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 Telepsychiatry Division 

MY INTEREST AND EXPERIENCE WITH TELEPSYCHIATRY

The Lado Healing institute of South West Florida is proud to announce the acquisition of telemedicine and telepsychiatry technologies to provide psychiatric care over the Internet. Dr Lado is now able to provide professional services over the Internet. Telepsychiatry and some areas of telemedicine are here to stay. It has many advantages in that a physician can bring his clinical skills to a distant place where help is needed such as rural areas, correctional and jail systems and inpatient psychiatric facilities. However telemedicine is very much limited to areas where data from the patient’s condition can be ascertained thru the history and in the case of psychiatry the mental status exam. Other new technologies such as computerized testing to validate and support the psychiatrist diagnosis. The most critical thing I was taught in my training first from surgery, if you don’t know what your looking at how can you treat it. The same applies to psychiatry. If you don’t have an accurate diagnosis how can you provide an effective treatment?

“There is no more difficult art to acquire than the art of observation, and for some men it is quite as difficult to record an observation in brief and plain language.” The latter is a quote from well know physician William Osler. The same principles continue to be true in an article by Tomoko et al 2012 and found “…that considering the correct diagnosis at the stage of history taking is especially important for making a correct final diagnosis among students performing clinical case simulation. To improve the diagnostic reasoning skills of medical students, they should be trained in methods for inferring the correct diagnosis from the case history.” The history and Mental Status Examination (MSE) are the most important diagnostic tools a psychiatrist has to obtain information to make an accurate diagnosis. A compilation of all information gathered throughout the interview and MSE leads to the differential diagnosis of the patient. Once this diagnosis is established, a treatment plan is formulated. In summary observation and listening whether done in person or thru a secure teleportal does not degrade or impact the treatment.

 

DOES TELEPSYCHIATRY REDUCE THE QUALITY OF TREATMENT?

Telepsychiatry was embraced by The American Psychiatric Association in 1998. The big concern has been will it degrade the quality and outcome using Telepsychiatry versus in person assessments. The answer is no. In fact “Out of a large Telepsychiatry literature published over the past 40+ years, only a handful of studies have attempted to compare Telepsychiatry, with in person directly using standardized assessment instruments that permit meaningful comparisons. However, in those studies, the current meta-analysis concludes there is no difference in accuracy or satisfaction between the two modalities. Over the next few years, we expect Telepsychiatry to replace in person evaluations in certain research and clinical situations” as observed by Steven Hyler MD a national recognized expert in Telepsychiatry

SO WHAT IS HAPPENING TO THE PATIENTS WITH MENTAL ILLNESS?

This lack of treatment is causing patients in with mental illness to land in the jail system in fact the Cook County Jail in Chicago on any given day the complex holds about 10,000 inmates and on average one in four is suffering some kind of mental illness. In a 2006 Special Report, the Bureau of Justice Statistics (BJS) estimated that 705,600 mentally ill adults were incarcerated in State prisons, 78,800 in Federal prisons and 479,900 in local jails. In addition, research suggests "people with mental illnesses are overrepresented in probation and parole populations at estimated rates ranging from two to four time the general population" (Prins and Draper, 2009). Growing numbers of mentally ill offenders have strained correctional systems.

Many patients are turning to Emergency Rooms and Urgent Care Clinics for their mental health care. Often times these places too are affected, not able to have a psychiatrist on staff, causing the patient to be evaluated by ER/general practice doctors who are not trained to treat mental health patients. Telepsychiatry provides patients with a licensed psychiatrist online through video conferencing in areas where mental health patients would normally have to do without, as well as providing hospitals/mental health clinics an alternative to staffing a full time psychiatrist.

Also, The telepsychiatry medium will allow more access to patients with difficult and distant places where access to a psychiatrist is difficult.

WHY IS TELEPSYCHIATRY BECOMING A GROWING DEMAND?

The Council on Graduate Medical Education (COGME), formed in the mid-1980s, was created with the mandate to provide advice and recommendations to Congress on the supply and distribution of physicians in the United States. The most recent report  COGME 2005 SIXTEENTH REPORT.  In sum, when the midpoint of the predicted range of supply and demand is used, the Nation is likely to face a shortage of about 85,000 FTE physicians in 2020. When the midpoint of the predicted range of supply and need is used, the Nation is also likely to face a shortage of about 96,000 physicians in 2020. Fewer than 5% of med students are choosing psychiatry as a specialty at medical schools across the country according to the NIMH (National Institute of Mental Health) and 55% of practicing psychiatrists are 55 years of age or older, which will worsen the already dire condition the field of psychiatry is presently undergoing. The solution will be on the shoulders of our academic institutions to attract students with this new technology and training them. There are many hidden benefits in Telepsychiatry using technology of obtain accurate data better that our eyes can see. This is another topic.

THE MENTAL ILLNESS EPIDEMIC. HOW SERIOUS IS THIS?

The shortage of psychiatrist is best exemplified by a growing need for treatment, insufficient staffing and a dramatic dip in services, the nation's psychiatric workforce will be short more than 22,500 physicians by 2015, experts and officials predicted. It seems that Americans are in the midst of a raging epidemic of mental illness, at least as judged by the increase in the numbers treated for it. The tally of those who are so disabled by mental disorders that they qualify for Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) increased nearly two and a half times between 1987 and 2007—from one in 184 Americans to one in seventy-six. For children, the rise is even more startling—a thirty-five-fold increase in the same two decades. Mental illness is now the leading cause of disability in children, well ahead of physical disabilities like cerebral palsy or Down syndrome, for which the federal programs were created in article written by Marcia Angell. 


SO WHAT SOLUTION DOES THE LADO HEALING INSTITUTE HAVE FOR THIS CRISIS AND NEED?

I am privileged to have been trained at the The university of houston health science center Department of Psychiatry and behavioral science between 1990 and 1993. It was balance of psychodynamic and psychopharmacological training. I have been inspired by many of my teachers but one that always stood out was Efrain Gomez MD Deceased in 2010. I never forget a comment he made  citing “why are psychiatrists so unique in having patients come to us when we go them and better serve our profession.” His vision of reaching out was ahead of his time. I have been very lucky since such training has helped my national perception of my own peers.

I have been studying this problem for the past 20 years and have focused on practical use of technologies to help out in this epidemic. In addition developed paperless workflows to focus more on the patient while providing the documentation needed by insurance companies. My practice has developed a cost effective and hippa compliant solution to provide such services over the Internet.  It provides two layers of protection that include software and hardware technologies One of these technologies used by my practice has reporting tool will help us turn log data about firewall attacks, bandwidth usage and user activity into meaningful reports. If the hospital and our practice are audited, we can easily create profiles that will illustrate our efforts to comply with HIPAA using a specialized hardware firewall modified for the use of Telepsychiatry. The technology and work flows we have developed has also the following features

  • ISO 27001 (International Organization for Standardization)
  • FISMA (Federal Information Security Management Act)
  • HIPAA, with Business Associate Agreement memorializing implementation of physical, technical and administrative safeguards, and breach notification requirements of ARRA/HITECH
  • EU Safe Harbor
  • EU Model Clauses
  • Data Processing Agreement


ARE THERE SUPPORTING TECHNOLOGIES TO INCREASE THE QUALITY OF TREATMENT ALONG SIDE TELEPSYCHIATRY?

The answer is yes! We have partnered with a reputable computerized testing company that assist in diagnosis and outcomes highly needed in the current industry. We have also partnered with a key pharmacogenomics company that we can match our patient’s genes to medication response reducing the guesswork of prescribing. Lastly, we have partnered with an innovative electronic prescription system that is paving the way and facilitating prescriptions across state lines in compliance with DEA requirements for Electronic Prescription for Controlled Substances (ECPS)

 IS TELEPSYCHIATRY PERMITTED IN ALL STATES?

You can imagine the excitement of hospitals and correctional facilities becoming aware that telemedicine is an option to help their population. However phsycians must be extremely careful and knowledgeable of laws for each state. Some states have become leaders in approving telemedicine including Texas, Kentucky, Ohio and other states. However it is not widely accepted yet. As of August 2012 here are the summary findings from the Federation of State Medical Boards (FSMB):

  • Ten (10) state boards issue a special purpose license, telemedicine license or certificate, or license to practice medicine across state lines to allow for the practice of telemedicine.
  • Fifty-seven (57) state boards plus the DC Board of Medicine require that physicians engaging in telemedicine are licensed in the state in which the patient is located.
  • Minnesota allows physicians to practice telemedicine if they are registered to practice telemedicine or are registered to practice across state lines.
  • Nineteen (19) states require private insurance companies to cover telemedicine services to the same extent as face-to-face consultations.
  • Massachusetts permits coverage for services provided through telemedicine as long as the deductible, copayment or coinsurance doesn’t exceed the deductible, copayment or coinsurance applicable to an in-person consultation.

 

IS TELEPSYCHIATRY REIMBURSED BY INSURANCE COMPANIES?

Telepsychiatry is reimbursed and recognized by Medicare  and Medicaid.  Medicare reimburses for Telepsychiatry at the same rate as face-to-face.  Medicare also reimburses $18 per session for the staff person presenting with the client (Telehealth originating site facility fee - CPT code Q3014).  Medicare imposes three restrictions on the use of Telepsychiatry/telehealth:

  • Geographic - The consumer must be located in a non-metropolitan statistical area  
  • Facility - The consumer must be located in a qualifying facility and accompanied by a qualified staff person.
  • Procedure - Must be an approved procedure for telehealth

Currently approved Medicare telehealth services include the following evaluations and procedure:

  • Initial inpatient consultations
  • Follow-up inpatient consultations
  • Office or other outpatient visits
  • Individual psychotherapy
  • Pharmacologic management
  • Psychiatric diagnostic interview examination
  • End Stage Renal Disease (ESRD) related services
  • Individual medical nutrition therapy (MNT)
  • Neurobehavioral status exam
  • Individual health and behavior assessment and intervention (HBAI)
     

SO IS THIS EXPENSIVE TO IMPLEMENT IN A HOSPITAL OR CORRECTIONAL FACILITY?

There are many companies out there that provide very expensive start up cost and annual maintenance. Thus making Telepsychiatry not attractive to Hospital and correctional facilities. In Fact The california Institute for Mental Health in 2002 came with cost. Looking at this report it can be discouraging.

However, The Lado Healing Institute will provide the facility with the technology needed for Telepsychiatry All that is required at the facility is an exam room with a computer and a webcam. We will loan and license our technology for the facility for a very nominal monthly fee. It will not cost your facility thousands of dollars often offered by big companies.  We can work along side with any of your allied health staff such as a nurse practitioner and information will be available for clinicians in treatment teams that will meet Medicare Benefit Policy Manual Chapter 2 ongoing criteria for  inpatient psychiatric treatment but also for prisons and jail inmates.
 

WHAT ARE THE REGULATORY STANDARDS FOR TELEPSYCHIATRY?

Lado Healing Institute implements technology that meets the standards of The Department of Defense Task Force on Mental Health established by section 723 of the National Defense authorization Act (NDAA). Our system also meets all the standards of JACHO standards of telemedicine.

Using telemedicine does not require any new forms except a telemedicine consent form by the patient. We can use any implemented Electronic Health records system in the facility. However, If the hospital does not have Electronic Health Records, our technology also has the ability to convert the facility-approved forms into a digital format that can be distributed to the nurses, treatment team, therapist etc. without incurring additional cost on the facility. Set up is done directly from our home office in florida without utilizing the hospital or facility personal or resources but it is very welcome. We will provide the facility with two or three hardware devices to meet the TITLE XIII—HEALTH INFORMATION TECHNOLOGY requirements.
 

SO WHAT DO YOU NEXT?

1. HOSPITAL AND CORRECTIONAL FACILITIES.

Our business plan and contracts meets all the guidelines Federal Fraud and Abuse: Anti-Kickback Statute for telemedicine. A detailed one-hour presentation is all that is required to show you the product. Please call our office or send an email to set up a meeting by teleconference or in person. A non-disclosure agreement will be required before the meeting to protect the trade secret of our cost effective technology. After years of experience we have fine-tuned the system that is difficult to duplicate the highly secure product while keeping the cost low. We are not selling any electronic records but rather the professional services to provide psychiatric care over in the internet meetin the needs of your hospital or correctional facility. Even though we have the capability of medical documents management it would a separate product not needed to implement Telepsychiatry.

2. PSYCHIATRIST AND LOCUM TENEMS COMPANIES

The Lado Healing Institute can license this technology to psychiatrist and locum tenems companies. There is an initial setup fee for less than $1000 which will cover equipment needed to attach to the computer as well HIPPA required settings. We preconfigure the security settings at our home office the rest of the setup can be done remotely. Depending on the number of patients that you will use for the equipment we can arrange a less than $20 per patient fee or monthly agreed payment depending on the number of patients the psychiatrist will evaluate. The monthly agreed payment are discounted and less than per patient use. Technical support 24/7 is included in the contract with no additional cost. The setup for the software and hardware can take up from 3 to 5 business days from our technical staff. Your are required to have a computer with a webcam only. We do the rest. Email us or call us.  A non-disclosure agreement will be required before the meeting to protect the trade secret of our cost effective technology.

you can send us an email to email@ladomd.com or call (239) 948-4325 ext 2. Make sure you mention that you are calling for telepsychiatry and leave a message.

Psychiatry | Addiction Recovery | Suboxone and Campral treatments in Naples, Bonita Springs & South Florida

Lado Healing Institute ®
Leonard A Lado MDTM, RPh, ABPN

American Board of Psychiatry and Neurology
Board Certified Psychiatrist

9776 Bonita Beach Rd Suite #202B
Bonita Springs, FL 34135
Phone: (239) 948-4325
Fax:    (239) 288-0574
Email: email@ladomd.com

>>> Located inside the HealthCare of Bonita Springs Building!


© 2007 -2017 copyright Leonard A Lado MDTM
® http://www.ladomd.com/

9776 Bonita Beach Road SE, Suite 202B

Bonita Springs, FL 34135
>>> Located inside the HealthCare of Bonita Springs Building!
 

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