With the introduction of the telephone by Bell in 1876, part of the patient - doctor relationship has changed and, since then, technology assisted doctors in their profession.
There is more than one definition for telemedicine. The terms eHealth and telemedicine are intertwined and currently there isn’t a unique definition used by institutions and in literature. Literally, telemedicine means “far medicine”, coming from the Greek word “tele” - meaning “far”. In order to understand the term, some examples of definitions are mandatory.
European Health Telematics Association proposed the following definition: “Telemedicine services provide means to improve accessibility to high quality health care in case of shortage of appropriate health care providers or the necessary medical expertise or skills at the site of the patient. Telemedicine thus covers a broad spectrum of services, such as teleconsultation, second opinion, telehomecare and teletraining, and is build on technologies such as video-conferencing supported by the exchange of medical images and medical records as well as remote monitoring. Communication infrastructure include ordinary telephone land-lines, Internet connections of various speeds and in many instances also satellite links to enable health care in remote and isolated areas” (EHTEL, 2008).
The World Health Organization proposed a broader definition: “Telemedicine is the practice of medical care using interactive audiovisual and data communications. This includes the delivery of medical care, diagnosis, consultation, and treatment, as well as health education and transfer of medical data” (Geertsema et al., 2007).
Telemedicine came into the attention of the European Commission, which defined it as “the provision of health care services, through the use of ICT, in situations where the health professional and the patient (or two health professionals) are not in the same location. It involves secure transmission of medical data and information, through text, sound, images or other forms needed for the prevention, diagnosis, treatment and follow-up of patients”.
Telemedicine encompasses a wide variety of services such as teleradiology, teleconsultation, telemonitoring, teleophtalmology, telesurgery, teledermatology, telepsychiatry, which can therefore be regarded as different forms or ways of delivering telemedicine.
Two types of telemedicine may be distinguished: the telemedicine services between health care professionals (“doctor to doctor” – D2D) and the telemedicine services between health care professionals and patients (“doctor to patient” – D2P) (EHTEL, 2008).
D2D telemedicine can be useful, for example, in creating access in rural areas with small hospitals without all specializations available. D2P telemedicine services are offered directly to patients and this is the second generation of telemedicine services and the development is mostly driven by the scarcity of resources and the patients demand (EHTEL, 2008). The main objective of D2P telemedicine is empowering patients, increasing the ability for patients to live independently, and disease management and prevention.
The first published accounts of telepsychiatry date back to the late 1950s, when a two-way closed-circuit television system in Nebraska was used for medical and educational purposes, with a focus on psychiatry (Wittson et al., 1961). Telemedicine focusing on psychiatric care holds great promise in healthcare as it has given an increased number of patients access to care (Leonard, 2004).
There are many benefits of telepsychiatry and the most important is the access, due to the fact that services are provided in the location of convenience for patients. This might improve the adherence to treatment, the effectiveness of psychoeducation and therefore the acceptance of changes in the lifestyle. These consequences could lead to an improved quality of life. Another important benefit of telepsychiatry for patients could be a lower stigmatization regarding the usage of psychiatric services.
At this point, there are already studies regarding the usefulness and effectiveness of telepsychiatry. A large review (Garcia-Lizana, 2012), centered on the effectiveness of telepsychiatry, identified 620 articles, which included 10 randomized controlled trials. This review concluded that although more research is needed in this field, there seem to be no significant differences between face-to-face therapy and telepsychiatry, and therefore this new approach is a useful alternative. The analyzed studies showed that telepsychiatry is useful in diagnosing, treating and following people in isolated areas. Is also concluded that telepsychiatry and videoconference especially lead to the improvement of the symptomatology of patients. As stated in other studies and reviews, the main barrier in a further development of telepsychiatry is the acceptance by the professionals and the resistance to change.
Another more recent review (Gajaria et al., 2015) analyzed the usefulness of telepsychiatry in the assessment and treatment of psychiatric illness. It is important to emphasize that there were positive results concerning the medication adherence, the self-reported mental health status, the readmissions and the emergency visits. These are encouraging results and healthcare professionals should be aware of them. The studies included in the above-mentioned review evaluated patients with a variety of disorders: depression, dementia, schizophrenia, anxiety disorders, eating disorders and substance abuse.
The main difficulties encountered by the implementation of telepsychiatry are the resistance to change, the legal issues, technical problems and the costs.
Challenges in the implementation of telepsychiatry
The resistance to change is the first major barrier to telepsychiatry and to telemedicine in general. Most frequently, a reluctant clinician hampers the acceptance of telepsychiatry, not the patient or his or her family. The process of changing the workplace behaviors requires a motivation and a new perspective in daily routine procedures for clinicians. Therefore, knowledge, a better understanding and information will help clinicians to gain confidence in new methods of helping their patients. Both clinicians and patients must regard telepsychiatry as a treatment approach that will enhance success, access, and quality of care (Saeed et al., 2012).
Regarding the cost-effectiveness of telepsychiatry, O’Reilly et al. (2007) reported that telepsychiatry is 10% less expensive than face-to-face treatment. Other studies reported that telepsychiatry is more expensive than face-to-face assessment (Modai et al., 2006), so the problem of cost-effectiveness remains complex considering the multitude of factors that affect direct and indirect costs. While telepsychiatry requires additional technology, which can be expensive, its use reduces the travel costs for patients and their families when psychiatric services are not available locally.
There are many technical issues that could influence the implementation of telepsychiatry and some should be mentioned: the cost of the equipment, safety of data transfer, and technical skills required for the users. Some of the risks for telemedicine that should be considered are the safety of data transfer, interoperability between different telemedicine applications and organization of the delivery of health care. First of all, the use of information and communication technologies contributes to the risks concerning the security of telemedicine services. Errors in data transmission due to Internet connection can lead to false diagnosis or inadequate treatment. Telemedicine services using Internet connections are vulnerable to hackers, however adequate and up-to-date security of connections can reduce risks. Because medical information is highly sensitive and easily accessible through telemedicine, there is a high risk of abuse. Privacy considerations unique to telepsychiatry include the potential for nonclinical technical or administrative personnel to view telepsychiatry sessions. Increased video-conferencing over public networks also creates the potential for unauthorized access to protected health information. Technological solutions such as encryption and virtual private networks represent a must when accessing the telepsychiatry services.
There is a lack of guidelines or standards regarding the practice of telepsychiatry and this situation has an important impact in providing telepsychiatry services. Fortunately, there are some professional associations focusing on telemedicine and working on creating reliable guidelines, most of them being located in United States of America.
The evolution of telemedicine and telepsychiatry services has been rapid and led to major changes in the way healthcare is delivered. Unfortunately, the legal and regulatory aspects did not progress at a similar pace. The legal framework may stimulate or restrict the development of telemedicine services. Legislation related to telemedicine in Europe is a clear example of situation in telemedicine legislation in the world. The individual states have their own laws and customs, and according to them they shape telemedicine regulations.
The European Union does not have the power to impose standards and mutual laws to every state, and the burning problem is that in some countries the legislation related to telemedicine is insufficient. There is also a problem of different legal grounds, on which states build their legislation. In such a complex and sometimes confusing situation there is great need for common standards, laws and guidelines regarding telemedicine. There are many legal and regulatory questions that arise with the telemedicine development, and that need urgent legislation attention. One is the problem of defining jurisdiction. For example, it is not settled which country should have the jurisdiction: the one in which the practitioner is located or the one in which the patient is located. In some cases, there is even a third country involved. There are also questions related to the ethics, the confidentiality and the difference in language and culture between states.
Regarding the European legislation, an effort for harmonization is visible lately and some European Directives that apply need to be mentioned: Charter of Fundamental Rights and Freedoms, Directive 95/46/EC on data protection, Directive 2000/31/EC on electronic commerce, Directive 2002/58/EC on privacy and electronic communication.
Even if Romania is part of the European Union, the Romanian legislation does not allow remote medical services, due to article 31 in the Code of Medical Ethics that prohibits distance consultations.
Telepsychiatry is a valuable and valid option for providing psychiatric services to patients in remote or isolated areas. The preference of patients should be taken into consideration since there are patients who opt for telepsychiatry services versus classic psychiatric services, due to stigma reduction. The studies so far offer evidence that telepsychiatry assessment and treatment is comparable with face-to-face care and barriers like costs or change resistance need to be overcome in order to increase the use of telepsychiatry (Saeed et al., 2012).