The asynchronous telepsychiatry model of collaborative care virtual visits supporting the patient-centered medical home

Michelle Burke Parish, MA
Steven Chan, MD, MBA
Peter Yellowlees, MBBS, MD


Background: Health information technologies — such as telemedicine — have been identified as important tools in advancing the patient-centered medical home (PCMH) by streamlining communication, boosting access, and decreasing time delays in seeing a specialist from months to minutes. Within mental health, studies show that telepsychiatry can help patients gain better access to specialists. However, telepsychiatry (STP), which traditionally uses synchronous, live two-way videoconferencing, has scheduling issues, cost limitations, and administrative barriers — similar to in-person care — that have prevented wide-scale use of this technology. A novel method, asynchronous telepsychiatry (ATP), a virtual mental health visit, is a more rapid, efficient, and administratively simple way for primary care providers to gain access to psychiatric expertise —supporting a collaborative model of care.

ATP is an emerging technology in the field of mental health that supports PCMH and in particular helps PCP's better manage patients with comorbid physical conditions and mental illness. ATP also encourages patient involvement in their own mental health care by creating a patient-provider-specialist communication triangulation and paves the way to utilize patient-generated data in routine mental health care. Following successful pilots, feasibility trials, and preliminary cost-benefit analysis, we are conducting a randomized clinical trial of clinical outcomes, funded by the Agency for Healthcare Research and Quality (AHRQ), evaluating the clinical effectiveness of ATP compared with STP.

Methods: English- and Spanish-speaking adult patients referred by their PCP for evaluation for a non-urgent mental health issue — mood, anxiety, substance abuse or posttraumatic stress disorder (PTSD) — were recruited from rural and urban primary care clinics, screened and randomized into one of two treatment arms: (1) STP — in which the patient speaks through live, real-time videoconferencing to a psychiatrist, or (2) ATP — in which a local clinician interviews the patient, and a video of the encounter and clinical progress note is recorded and sent to a psychiatrist for consultation. Consultation and patient- provider- specialist communication is fully integrated into the secure electronic medical record and clinical communications infrastructure of the University of California Davis Health System. A total of five appointments over 2 years of follow up are planned for each of over 200 enrolled patients.

Results: Data from the first 50 patients enrolled from rural and urban primary care clinics will be presented. Preliminary qualitative analyses from participating psychiatrists and PCP's indicate wide acceptance of the ATP consultation model. Advantages noted by the psychiatrists include the ability for consultants to rewind videos and compare changes over time, to observe the interaction between the interviewer and interviewee, to multitask during consultations and to easily fit ATP consults into their schedules. Advantages noted by PCPs and patients are shorter wait times for appointments and quicker access to the psychiatrist’s recommendations. 

Conclusions: ATP is clinically acceptable to providers and specialists. We are collecting satisfaction and clinical outcome metrics from the primary care providers and the patients as well as conducting a wide scale cost-benefit analysis of the two models of care.

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