Telemental Health (TMH) revolutionized access to the delivery of evidenced-based clinical mental health services, yet education for clinicians and trainees to optimally utilize telehealth technologies had just begun to be addressed. The U.S. Department of Veterans Affairs (VA) developed a comprehensive National Telemental Health Training Program to educate psychiatrists, psychiatric residents, and medical students to deliver care using clinical video technologies (CVT). This national TMH training program itself uses innovative and technological educational modalities, including comprehensive web-based modules, national satellite broadcasts, a national teleconferenced journal club, interactive internet applications, and live real-time simulated remote competency assessments. Additional training opportunities include participation in comprehensive national educational conferences, advanced fellowships, special mentoring projects, and telemental health leadership opportunities.
Over 50,000 remote patients annually are receiving telemental health nationwide services through the U.S. Department of Veterans Affairs (VA), an approximate eightfold increase since 2002 (1). Telemental health in the VA now provides general and specialty mental health services for nearly all diagnoses (e.g., PTSD, substance use disorders, schizophrenia, bipolar disorder, pain), and includes multiple modalities of treatment (e.g., psycho-pharmacological intervention, individual and group therapy, cognitive-behavioral and processing therapies, neuropsychological evaluations, psychosocial rehabilitation, and expert clinical consultation).
Little has been published on educating psychiatrists and trainees in the actual delivery of telemental health services. Osterheld et al. (2) published the sole manuscript proposing an introductory telepsychiatry curriculum in 1999 for a single linkage between the University of South Dakota and a hospital in Sioux Falls. The November–December 2006 issue of Academic Psychiatry addressed a number of other topics related to technology in medical education, including electronic portfolios, electronic medical records, personal digital assistants, distance and electronic learning systems, and virtual-reality training (3). Quinlan et al. (4) discussed the use of telepsychiatry in oral board examination preparation. Scaturo and Huszonek (5) described telepsychiatry as promising in training psychiatrists and psychologists in collaborative settings. Szeftel et al. (6) studied the effectiveness of using telepsychiatry for side-by-side supervision.
This Educational Resource report details the development of a comprehensive national training program for psychiatrists, psychiatric residents, and medical students to optimally deliver remote telemental health services using clinical video technologies, and to become telemental health leaders. This article describes the basic principles, new modalities, applications, and monitoring of this program.
Psychiatrists, psychiatric residents, and medical students who will begin to deliver mental health services remotely, are targeted for focused training, which includes:
Context and Background: Information is provided about the history of telemental health since its beginning in the 1960s, through to the robust level of evidence-based TMH activity that has since evolved. Seminal studies and landmark manuscripts are referenced for more academic analysis.
Clinical Conduct of the Interview: Operational clinical instruction includes topics to better relate to the patient remotely; for example, maximizing eye contact, optimizing environmental factors, and remote relationship-building techniques, such as a pre-session internet search of local news at the patient’s site for relevant discussion.
Safety/Legal Issues: The training emphasizes remote assessment of dangerousness (6), along with legal parameters such as remote detainment and commitment laws, remote prescribing laws, and remote licensing regulations.
Initial Competency: Delivery of telemental health care is assessed in a 1-hour simulated remote clinical videoconference conducted by a trained mental health educational expert.
Clinical Scenarios: Instructional clinical remote scenarios address emergency management of the suicidal and/or homicidal patient, voluntary and/or involuntary hospitalization, the medically unstable patient, interruption of equipment technology, dispensing of medications, any need for lab studies, and follow-up consultation and appointments.
Ongoing Competency: Ongoing national education facilitates the maintenance of up-to-date knowledge of the expanding telemental health evidence-base.
Innovative and technological modalities used in developing the National Telemental Health Training are available on the website of the Office of Telehealth, U.S. Department of Veterans Affairs (1). These modalities include the following:
The National Telemental Health Operations Manual, which establishes comprehensive national VA telemental health clinical guidance in clinical, technical, organizational, and emergency operations and policies applicable for psychiatrists, psychiatric residents, and medical students.
Comprehensive National Web-Based Telemental Health Training Modules consist of 75–100 screen frames of interactive internet information, generally providing 1 hour of Continuing Medical Education credit, and including basic information (historical background, evidence-base, and handling remote psychiatric emergencies), as well as advanced topics on detailed clinical techniques, equipment, and logistical implementation issues. Post-module measurements assess new knowledge acquired, program content, and satisfaction.
National Telemental Health Educational Satellite Broadcasts consist of an ongoing series of 60-minute, professionally produced, videotaped, and nationally-aired live educational programs on current aspects of relevance in telemental health.
National Telemental Health Internet Interactive CME Live Meetings combine teleconference with internet interactive screen materials. Psychiatrists, psychiatric residents, and medical students throughout the country can view electronic slide presentations while having the opportunity to discuss or pose questions to the presenter. Topics are generally chosen on the basis of need for further or specialized training.
The National Evidence-Based Teleconferenced Journal Club is the first such national entity to provide an innovative approach to the challenge of keeping up-to-date with the rapidly advancing field of telemental health. Participants are taught to review the two main telehealth journals (Journal of Telemedicine and E-Health and The Journal of Telemedicine and Telecare ) for recently published manuscripts relevant to mental health. Participants also search PubMed for articles listed under telemental health, telepsychiatry, and telepsychology. Whenever possible, authors present their own work or serve as discussants. Practicing psychiatrists and trainees are also offered the opportunity to participate as reviewers in this national forum.
Live Clinical Videoconferencing Competency Training is the first national remote experience to coach psychiatrists, psychiatric residents, and medical students in establishing baseline competency skills before having patient contact. A trainer conducts a simulated clinical encounter addressing conduct of the remote clinical interview, optimization of the clinical equipment, and emergency clinical management of the patient.
Comprehensive National Educational Conferences: Each year, the VA Office of Telehealth Services holds an extensive 1- to 3-day educational and training Telehealth Leadership Conference with a focused Telemental Health Track.
Individualized training programs are determined for different levels of new telemental health clinicians and trainees. At the basic level, two 1-hour, web-based modules are completed (telemental health operations and remote emergency management), coupled with participation in a live, real-time, remote interview conducted by the mental health educational expert.
For those interested in more advanced training, additional components include completion of advanced web-based modules and CME interactive live-meeting educational pieces, participation in national journal club literature review, observation of topic-specific satellite broadcasts, attendance at national telemental health educational conferences, and appointment to local and national telemental health leadership activities.
These training modalities are being used in traditional academic-affiliate and VA-owned programs, for attending physicians and residents in psychiatry and for medical student-level interviewing-skills classes. Also, the Yale Graduate Medical Education Committee has approved a 5th-year, non-ACGME psychiatry Advanced Fellowship in Telemental Health, designed to offer postgraduate training in telemental health direct clinical and clinical research activities. Special mentoring projects are available for advanced training in areas such as home telemental health monitoring and the remote delivery of cognitive-behavioral therapies to specialized patient populations. Psychiatrists and psychiatric trainees at all levels are afforded opportunities to participate in National Telemental Health Leadership Committees, including activities and projects to encourage leadership development and postgraduate telemental health roles.
Evidence of the impact of this comprehensive training program is first apparent in the existence of a National Telemental Health Training Program where there previously was none. Also, the completion of didactic material is documented. From January 1 through December 31, 2010, 614 mental health clinicians and trainees completed the web-based Telemental Health Operations Manual CME module; 776 completed the Telemental Health Suicide Preventions and Emergency Care CME module; and over 500 Telemental Health Live Simulated Remote Clinical Competency Trainings have been performed. Since 2004, a total of 2,072 participants have attended the Annual VA National Telemental Health Leadership Conferences, with specialized Telemental Health Tracks for psychiatrists, psychiatric residents, and medical students. The National Journal Club has had over 200 participants since its inception.
Program effectiveness is measured in post-training questionnaires. The national conferences are assessed by an 18-question post-conference evaluation addressing program content (purpose, objectives, teaching strategies, up-to-date nature of information), new skills and knowledge acquired, logistical, and satisfaction items. On a scale of 1%–100%, participants have ranked the conferences in the 88%–92% range, consistently, over each item and each year. Over 99% of participants found the conferences worthwhile and would recommend them to their peers. In electronic training modalities (e.g., web-based training modules, National Journal Club), participants demonstrated at least 80% scores in knowledge content questions to receive CME credit. Follow-up questions rated 80%–90% of the objectives as met, with 70%–90% in satisfaction scores.
Other agencies, such as the Department of Defense and the Indian Health Service, have used the VA National Telemental Health Training Program either directly or as models for the development of their own programs, with continuing potential for transferability to other learning organizations. Presentations to disseminate information about the VA TMH Training Program have been made at national and international peer-reviewed conferences, including those sponsored by the AAMC.
Ultimately, with more psychiatrists and psychiatric residents being trained to deliver telemental health services, TMH continues to increase at the VA, in number of patients, number of encounters, types of clinicians delivering services, diagnoses being treated, kinds of treatments being delivered, and number of trainees being appointed to jobs involving telemental health components, including leadership positions in the National Telemental Health Center (1).