Month: May 2016

Using Telehealth for Behavioral Crisis Assessments in Rural Communities

The third in a series of articles on developments in telepsychiatry.

Rural communities throughout the U.S. face severe shortages of trained mental health professionals. Here are some key statistics:

  • More than 60% of rural Americans live in mental health professional shortage areas.
  • More than 90% of all psychiatrists and psychologists and 80% of all MSWs work exclusively in metropolitan areas.
  • More than 65% of rural Americans obtain their mental health care from their primary care provider.

As a consequence, more than 91 million Americans live in areas with a mental healthcare provider shortage. Further, nearly 1 in 8 patients who present to the hospital emergency department (ED) come with a mental health and/or substance abuse issue, which on average require a lengthier boarding period than patients with non-psychiatric complaints. Telehealth presents a potential solution to the challenges confronted by patients and providers in rural settings, especially within the context of the ED.

Small towns face a number of unique behavioral care challenges. These challenges include elevated stigma around issues of mental health, increased liability and inpatient admissions, inadequate medical necessity documentation, higher rate of patient return visits to the emergency department, and a general lack of access to behavioral health resources. To tackle these issues, small towns should aim for better assessment and clearer patient psych picture in the ED, increased support for patients discharged from the ED, reduce repeat visits to the ED, and reduced re-admissions to the behavioral health unit.

Telehealth administrators should anticipate and prepare to respond to several concerns that emergency room providers may voice, including the potential for delay to ED patient care, loss of decision-making rights, and concerns about the process specific to behavioral health. Administrators must also manage effective networking and partnerships for successful treatment of patients in rural settings, including between the care team, patient and family, community providers, hospitals and clinics, and technology partners.

Providers can assess the success or failure of a telehealth implementation at their care site by measuring a number of metrics around patient care, including: (i) number of discharged patients connected to care (ii) percentage reduction in inpatient lengths of stay (iii) percentage reduction in inpatient re-admissions (iv) percentage reduction in re-assessments (v) percentage reduction in total admissions (vi) percentage reduction in denials (vii) percentage reduction in 1-to-1 patient watch (viii) percentage reduction in transportation costs (ix) percentage reduction in wait times (x) percentage increase in shared decision-making (xi) percentage improved assessment and documentation (xii) percentage bed access rate.

A successful telehealth program can provide small town providers with increased ED care team education, appropriate treatment recommendations, clearer clinical picture with thorough documentation, improved communication between the ED and follow-up care, and expansion of behavioral health services. In addition, telehealth enables providers increased access to health history and leads to better performance in provider reviews and surveys and, for patients, provides reduced travel expenses, comprehensive care, access to more providers, and timely access to follow-up care.

Prescribing Controlled Substances via Telemedicine

The second in a series of articles on developments in telepsychiatry.

Controlled Substances Act

The Controlled Substances Act (CSA) of 1970, a key structural element of the DEA’s authority, combined existing federal drug laws and expanded their scope, changed the nature of federal drug law policies, and expanded federal law enforcement pertinent to controlled substances. Several amendments to CSA followed over the next several decades up through 2010, which together circumscribe the prescription of controlled substances via telemedicine.

Definition of Controlled Substances

Controlled substances may fall under one of five schedules, as described in the following table (state and local laws may be more restrictive):

Schedule I No accepted medical use; high potential for abuse (e.g. heroine, ecstasy)
Schedule II Accepted medical use with severe restrictions; high potential for abuse (e.g., cocaine, morphine)
Schedule III Accepted medical use; moderate to low potential for abuse (e.g., codeine, Vicodin)
Schedule IV Accepted medical use; potential for abuse, but less than Schedule III (e.g., valium, Ambien)
Schedule V Accepted medical use; low potential for abuse (e.g., Robitussin AC)


Ryan Haight Online Pharmacy Consumer Protection Act

The Ryan Haight Online Pharmacy Consumer Protection Act of 2008 amends the Controlled Substances Act to prevent the illegal distribution and dispensation of controlled substances by means of the internet. The Act was passed by Senator Feinstein in response to the death of Ryan Haight, a teenager who overdosed on pain killers that he obtained in an illegal manner by exploiting gaps in the U.S. pharmacy system.

The Ryan Haight Act specifies that a prescribed controlled substance, as determined under the Federal Food, Drug, and Cosmetic Act, may not be delivered, distributed, or dispensed by means of the internet without a valid prescription. A valid prescription is a prescription issued for a legitimate medical purpose in the usual course of professional practice by a practitioner who has conducted at least 1 in-person medical evaluation of the patient, or a covering practitioner. A covering practitioner is a practitioner who conducts a medical evaluation (other than an in-person medical evaluation) at the request of a practitioner who has (a) conducted at least one in-person medical evaluation of the patient, or an evaluation of the patient through the practice of telemedicine within the previous 24 months and (b) is temporarily unavailable to conduct the evaluation of the patient. The intent of the Act is to prevent the generation of a prescription by an online pharmacy that also dispenses the medication; in other words, to separate the prescriber from the dispenser.

In addition, the Act exempts practitioners from the in-person exam requirement so long as they meet the federal definition of telemedical practice. A physician who practices telemedicine may prescribe a controlled substance without an in-person evaluation if (a) the patient is treated by and physically located in a hospital or clinic with a valid DEA registration, and (b) the telemedicine practitioner treats the patient in the usual course of professional practice.

DEA Electronic Prescriptions for Controlled Substances Rule

The DEA Electronic Prescriptions for Controlled Substances Rule of 2010 further revises DEA prescription regulations to (i) provide practitioners the option to write prescriptions for controlled substances electronically, (ii) permit pharmacies to receive, dispense, and archive these electronic prescriptions, and (iii) provide pharmacies, hospitals, and practitioners the ability to use modern technology for controlled substance prescriptions while maintaining the closed system of controls on controlled substances. The regulations supplement and do not replace existing DEA rules.

State Policies On Controlled Substance Prescription

In addition to the Ryan Haight Act and Electronic Prescriptions for Controlled Substances Rule, providers must be cognizant of state-specific laws and policies, as published by the National Association of State Controlled Substance Authorities. Further, controlled substances may be prescribed only through an electronic health record (EHR) system. An even split exists between states that require controlled substance registration and states that do not.

The following chart describes recent policy changes by a subset of states:

Arizona Providers do not pay a fee
Delaware Providers must complete 2 hours of controlled substances CME
Florida Prescriber profile designation
Minnesota Providers are exempt from registration
Mississippi Providers are exempt from registration, unless handling a controlled substance
Montana Providers are exempt from registration, but must pay a fee
New Hampshire Providers must participate in a drug monitoring program
North Carolina Solo practitioners are exempt from registration
Ohio Businesses that generate prescriptions must register
Oklahoma Providers must possess state residency



Practitioners engaged in the electronic prescription of controlled substances must develop comfort and familiarity with the Ryan Haight Online Pharmacy Consumer Protection Act, DEA Electronic Prescriptions for Controlled Substances Rule, and relevant state and local policies. Further, the variability in laws and policies state to state on this issue suggests that practitioners ought to take an active role in the influence of policymaking, work with EHR vendors to optimize process, and engage with associations and popular press to advance requirements and best practices central to electronic prescription of controlled substances.


Telemedicine and the Interstate Medical Licensure Compact

The first in a series of articles on developments in telepsychiatry.

A Barrier to Telemedicine Adoption

One barrier to the adoption of telemedicine services over the last several years has been a lack of integration within the state medical licensing system. Requirements vary by state, however, the general consensus is that a physician must be licensed in both the state where he or she is located and the state in which the patient is located.

Physicians who wish to treat patients in multiple states must proceed through a lengthy and expensive licensure application for each state in which they wish to practice. The process also often requires extensive paperwork, lengthy processing times, and in some cases, written exams. A flood of bills in recent years, including the Telehealth Enhancement Act of 2015, VETS Act, and TELE-MED Act of 2015, have sought to eliminate the geographic restrictions on telehealth services and, thus, enable doctors to deliver care to patients across the U.S. In this regard, the Interstate Medical Licensure Compact system developed by the Federation of State Medical Boards marks a major milestone in eliminating one of the barriers to telemedicine adoption.

Interstate Licensure Compact System

An Interstate Compact Commission will meet later this year to discuss the specifics of management and administration of the newly enacted Compact, but many important points have already been established. First, since telemedicine must be practiced appropriately and within the standards of licensing boards, the Compact maintains the existing authority of all participating state’s licensing boards. Secondly, the Medical Practice Act, which outlines the laws and regulations governing the practice of medicine within state boundaries, is maintained. Lastly, states will still receive the licensing fees of physician applications and maintenance of licensure and there will be no increase in state spend with the Compact.

The Compact does not provide one universal license for all participating states. It does, however, increase the ease and reduce the time required to obtain a medical license in other member states. Once physicians have completed the Compact process to receive another state medical license, they follow the same rules and regulations as if he or she had applied the traditional route. In order to join, physicians must meet the following requirements: (i) possess a medical license in one of the Compact states (ii) have a specialty certification (iii) have no discipline on any state medical licenses, and is not under investigation (iv) passed the USMLE or CMLEX (v) completed a GME program. In the application, physicians simply designate his or her state of principal licensure and select the other member states in which licensure is sought.

State-Level Adoption and Introduction of Compact Legislation

12 States have adopted the Interstate Medical Licensure Compact, including Alabama, Idaho, Illinois, Iowa, Minnesota, Montana, Nevada, South Dakota, Utah, West Virginia, Wisconsin, and Wyoming. States who participate in the Compact agree to expedite license applications for physicians who seek to practice medicine across state lines. Compact legislation has been introduced in 14 additional states, including Alaska, Arizona, Colorado, Kansas, Maryland, Michigan, Mississippi, Nebraska, New Hampshire, Oklahoma, Pennsylvania, Rhode Island, Vermont, Washington, with more expected to join this year. Most states’ physician licensure guidelines adhere to the telemedicine guidelines set forth by the Federation of State Medical Boards.


The Compact will join the ranks of similar professional regulations that facilitate interstate health care like the Nurses Licensure Compact (NLC) which launched in 2000. Other healthcare professions are also following suit and exploring their own licensure compact structures. The Compact represents a major step forward in the nationwide adoption of telemedicine and, in turn, the critical effort to bring quality patient care to rural and underserved areas.

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