Long before the state of North Carolina decided to implement its statewide telepsychiatry program (NC-STeP), some health systems in the state were already delving into the approach. For instance, Charlotte, NC-based Carolinas HealthCare System was among the first to deploy telemedicine in the state, and the potential to use the technology for psychiatric consults was recognized early on, according to Brad Watling, MD, FACEP, FAAEM, system medical director at Carolinas Medical Center in Charlotte, NC. “It had some fits and starts … but over the last couple of years we have hit the ground running with it,” he says.
Having psychiatrists available to see patients who present to the ED with mental health needs has made a big difference to emergency physicians, observes Watling. “We have the ability as emergency physicians to make a quick determination on the obvious [psychiatric] patient,” he explains. “What we don’t have are a lot of the nuances … so to have someone side-by-side is great.”
The remote encounters that take place between the psychiatrists and patients, utilizing the telemedicine technology, work very well, adds Watling. “I have even had some patients say that they really appreciate it, especially those patients that don’t have to stay and end up being able to receive follow-up as outpatients,” he says. “It just gives us a comfort level. Emergency departments and emergency physicians in general aren’t real comfortable with the fact that patients are having real long lengths-of-stay (LOS) and are sitting in the department because we aren’t really designed to manage that, so this certainly has been helpful.”
While the telepsychiatry system is humming now, there were a number of challenges involved with implementing the approach. The first hurdle involved getting both the emergency and psychiatric providers accustomed to the new technology and how the interactions would work, explains Watling. “I see this [issue] with any new technology,” he says, likening the difficulties to what providers experienced during the first implementation of electronic medical records (EMR).
A second challenge involved getting the resources and the behavioral health organization in place so that the approach functioned optimally, and this took some time, acknowledges Watling. “The technology piece is not that difficult. It’s a matter of getting emergency medicine and psychiatry sitting at the table and coming up with how it is going to work, and then deploying it in an organized fashion,” he says. “It is typical of anything. You’ve got to put the work in and dedicate the resources. It is not something that happens overnight.”
“As time has gone on, the [remote psychiatric consultants] have become much more acceptable to where for any new physician in any one of my departments there is an expectation that they are going to have the ability to get this done in a reasonable fashion; and not only the emergency physicians, but the staff in general,” says Watling. “As you can imagine, [emergency physicians] don’t interact [with the remote visits] as much as the nursing staff and techs in the department. But to have a psychiatrist essentially laying eyes on a patient at every stage in [his or her] stay is a wonderful thing.”
One benefit to the system-wide implementation is that seven of the EDs within the Carolinas HealthCare System function similarly in terms of their EMR programs and operations. “When we are doing telemedicine evaluations, it is our own equipment and our own portal that we are using to go between the emergency psychiatrists who are in our system and our EDs,” says Watling.
While psychiatrists can evaluate patients remotely, they also see patients in person on occasion, notes Watling. “There are facilities where we have psychiatrists that round, and there are some where we have psychiatrists who come into the ED from time to time, so there is a little bit of variability,” he says. “However the majority of all evaluations are done through telemedicine. Certainly, in all of the facilities that I work in, it has got to be around 90% if not more.”
Watling adds that with the shortage of psychiatrists, telemedicine is almost a necessity. “From an emergency standpoint, we probably have more [psychiatrists] than most [health systems], but they are still a resource that needs to be better utilized, and telemedicine allows that.”