Telepsychiatry Appointment Adherence and Productivity During COVID-19

The United States healthcare system has been transformed by COVID-19, with telemedicine technology being one of the most significant drivers of thought and change. Prior to COVID-19, telepsychiatry had already experienced significant expansion. The great promise of telepsychiatry was to provide a feasible alternative for scarce mental health services and to alleviate the problem of underdiagnosing and undertreating persons with mental illness. By 2019, the entire United States and the District of Columbia provided some coverage for telepsychiatry services for Medicaid members, and 42 states had telepsychiatry commercial payer laws, although there was considerable variability across states.

Despite increased financial reimbursements and studies suggesting a high degree of patient satisfaction and acceptance, systematic and policy concerns dissuaded many providers from entering telepsychiatry services. (4) By 2018, only about 5% of psychiatrists who provided care in the Medicare system had provided at least one telemedicine visit. Uncertainty regarding state-to-state policy differences, lack of reimbursement parity, lack of comfort with telemedicine technologies, confidentiality concerns, licensure, and credentialing restrictions, and malpractice risks were impediments to the implementation and sustainability of telepsychiatry services. As COVID-19-related illnesses necessitated shelter-in-place orders across the country, many psychiatrists were faced with the challenge of transitioning to telemedicine within a matter of days. This difficult transition was made possible by immediate changes in the regulation and reimbursement of telemedicine.

The legislation allowed for the easing of telehealth restrictions for Medicaid patients by removing penalties for potential HIPPA violations, changing regulations to allow providers to practice telemedicine across state lines, and suspending the Ryan Haight Act which had prohibited the use of telehealth when prescribing controlled substances. The common denominator of these policy changes is that they address the economic and technological barriers which have hampered the growth of telemedicine. The field of psychiatry, however, is particularly dependent upon personal interaction and subjective client-patient dynamics for successful practice. The unknown and previously unstudied variable is whether psychiatric services can transition to a virtual-meeting format during a public health crisis without the loss of appointment adherence. There has been researching prior to COVID-19 on adherence to appointments and clinic productivity comparing telepsychiatry to face-to-face meetings.

Studies have found comparable and sometimes superior adherence with telepsychiatry, they generally involved a retrospective process in which patients were randomly assigned voluntarily to one modality versus the other. COVID-19, in contrast, has caused an abrupt and mostly involuntary transition to telepsychiatry. To better understand the impact of this change in psychiatric care delivery, this retrospective chart review was conducted to compare equivalent time intervals preceding verses after telepsychiatry implementation with the intent of comparing productivity and medication check appointment adherence at a community mental health center. Methods This retrospective chart review study was conducted at Southwestern Human Services, a community mental health center in Pittsburgh, PA.

The variables for the study were the total number of psychiatric medication checks scheduled, the number of missed appointments (no-shows), and psychiatric productivity, which was defined as the percentage of available psychiatric med check time utilized with patient encounters. Initial psychiatric evaluations and psychotherapy visits were not included in the study. Telepsychiatry services were started on March 23, 2020, which is the date that Pittsburgh and surrounding regions were ordered by the Governor of Pennsylvania to shelter in place due to COVID-19. No telepsychiatry services of any type were performed at the clinic prior to that date. The telepsychiatry service time interval studied was the 11-week span from March 23, 2020, to the end date of the shelter in place order, which was June 5, 2020. During this period, the clinic did not offer the option of face-to-face meetings. January 6, 2020, to March 22, 2020, was the 11-week interval preceding telepsychiatry studied for comparison.

For this study, a no-show was defined as a psychiatric med check for which the parent, guardian, or identified client did not attend without advance same-day call or notification. Prior to the transition date of March 23, 2020, face-to-face psychiatric med checks were scheduled from 2 to 12 weeks in advance, with an appointment reminder by telephone call one business day prior to the scheduled appointment. For the purpose of implementing telepsychiatry visits as of March 23, patients were contacted by phone 24 hours prior to each scheduled appointment as a reminder that a text message link enabling entry into the psychiatrist’s ‘Doxy.me’ virtual waiting room would be sent to the patient’s cellphone 15 minutes prior to the appointment. ‘Facetime’ or ‘Google Duo’ platforms were used as back-ups in the event of a ‘Doxy.me’ connection failure.

At no point in the study did the clinic utilize a no-show fee or any similar penalty for a missed appointment. Per clinic protocol, all minor-aged patients were required to be attended by a parent or legal guardian for face-to-face and telemedicine visits, unless otherwise legally emancipated. The no-show rate and psychiatric productivity for the 11-week period prior to the implementation of telepsychiatry med checks as compared to the 11 weeks afterward using a one-tailed Z test for statistical significance (alpha = 0.5). Results For 11 weeks preceding the implementation of telepsychiatry med checks, 1053 med checks were scheduled of which 948 were attended and 105 were no-showed, representing a 9.97 % no-show rate. For the 11 weeks after the implementation of telepsychiatry, 915 med checks were scheduled of which 829 were attended and 86 were not shown, representing a 9.40% any show rate.

There was not a significant difference in no-show percentages between the compared time intervals. (Z = 0.428, p = .3336) There were 1188 med check time slots available prior to the implementation of telepsychiatry, of which 948 were attended, representing productivity of 79.80%. After the implementation of telepsychiatry, there were 1012 med check time slots available, of which 829 were attended, representing productivity of 81.92%. There was not a significant difference in productivity between the compared time intervals. (Z = -1.257, p = .10383) Discussion The results of this study suggest comparable psychiatric med check no-show percentages and productivity before and after the implementation of telepsychiatry services, reflecting the findings of relevant past studies done prior to COVID-19. Research on appointment nonadherence in psychiatry has found a myriad of contributing variables such as transportation problems, motivational limitations, and financial concerns about missing work.

Telepsychiatry would seem to be a potential solution to issues of compliance and productivity, and some pre-COVID-19 studies have found no difference in patient satisfaction with telepsychiatry as a modality when compared to face-to-face appointments. Despite the temptation to conclude that telepsychiatry is the preferred venue for the future of psychiatric services, there is much to consider. Abruptly transitioning large numbers of mental health clients to telepsychiatry amid a public health emergency was an undesired, untested, and unstudied experience. The clients in this study had no alternatives to virtual meetings, and adherence does not necessarily equate with satisfaction. The absence of comparative patient satisfaction ratings is an obvious limitation of this study. Another major limitation is the omission of objective measurements to study COVID-19-related influences on mental health. There is mounting evidence that COVID‐19 is having a profoundly negative effect on societal mental health, with anxiety, sleep disturbance, irritability, and feelings of despair becoming widespread.

The question remains whether, amid the prolonged physical and emotional isolation of a pandemic, telepsychiatry will enable, enhance, or hinder the conventional doctor-patient relationship. One concern is that virtual visits could produce a false sense of presence which would worsen preexisting feelings of social isolation. In conclusion, this study is further evidence of the transformative impact of COVID-19 on healthcare. Whether patients will be better served as a result remains to be determined. Perhaps the only certainty is that COVID-19 will persist for the foreseeable future, creating a tenacious innate experiment that will force each of us to constantly reexamine how to best serve the needs of our patients.