When is telemedicine appropriate? A qualitative exploration of psychiatrists’ decision-making

Abstract

Objective:

With widespread adoption of telemedicine, psychiatrists must determine which visits are best conducted via telemedicine vs. in-person. While some telepsychiatry guidelines and best practices have been developed, no literature has described how psychiatrists make decisions about offering different care modalities. We aimed to explore how psychiatrists make decisions about the appropriateness of telemedicine for a given patient.

Methods:

From June 25-August 4, 2021, we conducted 20 semi-structured interviews with outpatient psychiatrists. We used critical incident technique and clinical vignettes to identify conscious and unconscious factors that influence the decision to offer telemedicine. Interview data was analyzed using inductive thematic analysis.

Results:

Psychiatrists perceived that almost all patients are good candidates for telemedicine visits in the context of hybrid care models. What drove telemedicine vs. in-person care was patient preference as well as situational factors like access to private space instead of any particular diagnosis or patient demographic. Psychiatrists described numerous factors affecting their decision to offer telemedicine, and they were generally driven to try telemedicine and adjust as needed to “meet patients where they are” and improve engagement in care. Psychiatrists reported using telemedicine as a bargaining chip in negotiations with patients, levering the offer of telemedicine to improve attendance or adherence with treatment.

Conclusions:

This first detailed assessment of how psychiatrists make decisions about different care modalities can inform clinical practice guidelines and reimbursement policies that mandate in-person visits with some frequency. Results showed that psychiatrists do not perceive intermittent in-person visits to be essential for high-quality care.

Introduction

The pace of adoption of telemedicine by U.S. psychiatrists has been staggering. While the majority of psychiatrists reported no experience with telemedicine priors to the COVID-19 pandemic, in the spring of 2020 85% reported seeing more than three-fourths of their patients via telemedicine.(1) Although overall telemedicine use has declined from its peak early in the COVID-19 pandemic,(2) it has remained a dominant model among specialty behavioral health providers. As of December 2020, it was estimated that more than half of all behavioral health visits occurred via telemedicine.(3)

It is clear that telemedicine will become a permanent feature of practice, and psychiatrists will increasingly offer hybrid care models that consist of both telemedicine and in-person visits.(4) Although there is uncertainty about the future of telemedicine policy in other clinical areas, payers appear to be committed to covering telemedicine visits for behavioral health care in a hybrid model. In the Consolidated Appropriations Act passed in 2020, Congress permanently expanded telemedicine coverage for behavioral health but required that clinicians have some in-person visits.(5)

The potential advantage of a hybrid approach is that it allows clinicians and their patients to leverage the relative strengths of each modality. For example, telemedicine can increase access and convenience, and in-person visits can better support physical exams and on-site laboratory testing. However, offering hybrid models adds another layer of complexity, requiring clinicians to use their judgement to make individualized decisions about the appropriateness of different modalities. Given that many patients and clinicians are becoming comfortable with in-person care as the pandemic progresses,(6) psychiatrists are increasingly in a position to determine which visits are best conducted via telemedicine vs. in-person. While some telepsychiatry guidelines and best practices have been developed,(7–9) we could not identify any literature describing how psychiatrists make decisions about different care modalities and assess the appropriateness of telemedicine for a given patient.

Understanding how clinicians make decisions about telemedicine vs. in-person care is key to informing clinical practice guidelines as well as reimbursement policies that mandate in-person care with some frequency. To fill this gap in knowledge, we conducted semi-structured interviews with psychiatrists across the U.S. to explore how they make decisions about offering telemedicine.

Methods

Study Participants and Sampling Strategy

From June 25-August 4, 2021, we conducted 20 semi-structured interviews with psychiatrists practicing in outpatient settings. We worked with a research firm with an online panel of 730,000 physicians to recruit participants. The panel is composed of physicians who have joined the platform to access clinical content and continuing medical education activities, and has been used in multiple prior research studies.(10–12)

Psychiatrists in the panel were sent an eight-item screener survey to assess eligibility for participation, and those deemed eligible were invited to participate in a 60-minute videoconferencing interview with the study team. To be eligible, psychiatrists needed to have conducted both telemedicine and in-person visits in the prior month, and no one modality could represent more than 90% of all visits. In addition, they needed to work in an outpatient setting (providing direct clinical care for 8 or more hours per week) and treat adults. We conducted criterion sampling, but also sampled for heterogeneity to ensure that the final sample of psychiatrists varied along the following dimensions: practice setting, U.S region, and rurality.

Interviews

At the start of each interview, we defined telemedicine visits as synchronous video visits. We included probes about audio-only visits but did not include findings unique to that modality because participants reported providing relatively few audio-only visits. Interviews followed a semi-structured protocol that incorporated critical incident technique and clinical vignettes. Questions were designed to uncover both conscious and unconscious factors that influence the decision to offer telemedicine visits.

Critical Incident Technique

We first used the critical incident technique to uncover unconscious factors that influence the decision to offer telemedicine. This method asks participants to reflect on real-life experiences and as such “obtains a record of specific behaviors.”(13) It has been used in prior studies to explore prescribing and referral behaviors.(14–16) We asked psychiatrists to describe an example of a telemedicine visit where the quality of the visit was equivalent to an in-person interaction, and an example where they felt uneasy or uncomfortable about the quality of the visit.

Clinical Vignettes

Second, we presented four clinical vignettes developed by two psychiatrists on the study team (Box 1). Clinical vignettes are a research method in which a story or scenario is presented to research participants, and participants are prompted to reflect on it.(17) The literature on vignettes notes that this research method is particularly valuable in exploring an unobservable phenomenon (e.g., clinical decision-making).(18)

Box 1: Clinical Vignettes.

Vignette 1:

Mr. Jones is a 42-year-old single man with social anxiety disorder and agoraphobia, and a history of alcohol use disorder (moderate severity) and suicidal ideation. His anxiety has interfered with his engaging in AA and so he has limited support around maintaining his sobriety. He lives alone and has limited social/family contacts. He is stably housed, commercially insured, and employed full-time. He had a serious suicide attempt 3 years ago in which he required an ICU stay. His suicidal ideation worsens when he uses alcohol. He reports his last alcohol use was 6 months ago, but he increased craving over the past month. He denies current suicidal ideation, but you know from past experience with him that sometimes he is not entirely forthcoming about this initially. He has been in treatment with you for 1 year and until recently, adherent with visits and your treatment plan (medications and psychotherapy), but his anxiety continues to interfere with his functioning, and he struggles to leave the house, except for work, which he is managing to do with effort. You have recently started to transition to a new antidepressant to help alleviate his symptoms. You have noticed that over the past few months he has cancelled a couple of office sessions, often with a plausible excuse, but after the last cancellation you wondered if his anxiety/agoraphobia was a factor in this change of attendance.

Vignette 2:

Ms. Smith is a 23-year-old married woman with major depression who has been in treatment with you for the past year. She denies history of suicidal ideation or substance use disorder. She is stably housed and lives with her husband. She has talked about conflicts at home with her husband and describes their living space as cramped and hard to get any space to herself. She has struggled to maintain employment the past several years due to depressive symptoms, which have only been partially responsive to antidepressants and psychotherapy. Concerned about her persistent depressive symptoms and their impact on her functioning and quality of life, you have recently augmented her antidepressant with lithium. She recently began work in a fast-food restaurant, but the hours are not routine, and her schedule frequently changes. One thing that she enjoys about her job in the restaurant is that it gets her out of the house more. She is motivated in treatment but sometimes has missed office appointments due to scheduling conflicts related to work. Over the past several weeks she has become more depressed in the context of her mother being diagnosed with terminal cancer, and she notices that conflict with her husband seems worse. You screened and ruled out the possibility of intimate partner violence.

Vignette 3:

Mr. Columbo is a 54-year-old man with chronic paranoid schizophrenia and periodic marijuana use. He has been a patient in your practice setting for several years. He is disabled due to his schizophrenia and has Medicare and Medicaid insurance. He is prescribed antipsychotic medication; about once a year he stops taking it and then becomes paranoid and agitated, typically requiring a psychiatric hospitalization. He has refused long-acting injectable antipsychotic medication. He lives with his mother, who is 78. She is engaged in his care and supportive, but as she gets older it’s harder for her to oversee his care. You would like to see him more often, but he is resistant, typically agreeing to come in about once every 2 months. Neither he nor his mother drive, and he is unhappy about how long it takes when he comes by bus (the only public transportation available to him).

Vignette 4:

Mr. Doren is a 66-year-old man with a history of depression, who has been on fluoxetine 20mg for 4 years with recent dose increase a few months ago to 40mg. He is still reporting worsening depression, anxiety, and poor sleep in the setting of being laid off from his job 10 months ago. He feels depressed lately about being out of shape; he used to be fit but over the last 1–2 years has said his legs and arms feel heavy when trying to jog, sometimes one more than the other, and he feels depressed about aging. His wife mentioned he has seemed fatigued and fidgety or edgy, maybe because his sleep is often restless. He called to note some lightheadedness in the mornings over the last couple months, and he asked if it might be related to the medication dose increase. He reports that even walking feels effortful some days, he has felt gradually less coordinated and fit over time, and he feels overall less motivated to leave the house because of the effort required.

In the interviews, participants were asked to read each vignette and discuss their thoughts on the appropriateness of telemedicine in that particular case. Interviewers probed about what factors they considered in their decision.

Three members of the study team trained in qualitative research conducted the interviews. Interviews were recorded and transcribed. Participants were given a $225 gift card for their participation and provided verbal informed consent. This study was approved by RAND’s Institutional Review Board.

Data Analysis

We analyzed interview data using inductive thematic analysis.(19) We first conducted open coding of interview transcripts followed by axial coding to establish connections among themes. We treated decision-making factors that participants reported consciously considering as well as those revealed through thinking aloud (in vignette or critical incident technique questions) as equally important and triangulated findings across.

The lead author developed the initial codebook by reviewing 8 transcripts. The codebook was then discussed, refined, and finalized in group meetings among three members of the study team. The lead author then coded all transcripts using NVivo (Version 12) data analysis software.(20) Analyses began after three interviews had occurred, and saturation was reached (i.e., no new themes emerged) after 16 interviews.

Results

A total of 20 psychiatrists representing 13 different states participated. On average, participants reported they provided 58.0% of their visits via telemedicine (range 12.5%- 90.0%) (Table 1).

Table 1:

Participant Characteristics

	n (N=20)	%
Characteristic
Region of the U.S. *
Northeast	5	25
West	7	35
South	3	15
Midwest	5	25
Practice Setting
Community health center**	3	15
Community mental health center	1	5
Hospital-based outpatient clinic	7	35
Non-hospital based behavioral health specialty group practice	3	15
Partial hospitalization or intensive outpatient program	1	5
Solo private practice	5	25
Patient Population
Adults only	7	35
Children and Adults	13	65
Practice Location
Large city	9	45
Suburb	4	20
Rural area or small town	7	35
Time in Outpatient Setting
Full time (≥35 hours per week)	14	70
Part time (10–34 hours per week)	6	30
% of visits via telehealth in the prior month (mean, range)	58.6	(12.5, 90)

^*States represented included: Arizona, California, Georgia, Iowa, Kansas, Maryland, Michigan, New York, Ohio, Pennsylvania, Rhode Island, Texas, Washington,

^**Examples of community health centers include Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs).

Decision-making context

Impact of Spring 2020

Experiences converting visits to telemedicine in the spring of 2020 changed attitudes about telemedicine. At the time of interviews, participating psychiatrists were comfortable conducting telemedicine visits with a wide variety of patients. Because the majority of psychiatrists in the sample provided ALL of their visits via telemedicine for a period of 2–12 months starting in March 2020 and this transition was viewed positively, psychiatrists reported becoming comfortable with the care modality. As a psychiatrist from a hospital-based outpatient clinic in Georgia explained, “For the most part, I don’t think that five years ago anybody would have thought that seeing 100% of your patients via telemedicine would work, but of course, it has.”

Decision-Making without Constraints

Psychiatrists were free to make decisions about telemedicine use without constraints. Psychiatrists reported few limits on their decision-making by their organization or practice setting. As such, the decision to offer telemedicine was largely their own, and they were free to use their clinical judgment. Psychiatrists generally commented that the decision to conduct telemedicine visits requires clinical discretion and that any move to limit clinician autonomy (e.g., by limiting reimbursement to certain types of visits) could discourage legitimate uses of telemedicine. A psychiatrist in private practice in New York explained, “For every example of something that’s usually a bad idea [for telemedicine], I can come up with one scenario where it might be a good idea.”

Role of Patient Preference

Patient preferences drove a significant fraction of in-person care. Participating psychiatrists repeatedly mentioned that when deciding whether to offer telemedicine vs. in-person visits, they generally tried to accommodate patient preferences. A psychiatrist in private practice in California explained, “I believe a patient’s comfort, a patient’s preference comes first. So, for me it definitely makes a big difference. If they want to come in, then I try.” Multiple participants pointed out that a large majority of their in-person visits were driven by patient demand (not by psychiatrist request). Participants provided several reasons why certain patients prefer in-person visits, including better connection and rapport and lack of comfort with technology.

General beliefs and approach to hybrid care

Candidates for Telemedicine

Psychiatrists generally believed that all patients are good candidates for telemedicine. Psychiatrists generally believed that telemedicine was appropriate for most patients. As a participant from a community mental health center in Washington stated, “I really haven’t run into anything where I feel like it can’t be done with telemedicine versus in person.”

Beliefs about Hybrid Care

There was disagreement on the appropriateness of telemedicine-alone vs. hybrid models in the long term. Some participants thought that some patients could be managed exclusively through telemedicine; however, others reported that for care to be of high quality it is necessary to offer hybrid models and mix telemedicine with in-person care. For example, one concern is that telemedicine on its own can enable deterioration over the long term. A psychiatrist in private practice in New York explained: “Behavioral activation is part of the treatment for depression. Letting you sit at home [with telemedicine] and do nothing is actually worsening depression.”

Telemedicine as Part of Longitudinal Care

In selecting the care modality, psychiatrists didn’t focus on whether a particular “visit” was appropriate for telemedicine. Rather, they considered whether telemedicine was appropriate for an individual as a component of their longitudinal care, and they reported experimenting and adjusting over time. Psychiatrists explained that patient engagement as well as various non-clinical factors are critical to the success of telemedicine, and these factors are not immediately evident. As a result, psychiatrists typically experiment with telemedicine and adjust the treatment plan depending on “how it goes.” Participants also explained that if telemedicine is not successful, they can correct this by requesting that the patient attend an in-person visit. A psychiatrist from a hospital-based outpatient clinic in Texas explained, “I’d be willing to try telemedicine once [with this patient] and then if I thought it didn’t go well, it’s like ‘hey, I need to see you in-person maybe tomorrow or within the next week.”

Visit Frequency

Psychiatrists argued that the frequency of visits is more important than the modality, and some telemedicine care (if that is the only option) is preferable to no care. Participants pointed out that because telemedicine removes certain access barriers, it can allow patients to be seen more often. Some noted that ensuring frequent contacts trumps other considerations. As a psychiatrist in private practice in Washington explained, “If you get more communication and contact with the patient [via telemedicine], that supersedes the loss that you get from not seeing her in-person if she’s missing appointments because of work… I think it’s realistic to work with her on tele-visits to ensure those more frequent contacts.” A different psychiatrist in private practice in California explained, “My general philosophy with patients is that any contact is better than no contact. I’m pretty sure that with this patient if I were to insist ‘Oh no, I don’t do telemedicine, you have to come in’ then he would just be noncompliant with care.” Several participants acknowledged that telemedicine visits may not be equivalent to in-person visits for certain scenarios (e.g., low functioning patient with a psychotic disorder) but that telemedicine can still play a role. A psychiatrist in private practice in New York explained:

When you have these patients who are at risk for falling out of care if you don’t offer them telemedicine but are also at risk for getting slightly sub-optimal care when you do offer them telemedicine, it is a very case-by-case judgment call in terms of the risks and benefits of enabling the telemedicine.

Facilitating Engagement

Telemedicine was viewed as a tool to “meet patients where they are,” and psychiatrists leveraged it to facilitate engagement in care. Psychiatrists felt that telemedicine provided flexibility to patients and that offering telemedicine can improve attendance. According to a psychiatrist from a community health center in Kansas, “[Referring to a patient who has missed some in-person visits] I think that a flexible solution would be telemedicine, because we need to meet the patient where they are. So, this offers a flexible alternative.” Further, interviewees suggested that once patients are seen more regularly with telemedicine, they can more easily be transitioned to in-person visits when needed. A psychiatrist in private practice in Michigan explained, “If a patient is struggling to make in-person, telemedicine can offer a path to re-engagement.” A different psychiatrist in private practice in Rhode Island said, “I want to treat this [hypothetical patient with agoraphobia] patient and I might have a goal to wean him off telemedicine once he’s doing better, to not feed into his agoraphobia too much. But I wouldn’t have a problem with starting with telemedicine.”

Telemedicine as a Bargaining Chip

Psychiatrists framed telemedicine as a privilege and used the offer of telemedicine as a bargaining chip in negotiations with patients. Multiple participants discussed actively “negotiating” with patients and offering telemedicine to improve attendance or adherence with treatment. A psychiatrist in private practice in Maryland described a hypothetical conversation with a patient:

I want you to walk. You’re telling me you’re out of shape. So, we’re going to have a tradeoff. All the time that you would spend, all the energy and all the dread coming to see me in my office because you don’t even want to leave the house, I need you to take walks around the block for me. Is that a fair deal? Otherwise, I’m still going to make you come and see me, and it’s a hassle.

Several participants also spoke about requiring patients to demonstrate proper telemedicine etiquette and comply with the rules of the visit. According to a psychiatrist from a hospital-based outpatient clinic in New York:

I set boundaries [for telemedicine visits with lower functioning patients] like you have to be fully clothed, you have to be sitting up… I told a patient, please be fully focused on the interview. You shouldn’t be cooking. I phrased it as a warning, and if it continues, then the visits will need to be in person, or they can be discharged from the clinic.

Factors influencing the decision to offer telemedicine to individual patients

Required Elements for Therapeutic Rapport

Psychiatrists pointed out that for a patient to be a good candidate for telemedicine, several elements were required to support therapeutic rapport. Clinicians felt these elements were much more predictive of success with telemedicine than any diagnosis or fixed patient characteristic. For telemedicine to work well, the patient must be willing and able to engage (i.e., the patient and psychiatrist are open and forthright via video); able to take direction (e.g., angle camera, follow instructions in a mental status exam); in possession of good Internet connection and technical set up; respectful of telemedicine etiquette (which several psychiatrists suggested can be particularly challenging for patients with Borderline Personality Disorder or oppositional defiant disorder); and able to secure a private place to meet. What contributes to complexity is that the presence of these elements is not clear to the psychiatrist in advance, so it is necessary to attempt telemedicine with each patient to determine appropriateness. Illustrative quotes on these points, as well as the themes below, are included in the Online Supplement.

Contextual Considerations

In addition to assessing the presence of required elements for therapeutic rapport, psychiatrists considered several factors when deciding whether a particular visit could occur via telemedicine. They considered whether the patient had major barriers (e.g., transportation, scheduling) to coming in person, whether the in-person visit provided an important therapeutic benefit (e.g., if remaining at home could inadvertently contribute to decline), and the relative importance of conducting a physical exam and taking vital signs (and whether the patient had the ability to monitor vitals independently with the use of home monitoring devices). Finally, they considered whether the patient was routinely meeting in-person with other providers (e.g., primary care provider, therapist), and whether they had supportive caregivers who could provide collateral information or technical support during the telemedicine visit.

Psychiatrists also reported requesting telemedicine visits with specific patients to leverage its unique benefits. For example, they sometimes recommended a telemedicine visit to obtain insight into patient’s home lives and how they were functioning at home, to involve family members who could not accompany patients in-person, or to ensure the safety of the psychiatrist and staff (e.g., in case a patient becomes aggressive or violent).

Challenging Conditions or Situations

There was no consensus among clinicians on conditions or situations that were less appropriate for telemedicine. A subset of respondents felt telemedicine was inappropriate or less appropriate for the following: substance use disorders, suicidal ideation, psychotic disorders, eating disorders, trauma, greater functional impairment, and intimate partner violence. However, others disagreed, suggesting that telemedicine offered unique benefits even in these cases (e.g., improved patient safety, reduced likelihood of escalation).

Discussion

In semi-structured interviews, psychiatrists reported that almost all patients are good candidates for telemedicine visits in the context of hybrid care models. What drove telemedicine vs. in-person care was patient preference as well as situational factors like access to private space instead of any particular diagnosis or patient demographic. Psychiatrists described numerous factors affecting their decision to offer telemedicine, and they were generally driven to try telemedicine and adjust as needed to “meet patients where they are” and improve engagement in care.

A 2021 Substance Abuse and Mental Health Services Administration-supported guide on telemedicine for mental health professionals echoed some of the same factors discussed by psychiatrists in our sample.(9) For example, the guide suggested that when assessing whether telemedicine is appropriate it may be necessary to consider the patient’s history of cooperativeness with the provider, substance use, violence, and self-injurious behavior. It also suggested that psychiatrists trial telemedicine before committing to ongoing telemedicine care,(21) suggesting a need to “experiment” with telemedicine to assess appropriateness. We identified additional factors (e.g., possible therapeutic benefit of coming in-person, safety of psychiatrists and staff). Notably, we also found that the offer of telemedicine can be leveraged in “negotiations” to improve engagement, attendance, and adherence. If telemedicine is successfully negotiated in this way, and assuming patients feel more supported and engaged in care, hybrid care models could lead to higher quality care. Further, offering the option of telemedicine, with its added convenience and potential for privacy, could help individuals expressing ambivalence about treatment or behavior change overcome their personal activation barriers to engagement.

Our findings have implications for future reimbursement policy. At present, the Centers for Medicare and Medicaid Services is considering how often to require in-person visits in hybrid care models. The current proposal is that behavioral health providers using telemedicine with Medicare beneficiaries should be required to have an in-person visit within six months of initiating telemedicine and then every six months thereafter.(22) Our findings suggest that clinicians offered in-person care because of patient preference, but few felt that any specific scenarios required (only) in-person care from a clinical standpoint. Rather, many felt that telemedicine increased engagement, and decisions about telemedicine use remained fluid. While there may be arguments for requiring periodic in-person visits (e.g., to reduce the potential for fraud, deterring overuse of care and increased spending), it is does not appear that psychiatrists perceive intermittent in-person visits to be essential for high-quality care.

The study had some limitations. First, interview responses may be influenced by social desirability bias. Second, we used hypothetical case vignettes, which may not exactly mimic real-life clinical practice, and we presented only a few of many possible case scenarios. Third, we did not ask participants to differentiate between different visit types in their comments (e.g., medication management, psychotherapy sessions) due to time constraints. It is likely that the visit type influences decisions about the appropriateness of telemedicine.

To our knowledge, this is the first study exploring how psychiatrists make decisions about the appropriateness of telemedicine. Future research should further explore how hybrid care models with different doses and timing of telemedicine impact care quality. This research is especially important for clinical scenarios described as more challenging for telemedicine (e.g., active suicidal ideation, eating disorders).

Highlights:

• Psychiatrists perceived that almost all patients are good candidates for telemedicine visits in the context of hybrid care models.

• Diagnoses and patient demographics did not drive choice of care modality; rather, patient preference as well as situational factors played prominent roles.

• Psychiatrists described numerous factors affecting their decision to offer telemedicine, and they were generally driven to try telemedicine and adjust as needed to “meet patients where they are” and improve engagement in care.

• Psychiatrists reported using telemedicine as a bargaining chip in negotiations with patients, levering the offer of telemedicine to improve attendance or adherence with treatment.