Forensic Competency Assessment with Digital Technologies.

PURPOSE OF THE REVIEW: We review the application of videoconferencing (VC) to pretrial forensic assessments of competence to stand trial (CST). We summarize the benefits, legal considerations, and reliability of VC evaluations. Based on our experience with VC in forensic settings, we provide illustrations of challenges and recommendations regarding this capability to meet increasing demands for services. RECENT FINDINGS: CST evaluations are the most frequent type of forensic mental health assessment within the American legal system. VC can be a reliable method for conducting interviews with most defendants, including those with psychotic symptoms. Videoconferencing can improve the overall efficiency of evaluations while also improving the safety of the professionals involved with the competency evaluation. VC provides an opportunity to meet the increasing demand for evaluations and improve their efficiency. Forensic clinicians should become familiar with the uses of VC in delivering services so that VC is implemented ethically and effectively.

Best Practices in Videoconferencing-Based Telemental Health April 2018.

Telemental health, in the form of interactive videoconferencing, has become a critical tool in the delivery of mental health care. It has demonstrated the ability to increase access to and quality of care, and in some settings to do so more effectively than treatment delivered in-person. This article updates and consolidates previous guidance developed by The American Telemedicine Association (ATA) and The American Psychiatric Association (APA) on the development, implementation, administration, and provision of telemental health services. The guidance included in this article is intended to assist in the development and delivery of effective and safe telemental health services founded on expert consensus, research evidence, available resources, and patient needs. It is recommended that the material reviewed be contemplated in conjunction with APA and ATA resources, as well as the pertinent literature, for additional details on the topics covered.

Practical Issues in Delivery of Clinician-to-Patient Telemental Health in an Academic Medical Center.

BACKGROUND: In the age of online communication, psychiatric care can now be provided via videoconferencing technologies. While virtual visits as a part of telepsychiatry and telemental health provide a highly efficient and beneficial modality of care, the implementation of virtual visits requires attention to quality and safety issues. As practitioners continue to utilize this technology, issues of clinician licensing, treatment outcomes of virtual visits versus in-person visits, and cost offset require ongoing study. METHODS: This review provides an overview of the topics of technology, legal and regulatory issues, clinical issues, and cost savings as they relate to practicing psychiatry and psychology via virtual visits in an academic medical center. We review the telepsychiatry/telemental health effectiveness literature from 2013 to the present. Our literature searches used the following terms: telemental health effective, telepsychiatry effective, telepsychiatry efficacy, and telemental health efficacy. These searches produced 58 articles, reduced to 16 when including only articles that address effectiveness of clinician-to-patient services. RESULTS: The technological, legal, and regulatory issues vary from state to state and over time. The emerging research addressing diverse populations and disorders provides strong evidence for the effectiveness of telepsychiatry. Cost savings are difficult to precisely determine and depend on the scope of the cost and benefit measured. CONCLUSION: Establishing a telepsychiatry program requires a comprehensive approach with up-to-date legal and technological considerations.

Legal Mapping Analysis of State Telehealth Reimbursement Policies.

BACKGROUND: There exists rapid growth and inconsistency in the telehealth policy environment, which makes it difficult to quantitatively evaluate the impact of telehealth reimbursement and other policies without the availability of a legal mapping database. INTRODUCTION: We describe the creation of a legal mapping database of state-level policies related to telehealth reimbursement of healthcare services. Trends and characteristics of these policies are presented. MATERIALS AND METHODS: Information provided by the Center for Connected Health Policy was used to identify statewide laws and regulations regarding telehealth reimbursement. Other information was retrieved by using: (1) LexisNexis database, (2) Westlaw database, and (3) retrieval from legislative Web sites, historical documents, and contacting state officials. We examined policies for live video, store-and-forward, and remote patient monitoring (RPM). RESULTS: In the United States, there are 24 states with policies regarding reimbursement for live video transmission. Fourteen states have store-and-forward policies, and six states have RPM-related policies. Mississippi is the only state that requires reimbursement for all three types of telehealth transmission modes. Most states (47 states) have Medicaid policies regarding live video transmission, followed by 37 states for store-and-forward and 20 states for RPM. Only 13 states require that live video will be reimbursed "consistent with" or at the "same rate" as in-person services in their Medicaid program. DISCUSSION: There are no widely accepted telehealth reimbursement policies across states. They contain diverse restrictions and requirements that present complexities in policy evaluation and in determining policy effectiveness across states.

Connecting the disconnected: Preliminary results and lessons learned from a telepsychology initiative with special management inmates.

The use of telepsychology, such as videoconferencing (VC) systems, has been rapidly increasing as a tool for the provision of mental health services to underserved clients in difficult to access settings. Inmates detained in restrictive housing appear to be at an increased risk of experiencing emotional and behavioral disturbances compared to their general population counterparts, yet they are less likely to receive appropriate treatment due to security constraints. The primary purpose of this article is to describe the process of implementing a novel telepsychology intervention specifically designed to offer group therapy to high-security, administratively segregated inmates. In addition, preliminary results on treatment and therapeutic process outcomes in a sample of 49 participants are reported. Although some evidence indicated that telepsychology was less preferred than in-person sessions, group differences on measures of psychological functioning and criminal thinking were not found across 3 conditions (telepsychology, in-person, and a no-treatment control). Furthermore, a number of limitations associated with program implementation and study design suggest that results be interpreted with caution and should not be used to discount the use of telepsychology as a viable treatment delivery option. Recommendations for future development and evaluation of telepsychological programs are discussed within the context of correctional settings and beyond. (PsycINFO Database Record

Overcoming challenges to sustain a telestroke network.

Our objectives are to identify and help overcome obstacles to telestroke practice, to present tips for sustaining a telestroke network, to suggest strategies for obtaining buy-in from clinicians and administrative leadership and providers, and to identify and engage champions and stakeholders of telestroke.

Exempting in-home video telehealth from copayments. Direct final rule.

The Department of Veterans Affairs (VA) is taking final action to amend its regulation that governs VA services that are not subject to copayment requirements for inpatient hospital care or outpatient medical care. Specifically, the regulation is amended to exempt in-home video telehealth care from having any required copayment. This removes a barrier that may have previously discouraged veterans from choosing to use in-home video telehealth as a viable medical care option. In turn, VA hopes to make the home a preferred place of care, whenever medically appropriate and possible.

Informed consent for videoconsultations in Canada.

We performed a qualitative study of the practice of informed consent for videoconsultation in Canada. Fourteen cases were examined: the 13 provinces and territories, and the Federal jurisdiction representing aboriginal groups. Twenty-seven interviews were conducted with key informants (14 telehealth experts, 13 legal experts). The telehealth experts were people with direct experience of telehealth practice. The majority of the telehealth experts agreed that videoconsultations had not been integrated into the health-care system. An interesting finding of the study was that the integration status of videoconsultations was not indicative of informed consent practices. Telehealth providers favoured express written consent, or risk management practices, although there was a desire to move towards implied consent models for videoconsultations. The study also showed that the legal ramifications of the electronic transmission of non-recorded, real-time, personal health information had not been explored. This represents an important factor in guiding future consent for videoconsultations in Canada.

Videoconferencing and forensic mental health in Australia.

Videoconferencing is in common use in Australian forensic mental health services. It provides opportunities to link remote prisons, courts, and psychiatric clinics with distant specialist services, and enables a range of activities including assessment, treatment and feedback, expert testimony, education, and inter-service planning. These functions are acceptable to patients and clinicians, and in Australia videoconferencing minimizes disruption to small services and their patients, who might otherwise face lengthy journeys. In particular, marginalized patient groups, including indigenous people and prisoners, may receive better services. The evidence base supports use of videoconferencing despite a number of practical, legal, and clinical issues that may reduce its effectiveness compared with face-to-face assessments. Videoconferencing technologies are critical to effective forensic mental health services in Australia.

Telepsychiatry with rural American Indians: issues in civil commitments.

The use of live interactive videoconferencing to provide psychiatric care, telepsychiatry, has particular relevance for improving mental health treatment to rural American Indian reservations. There is little literature on civil commitments in telepsychiatry and none specifically addressing this topic among American Indians. This article reviews telepsychiatry in the mental health care of American Indians, civil commitments and telepsychiatry in general, and the current state of civil commitments in American Indian communities. We conclude by considering commitment through telepsychiatry in rural reservations and offering guidelines to assist practitioners in navigating this challenging landscape. Civil commitments of American Indian patients residing in rural reservations can be successfully accomplished through videoconferencing by thoughtful and informed clinicians. However, much more work is needed in this area, including research into the cultural attitudes and perspectives towards commitments and further inquiry regarding potential legal precedents, as well as case reports and examples of this work.

VA telemental health: suicide assessment.

The Department of Veterans Affairs (VA) encompasses one of the largest telemental health networks in the world, with over 45,000 videoconferencing and over 5,000 home telemental health encounters annually. Recently, the VA designated suicide prevention as a major priority, with telehealth modalities providing opportunities for remote interventions. Suicide risk assessments, using videoconferencing, are now documented in the literature, as are current studies that find telemental health to be equivalent to face-to-face treatment. Remote assessment of suicidality, however, involves complex legal issues: licensing requirements for remote delivery of care, legal procedures for involuntary detainment and commitment of potentially harmful patients, and liability questions related to the remote nature of the mental health service. VA best practices for remote suicide risk assessment include paradigms for establishing procedures in the context of legal challenges (licensing and involuntary detainment/commitment), for utilizing clinical assessment and triage decision protocols, and for contingency planning to optimize patient care and reduce liability.

Forensic telepsychiatry in the United Kingdom.

Forensic telepsychiatry remains in its infancy in the United Kingdom. This article sets out to describe how it can be used within a community forensic service, and the future challenges ahead in the United Kingdom. It looks at relevant academic, governmental, and legal resources and is designed as a scholarly reflection by clinicians rather than as a formal literature review.

Empirical evidence on the use and effectiveness of telepsychiatry via videoconferencing: implications for forensic and correctional psychiatry.

A growing body of literature now suggests that use of telepsychiatry to provide mental health services has the potential to solve the workforce shortage problem that directly affects access to care, especially in remote and underserved areas. Live interactive two-way audio-video communication-videoconferencing-is the modality most applicable to psychiatry and has become synonymous with telepsychiatry involving patient care, distance education, and administration. This article reviews empirical evidence on the use and effectiveness of videoconferencing in providing diagnostic and treatment services in mental health settings that serve child, adolescent, and adult populations. Descriptive reports, case studies, research articles, and randomized controlled trials related to clinical outcomes were identified and reviewed independently by two authors. Articles related to cost-effectiveness, technological issues, or legal or ethical aspects of telepsychiatry were excluded. The review of the evidence broadly covers mental health service provision in all settings, including forensic settings. Given the sparse literature on telepsychiatry in forensic settings, we discuss implications for mental health care across settings and populations and comment on future directions and potential uses in forensic or correctional psychiatry.

Teleconferencing model for forensic consultation, court testimony, and continuing education.

A medical center-based forensic clinic that provides the necessary comprehensive consultation, continuing education, court testimony, and clinical services through an applied model of teleconferencing applications is addressed. Telemedicine technology and services have gained the attention of both legal and clinical practitioners, examining trends and models of health care for underserved populations, and identifying where consultation with a team of professionals may benefit service providers in rural communities. The contribution offered herein provides an understanding of the history of the development of the clinic, a theoretical model that has been applied to a clinical forensic program that employs telepsychiatry services, and the ethical and malpractice liability issues confronted in using teleconferencing services. This model is examined through a child and adolescent forensic evaluation clinic. The goals of this model are offered, as are a number of applications within the broad spectrum of services utilizing telemedicine. Finally, changing patterns are addressed in clinically based health-care delivery for criminal justice, social services, and forensic mental health.

Informed consent to e-therapy.

E-therapy, the provision of mental health treatment through the Internet, poses many risks as well as benefits. This article addresses some relevant risks and benefits of e-therapy and discusses the practicality of using computers in the informed consent process. Although e-therapy has numerous proponents, no clinical trials have assessed its long-term effectiveness. To limit liability and to protect patients, e-therapy providers should disclose material risks as well as possible benefits and engage patients in an active dialogue. A thorough informed consent procedure enables patients to make an educated decision about whether e-therapy is right for them. In the future, e-therapy and informed consent online may become more common; in the mean time, clinicians must be prepared for e-therapy's uncertain legal status and allow patients to decide for themselves whether or not to seek counseling on the Internet.