talking to a psychiatrist over the web while in the emergency department, telehealth
An emergency department patient talks with a psychiatrist via a secure network. Photo courtesy of Albemarle Hospital. Photo credit: Richard Muldez.


In rural parts of North Carolina, the option of seeing a mental health professional via video link is easing access to care.

By Mebane Rash

Getting mental health care to the rural areas of North Carolina has never been easy. Twenty-eight counties across the state still do not have a psychiatrist. This workforce shortage is real, and it has a real impact on the lives of those needing mental health treatment in places that are far away. Often people resort to their local hospital emergency room for treatment. No one questions the existence of the problem, but solutions have been hard to find.

talking to a psychiatrist over the web while in the emergency department
An emergency department patient talks with a psychiatrist via a secure network. Photo courtesy of Albemarle Hospital. Photographer: Richard Muldez

On Jan. 1, the state launched a new statewide telepsychiatry program to change the way mental health care is provided to people in need in very rural areas all across our state. If it is successful, it may pave the way for other telemedicine initiatives, including urban areas. Gov. Pat McCrory supports the use of telepsychiatry and the legislature appropriated $2 million for 2013-14 and $2 million for 2014-15 for the program.

Telepsychiatry is part of a growing national trend called telemedicine, in which physicians can see patients from remote locations using secure videoconferencing. Using this system, a psychiatrist or other professional can talk to and physically view the patient through a video screen with a web camera and microphone. On the other end, the patient can view the psychiatrist through a similar audio-visual system.

This technology creates a way for mental health and substance-abuse services to be delivered in rural areas of the state, easing the pressure of the state’s mental health workforce shortage on hospital ERs. Sy Saeed, chair of the department of psychiatric medicine at East Carolina University, said, “There is no health without mental health. If you don’t have professionals in the area, you have a problem.”

The statewide program will build on the success of earlier telepsychiatry initiatives in northeastern North Carolina. Saeed pioneered the use of this technology; in operation since 1992, ECU has one of the longest continuously running telemedicine centers in the world. ECU’s telemedicine center provides telepsychiatry services at a variety of sites, ranging from state psychiatric hospitals to family doctors to pediatricians to residential schools for the deaf and blind.

Overcoming barriers

For many people, access to mental health treatment is the biggest barrier to recovery. Telepsychiatry will increase access, but this is not a slam dunk. The success of the program will depend on the answers to some important questions. Will in-state psychiatrists be able to meet the demand for services? Will iPads and other lower-cost handheld devices be able to be used? For North Carolina’s telepsychiatry program to be a national model, the state, private funders, providers, insurers and patients will need to work together.

Telepsychiatry connects patients that need help with providers that are located somewhere else. Right now, that somewhere else might be a psychiatrist at East Carolina University, for example. But it is not hard to imagine that someday the psychiatrist might be located out of state or even in another country. Rep. Jim Fulghum (R-Raleigh) said, “The non-North Carolina medical professional credentialing problem needs immediate clarification for all forms of telemedicine delivery.”

showing off the telepsychiatry equipment
Telepsychiatry project director Sharon Davies demonstrates how the telepsychiatry unit functions. Photo credit: Rose Hoban

A psychiatrist licensed and located in another state who wants to provide telepsychiatry services in North Carolina must also have a license to practice medicine here. A license is required in both states. For the state’s telepsychiatry program to be a success, there must be enough interest from licensed physicians in this state to meet the demand.

The technology

And lots of confusion exists about which devices can be used to provide telepsychiatry. The only thing that is clear is that technology is changing quickly.

Right now, the mobile telemedicine carts being used in the telepsychiatry program cost $19,000 and the desktop units for the psychiatrist cost $9,000. According to a statement from Blue Cross and Blue Shield of North Carolina, “The need for expensive equipment may not be justified for this type of program given the nature of videoconferencing capabilities in personal devices.” But it is important for the technology being used by the patient to align with the technology used by the providers.

Providers have two questions about using a device like an iPad. One question is whether it complies with the federal law known as HIPAA (the Health Insurance Portability and Accountability Act), which protects patient privacy. The other question is whether the treatment provided using an iPad would be covered by Medicaid.

Freddie Zufelt, an attorney who practices health care and privacy law, said, “Physicians that wish to use iPads or other mobile devices in their practices may do so in a HIPAA-compliant manner, provided that they evaluate the potential security risks associated with the device and implement reasonable and appropriate safeguards, such as encryption, to protect against those risks.”

North Carolina’s Medicaid policy indicates “video cell phone” conversations are not covered, and the state may need to clarify that the use of iPads is different.
Gwen Newman, a patient who uses telepsychiatry in Hyde County, told her provider, “Driving an hour and a half to go to the doctor or to get one of my family members there is exhausting and frustrating. This telemedicine program makes a huge difference for all of us. I know we’re healthier because of it.”

Mebane Rash is director of law and policy for the nonpartisan N.C. Center for Public Policy Research.

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