiting room.  When services are available in a rural area, the stigma of mental illness may prevent people from seeking care altogether.

Telepsychiatry is one promising response to the shortage of mental health care available in rural areas, and could link mental health professionals from urban areas with patients in rural areas. Initial reviews of telemedicine in the provision of mental health care are encouraging, including several studies that document telepsychiatry as equivalent to face-to-face treatment in terms of outcomes and patient satisfaction9,10. Current telepsych technology has served to secure American Psychiatric Association endorsement of telepsychiatry as medically sound and has also spurred academic research into its effectiveness compared to conventional practice.

The use of interactive videoconferencing to provide psychiatric services to geographically remote regions has been taking place for more than a decade, but in a very different configuration and using different technology from that proposed here.  With conventional videoconferencing technology, the patient goes to a specially equipped facility in their area that has the ability to link to a major hospital or clinic with corresponding videoconferencing capability. This infrastructure costs tens of thousands of dollars.

IconoPsych’s  “HomePsych” product is a web application that addresses inefficiencies in the process of mental health care delivery.  IconoPsych’s system exploits the increasing availability of broadband and of inexpensive webcams to connect patients with their doctor in a much wider range of settings for a fraction of the cost.

HomePsych is completely “portable”.  Although one or both parties are likely to connect from a clinic or community center, the patient and doctor could connect from their respective homes.  If patients are given the option of seeing a psychiatrist from home, the risk of being seen entering a mental clinic is eliminated. This would allow patients to overcome the stigma barrier to seeking help.

HomePsych may eliminate driving time by psychiatrists and, thus, makes use of “wasted” hours resulting from patients missing their appointments or canceling at the last minute.  During “no show” appointment slots, psychiatrists may see patients waiting for services (in an electronic queue) at a distant site.

The option of practicing psychiatry from home has the potential to further increase available provider hours.  Licensed professionals may earn extra income by practicing from their homes during evenings and weekends.  This is also expected to give some providers who have left the field the opportunity to return on a part-time basis.  For example, licensed stay-at-home mothers may earn income (while their children are being supervised by others, for example) by seeing a few patients by online videoconference.

In addition to the benefits of telepsychiatry, the founders of IconoPsych are developing products to meet the growing demand for more efficient electronic medical records (EMRs). The potential for regulatory pressure and the ability of electronic medical records to better meet patient needs has resulted in aggressive competition among candidate EMR system providers and to the emergence of an online Personal Health Record (PHR) being pursued by Microsoft and Google.

From the physicians’ perspective, there is growing concern about the quality of care for their patients, and many believe that time consumed with paperwork, including the record keeping associated with compliance with HIPAA and other requirements, detracts from their opportunity to provide optimal care to their patients.  Healthcare professionals have become data gatherers and data managers rather than clinicians.

Healthcare professionals recognize that improved efficiency creates the opportunity to see more patients and to increase the income of their practice.  Practitioners also foresee an opportunity to better defend themselves in malpractice cases if record keeping is electronic and also user-friendly.

Despite this concern and interest, physicians are not embracing EMRs in their present form, and few believe that EMRs deliver on their promised gains in efficiency.  As a result, progress towards the national goal for full EMR adoption is falling short, according to a 2006 study funded by the Robert Wood Johnson Foundation and the U.S. National Coordinator for Health Information Technology at the Department of Health and Human Services (HHS). Study researchers found that while approximately 24 percent of doctors use electronic records for basic patient information, only 9 percent have more advanced features that allow them electronically to write prescriptions, type patient notes and record laboratory test results. Researchers further found that solo practitioners and doctors in small group practices were less likely to use electronic records than those working in large group practices. The report indicates that healthcare providers are moving to electronic health records at a rate of  3 percent per year.

Psychiatrists have been particularly slow to adopt EMRs. Percentage of office-based physicians using electronic records by specialty (2003-2004), according to The National Center for Health Statistics:

In summary, there is a high demand for improvements in healthcare processes by the federal and state governments, the health care industry, doctors and patients. In particular there is an interest in how physicians and patients interact with each other and interface with health records.  There is wide recognition that such improvements need to include customization for each medical specialty. Based on this information, there is a significant market opportunity for an innovative EMR specialized for mental health.

Relationship with Research and Development

IconoPsych has completed the Phase I SBIR project with the goal to lay the research and development foundation for the HomePsych product.  IconoPsych surveyed potential customers and began development of an integrated system called HomePsych, which includes:

1. Telepsych video conference portal allowing psychiatrists and counselors to see patients from any computer with a web cam and high speed internet connectivity.
2. Efficient electronic medical record software customized for mental health providers.
3. Patient questionnaires and automated data population features that increase efficiencies and reduce costs.

HomePsych was designed by IconoPsych members Jason Cafer MD, Shane Bradley MD and Ali Hummos MD.