Keywords

Introduction

Cecil Wittson started tele-education and a TP program in the Psychiatric Institute in Nebraska (USA) back in 1959. However, the term “TP” was first used in a report from Massachusetts General Hospital in Boston, MA, USA, in 1973 (Dwyer 1973). The field grew slowly until the 1990s when improved technology paved the way for further growth and development. The primary impetus has the capacity to provide services to rural and underserved communities with further expansion to other underserved populations. Slowly but undoubtedly, TP in form of videoconferencing became a well-documented modality, developed in order to provide psychiatric services from a distance. It allows the patient and clinician to see and hear each other and interact in real-time despite distance. In its sixth decade, TP has increased access to care in urban, suburban, and rural settings – with patient, clinicians, and healthcare systems very satisfied with it for a wide variety of services and cultures (Hilty et al. 2013; Yellowlees et al. 2013; Mucic 2010).

There is now a substantial body of evidence to support the feasibility and effectiveness of TP (Hilty et al. 2013). TP has been shown effective for diagnosis and assessment across many populations (e.g., adult, child, geriatric, and ethnic), for psychiatric disorders in many settings (e.g., emergency, home health), and been found to be comparable to in-person care. It has been used with a variety of models of care (i.e., collaborative care, asynchronous, mobile, telemonitoring) with equally positive outcomes (Hilty et al. 2013).

There are two models of TP in use nowadays: “real-time” synchronous TP (STP or videoconferencing) and asynchronous TP (ATP, formerly store-and-forward). TP may include direct assessment of a patient; “indirect care” of patients, such as through case consultation and supervision; education for healthcare learners, physicians, and/or interprofessional healthcare providers; and program development (Myers and Turvey 2013; Sargeant et al. 2010; Hilty et al. 2004; Volpe et al. 2013; Shore 2013).

Cross-cultural TP may be defined as delivery of cultural appropriate mental healthcare from a distance, preferably via a patient’s respective mother tongue or in a language shared by the doctor and patient (Mucic et al. 2016a). The current refugee crisis within the European Union (EU) challenges mental health care systems throughout. There is a number of research describing difficulties in dealing with cross-cultural patients. An international TP service developed in Denmark is a role model for others in serving underserved cross-cultural patient populations and has been successful by using bilingual clinicians across national borders (Mucic 2009).

TP competencies for clinicians to practice effectively and achieve good clinical outcomes have been identified, outlined, and are beginning to be measured and evaluated (Hilty et al. 2015b). These are described at novice or advanced beginner, competent/proficient, and expert levels. For clinical care, feedback from patients, trainees, and faculty is useful. For continuing education/medical education events, pre- and postassessment and interactive feedback methods are suggested. TP skill competencies can be developed in training programs, seminars for agencies, local/regional/national continuing education/medical education events, and through leading organizations (e.g., American Telemedicine Association). Andragogical methods are suggested for use in clinical care, seminar, and other educational contexts; cross-sectional and longitudinal evaluation employs both quantitative and qualitative measures. Individual clinicians, programs, agencies, and other institutions may need to consider adjusted approaches to patient care, education, faculty development, and funding.

With the availability of increasingly sophisticated technology, TP’s applications for education and supervision are continuously growing. In order to develop a successful TP training program, the focus is on increasing clinicians’ competencies with patient care. Without formal exposure and education, psychiatrists may be hesitant to adopt TP into their practice, particularly if they view TP as an unfamiliar modality requiring specific technical and clinical skills (Sunderji et al. 2015). As with most other trainees, psychiatry residents are introduced to TP services delivery anecdotally during their clinical rotations, but actual training may lay a foundation that stimulates interest in TP as a mode of practice and provide the confidence and skills necessary to incorporate TP into future practice (Volpe et al. 2013; Glover et al. 2013).

To date, there are clinical guidelines, policies, and other developments across the world, but to our knowledge, this is the first chapter addressing TP training, based on international research and contextualized experience. The first clinical guidelines were published in the United States, but the American Telemedicine Association is an international organization (Yellowlees et al. 2010). Policies and guidelines for the practice of TP have also been published in Australia (RANZCP 2013), South Africa (Chipps et al. 2012), and Canada (CPA 2013). On the other hand, development of TP in Europe has been much slower, and training programs are very limited or almost nonexistent. To our knowledge, this is the first chapter offering ideas and suggestions related to training in TP in European context, based on international research and European TP-related experiences.

This chapter will attempt to move forward the emphasis on skills in a variety of ways (e.g., interviewing, assessment) while attending to key attitudes that ensure quality care (e.g., appropriate model, legal standards, privacy). The objectives will help the learner to

  1. 1.

    Be aware of the history and scope of practice related to TP and other e-mental health (eMH) technologies

  2. 2.

    Self-assess and evaluate strengths and weaknesses in alignment with precompetencies, (core) competencies, and advanced TP competencies

  3. 3.

    Consider clinical and curricular methods for TP skill development (e.g., bedside, continuing education/medical education training)

  4. 4.

    Begin to explore other eMH technologies within a broader context of care and consider additional competencies that are indicated

A TP Service, Its Components, and How to Set It Up

But before speaking more about important aspects of training in TP, it may be useful to briefly outline the basics of what a TP service is and how to set one up (Jones et al. 2006; Myers et al. 2008; Mucic and Hilty 2016). Principles for establishing of such a service are in Table 1 (Myers et al. 2008).

Table 1 Principles for establishing a TP service
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Equipment

The main requirements are a room equipped with a computer, a camera, a screen, a microphone, and speakers and a method of conveying the information between the respective TP stations. It is also useful to have a telephone in each TP station so that a contact can be made in the event of rare failure of the video equipment. Occasionally, too, this is used to add in an interpreter if a common language is not available and an interpreter is not available on site.

There are a number of considerations when choosing equipment. In the past, cost was likely to be a limiting factor for many services, but now so many low cost systems are available. Many services use computers with a built-in video camera, videoconferencing software (e.g., Skype Business, Vi-Vu, Lifesize softphone), a remote control camera, and encryption safeguards. Additional options preferred by professionals are a mobile laptop computer with an external camera and microphone that can go from site to site or home to home. This also enables a healthcare professional to have consultation with a senior colleague. Nowadays, it is most common to use iPad in such situations or even iPhone via “Face-Time” function if it maintains privacy standards.

The model that is most expensive, but in the exchange offers many more options without compromising with the quality, is the use of so called “stand alone” video cameras. These are more expensive, but on the other hand do not require additional use of computers and are more safe and stable. Stand-alone camera shall be connected to the TV screen and to the Internet. Typically, stand-alone video cameras may also be remote controlled. This enables the doctor to move the patient’s video camera (e.g., zoom-in and zoom-out in order to observe the body language or check for a tremor) during the consultation. In the EU with refugees and other underserved populations, such opportunities are typically limited with “built-in” video camera.

The mode of conveying the sound and pictures between the TP stations is one of the most important considerations. The main issues are bandwidth, cost, and security. Earlier, and for many decades, it was usual to use a T1 line (i.e., 6 ISDN telephone lines) in order to “transport” the sound and the picture on distance in real-time. Nowadays, internet broadband enables transmission of highest quality for usually very low cost. The “security” issues are to be solved by simple use of encryption when using the computers. However, some professionals prefer the use of “stand alone” model as the risk for security/safety errors is lower compared to the use of computers.

Positioning of Camera Relative to the Screen

It is commonplace for the TP user to naturally look at the image of the person they are communicating with on the screen rather than directly into the camera (i.e., if the camera may be on top of the unit or elsewhere). This can give the impression to the remote viewer that the individual is not making eye contact. This happens even with laptop built-in cameras. In addition, a camera placed below the screen gives the remote viewer the sense that they are being “looked down on.” It is common practice for the camera to be placed on top of the screen, and if the users sit a little farther away from the camera (approximately 2–4 m), this reduces the angle between eye, camera, and screen; this improves the impression of eye contact. The camera should be set up to capture a head and shoulders view for most interactions.

A small version of the outgoing video picture in the corner of the clinician’s screen (“picture-in-picture”) is useful for the clinician to check their own position relative to the camera to make sure that the patient’s view of the clinician is good. The picture-in-picture should be turned off on the patient’s screen as this may be distracting and can make the patient self-conscious.

The Room and Appearance

The size and layout of the room is very important and influences the user’s perception of the system. The room should appear as much as possible like a normal consulting room. It should preferably have windows for natural light, be quiet/soundproofed, and have adequate heating or air conditioning. Above all it should be pleasant to use, as negative attitudes towards TP can develop based on experience of the working environment rather than on the quality of the interaction. This is particularly important for practitioners who spend a good part of the day or nearly full-time TP.

The background should be plain and uncluttered. It is unwise to set up a camera facing either a window or a door. Too much backlight from a window will silhouette the appearance of the individual on camera, and background movement seen through a window or glass pane in a door will be distracting. The color of the background should be neutral although some still suggest blue-colored background, which is considered to allow better viewing of individuals with different complexions.

The clinician’s appearance should be professional as usual. This is part of the work routine, which is important – even if practicing from home. Similar to television broadcasts, clothes with solid colors and for gentlemen ties without striking patterns may be best. Overall, telepsychiatrists may “need” to be an additional 15–20% more active and attentive – clinically, administratively, and in overall efforts to connect at a distance (Hilty et al. 2004).

The room should be large enough for at least one to two adults to attend and be included on screen. If more individuals will typically interact with the youth and provider at one time, such as team-based assessments or group therapy, a larger room should be considered. For care with children, for example, the room should allow the child to move around, both for the child’s comfort and to allow an appropriate examination of his/her skill, particularly for younger children whose motor skills and exploratory abilities may be compromised.

Development of a Protocol

As for the general telemental health guidelines, there are no established indications or contraindications for telemental health services with young people, other than the youth or parent refusing services. A brief discussion about the care, use of technology, and a few nuances is part of the informed consent process by the clinician or one of his/her designees. Most programs have written information about the service prior to exposure of the patient to TP, with attention to clinical care, legal, privacy, and other issues. It is key to assure patients that the sessions are not going to be recorded and that the Internet connection is encrypted/safe. Written consent should be obtained, documenting that the patient is voluntarily involved with TP, as well as he/she may stop with TP whenever during the course of treatment.

At the very beginning of the each session, the patient should be introduced to everyone that is at the distant TP station and giving a view of the entire room will reassure them that no one else is observing the interaction. Further, the patient should be told that the microphone is sensitive and the patient does not need to shout. Most community-based settings utilize a presenter (often also the telemedicine coordinator) in the telemental health encounters for both quality care and reimbursement requirements. The provider should determine the scope of the presenter’s assistance before the session (with scheduling, paperwork, and socialization to the behavioral health system) and after the session (with implementing recommendations, facilitating referrals, and coordinating with the system of care).

If care is delivered in a traditional clinic setting, the provider shall alert staff to any risks to the youth’s safety so that they can be aware of need to assist or notify security or other resources. If care is delivered outside of a traditional clinic setting, such as a school, additional planning may be necessary. On occasion, a presenter may be needed during the session (with technical and clinical support, including taking vital signs and assisting in emergency situations). The provider may decide when to include the presenter in the session. If the presenter remains outside of the room, the provider should determine how he/she will contact the presenter to join the sessions should there be a need for assistance.

Involved clinicians should receive preliminary training in the operation of the equipment. They should be aware of local policy regarding the actions that should be taken in the event of accidental equipment failure. In such case the clinicians should have the option to use the telephone and speak to the patient while the Internet connection is about to be fixed. More detailed aspects of necessary clinician-competencies will be reviewed later in this chapter.

Finally, after the TP session, the clinician dictates the statement that may be electronically transferred to respective authorities and/or the respective clinic where the patient is located/belongs (e.g., general practice, psychiatric department, outpatient clinic, asylum center).

Factors That May Affect Willingness to Learn About TP

There is very little research on training clinicians to optimize patient encounters when utilizing video conferencing. It is important that such training be provided, because maximizing the use of TP requires experience and an appropriate understanding of the unique challenges associated with this technology. It is not simply a matter of doing the same things that one does in a face-to-face session via video conferencing. As already mentioned, the literature on TP training is sparse, heterogeneous, and primarily descriptive. Even brief learning experiences may increase the likelihood that residents will incorporate TP into their future practice (Hilty et al. 2015a). Nevertheless, certain factors were found to be associated with trainees’ interest in TP.

The majority of trainees in recent survey were interested in TP and believed clinical exposure is an important aspect of training (Glover et al. 2013). Despite trainees’ high interest levels, only 21% reported that didactic exposure was offered and only 18% had direct patient care experiences via TP. In addition, only 29% of trainees planned to use TP upon completion of training. These results suggest that training programs may want to include TP experiences into the curriculum. A majority of trainees with clinical exposure reported that their experience increased their interest. Therefore, increased exposure during training may ultimately increase the number of psychiatrists practicing TP and improve access to care (Glover et al. 2013).

That information led to a broad call for more work in telepsychiatric education (Balon et al. 2015) related to a significant gap identified in the literature (Sunderji et al. 2015). A survey of 46 programs revealed only 21 have a curriculum or informal experience and 12 have only a curriculum (Hoffman and Kane 2015). A key issue, though, is whether our learners – the residents and fellows – and those teaching them have kept up with the growing evidence base of TP. The outcomes, satisfaction, and range of clinical services should be well known, but are they aware that many of these above concerns about TP have been widely discounted?

A survey of 270 participants in psychiatric training programs throughout the USA, including 123 residents and fellows, was completed (Hilty et al. 2015d). This included general psychiatry (54%), child and adolescent (33%), and other fellowships (13%; forensic, geriatric, psychosomatic and substance). In terms of geography, 76% of responders were practicing in an urban setting, 5% practiced in a rural setting, and 19% were from both settings. Residents and fellows reported practicing in urban setting (81%) and 66% were interested or very interested in TP and 10% were very uninterested or uninterested.

Overall the top ten most common concerns and reasons that the participants viewed TP as hard, daunting, and/or difficult to implement were that one cannot perform a physical exam (54%), poor Internet connection is a roadblock to implementing TP (52%), liability risks involved with TP are unknown (47%), certain cultures will be less accepting (39%), nonverbal cues are missed (36%), privacy is an issue (33%), TP is not as effective as to face to face psychiatry (32%), one cannot manage emergencies related to safety with TP (30%), residency is insufficient for one to become competent in TP (30%), and paranoid patients do not like TP (26%). Other concerns were at a rate of less than 5%. R/F specifically had concerns about: one cannot perform a physical examination 67% (up from 54% overall), poor Internet connection 57% (same), liability risks 52% (higher than 47% overall), certain cultures will be less accepting 52% (much higher than 39%), and paranoid patients using it 42% (much higher than 26%).

The findings of this survey are in three distinct areas. First, interest in TP is high and increases with exposure. Second, education/training is not seen as adequate, but now with TP competencies and methods delineated, programs may subcontract out clinical experiences and perhaps utilize online modules. Third, concerns of R/F, program directors, and faculty appear to relate to the effectiveness of clinical care, including nonverbal cues, managing emergencies, dealing with patients’ paranoia and cultural acceptability; the question about doing a physical exam may have been interpreted in too many ways. The exposure/experience increases interest and reduces concerns about effectiveness (e.g., nonverbal cues, engagement).

TP Competencies

Overview

Specific questions in the development of competencies remain unanswered: (1) how do skills required for the practice of TP compare to in-person care? (2) are skills required for TP part of a broader set of e-mental health (eMH) competencies (including use of telephones/e-mail, social media, electronic health records (EHRs), mobile apps, and Internet-based interventions)? and (3) what are the optimal andragogical methods for teaching trainees TP? Therefore, a competency-informed approach is needed to answer these questions and to contend with other barriers to TP implementation.

Competencies have also been organized in medical education at different levels:

  • Level 1 – novice (medical student)

  • Level 2 – advanced beginner (first-year resident)

  • Level 3 – competent (senior resident)

  • Level 4 – proficient (graduating resident)

  • Level 5 – expert (expert in TP) (Dreyfus and Dreyfus 1980)

For the TP competencies published (Table 2; Hilty et al. 2015b), this was simplified to three levels and this stratification fits better across disciplines and learner levels:

  • Novice or advanced beginner (e.g., advanced medical student, early resident, or other trainees)

  • Competent/proficient (e.g., advanced resident, graduating resident, faculty, attending, or interdisciplinary team member)

  • Expert (e.g., advanced faculty, attending, or interdisciplinary team member)

Table 2 An ACGME framework for social media/networking competencies for psychiatric assessment and treatment
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While competencies are the consensus for moving forward with education, there are different ways to organize them. At the level of medical students, the American Association of Medical Colleges (AAMC) outcomes are evidence-based, including the domains of medical knowledge, patient care skills and attitudes, interpersonal and communication skills and attitudes, ethical judgment, professionalism, lifelong learning and experience-based improvement, and community and systems-based practice (American Association of Medical Colleges 2015).

Perhaps the best approaches TP competencies for all clinicians and those in training is the milestone approach from the Accreditation Council on Graduate Medical Education (ACGME 2013) and the evidence-based CanMEDS framework (Royal College of Physicians and Surgeons of Canada 2005). The ACGME specifies patient care, medical knowledge, practice-based learning and improvement, systems- based practice, professionalism, and interpersonal skills and communication domains. The CanMEDS framework describes the knowledge, skills, and abilities that specialist physicians need for better patient outcomes, based on the seven roles that all physicians play: medical expert, communicator, collaborator, manager, health advocate, scholar, and professional.

The most important area described in the TP competencies is patient care. It is divided into two parts: (1) clinical – history, interviewing, assessment, and treatment and (2) administrative-based issues related to care – documentation, electronic health record (EHR), medico-legal, billing, and privacy/confidentiality. Systems-based practice includes outreach, interprofessional education (IPE), providers at the medicine-psychiatric interface, geography, models of care, and safety. Attitude, integrity, ethics, scope of practice, and cultural and diversity issues were grouped within professionalism. An additional domain, technology, was added to include some behavioral, communication, and operational aspects. Communication, knowledge, and practice-based learning are included for completeness, although many skills in this domain are similar to skills needed for in-person care.

Expert TP Competencies and Additional Considerations

Expert-level competencies for TP have been distilled into three main areas: (1) TP-specific complexity, (2) clinical, reasoning, and other patient-based skill issues (whether in-person or TP care), and (3) complexity based on system-based practice. Examples illustrate the complexity of integrating regular assessment, adapting to a setting, and working by TP:

  • Completion of a Mini-Mental Status Examination (MMSE) (Folstein et al. 1975) by TP. This involves efforts to preserve the MMSE testing integrity and ensure optimal communication, and other clinical reasoning is used to determine whether, for the sake of convenience with TP, a substitute item can be used without altering test integrity.

  • A child/adolescent patient evaluation includes the patient and parent, sibs, and teacher who may telephone in. This requires extra time management, toys on-site, the sequencing participation, and technology combinations.

  • For an evaluation of a Latino teenager, a parent and a pediatrician may be needed in a rural setting. This involves management of language (e.g., teenager fluent in English and a parent who needs an interpreter), cultural, and primary care/pediatrician needs. Ideally, a culturally competent bilingual clinician would be available if the patient has limited language proficiency.

Training programs should consider incorporation of a brief TP experience to fulfill both trainees’ interest and the growing demand for psychiatrists. Such training should address competencies that are (1) technical, (2) collaborative/interprofessional, and (3) administrative (Sunderji et al. 2015).

The above description shows that settings in which TP is used partly shift participants’ roles and the competency goals. A key dimension is the primary care provider (PCP) specialist relationship, that is, developing trust, a working relationship, and availability of the specialist by telephone, pager, or e-mail (Hilty et al. 2004, 2006, 2015c). Collaboration at a distance requires a systems perspective, with heightened awareness of the available resources and attention to using them efficiently. The needs and abilities of referring and other providers in distant communities need to be clarified, rather than making assumptions; joint negotiation of the type of assistance is useful. Timely, precise, relevant, and useful documentation is especially important when TP is the predominant means of interacting with distal providers. Careful listening is needed to recognize team formation and dynamics at a distance.

A variety of models have been used. For in-person work, a consultation care model to primary care provides patient education, case-based PCP education, and technical assistance to aid the PCPs’ prescribing medication (Katon et al. 1995). A randomized trial of disease management for depression by TP was successful (Hilty et al. 2007). The collaborative care model uses a long-term approach to build relationships with PCPs through continuing education and medication co-management (Katon et al. 1995); trials for PTSD and depression by TP have also been successful (Fortney et al. 2013, 2015).

Integrated care models are increasingly being adopted (Gilbody et al. 2006; Kates et al. 2011; Archer et al. 2012; Fortney et al. 2013; Woltmann et al. 2012), and competencies have been spelled out for residents and the psychiatric consultant for communication, training/supervision, collaboration, and leadership (Cowley et al. 2014; Hoge et al. 2014; Ratzliff et al. 2015). In addition, greater attention is suggested regarding roles in care coordination, system navigation, longitudinal training/mentoring, balancing the “leadership” and “equal team partner” roles, and providing mental health care outside of health care settings (e.g., residential settings and community agencies) (Sunderji et al. 2015) .

Teaching and Assessment Methods for TP Competencies

TP competencies add complexity to regular teaching plans and for curricular program directors, training directors, and staff. A combination of methods is suggested to address the many factors involved, with adjustments to facilitate skill development over time (Table 3). These methods may be used in curricula, continuing education/medical education programs and in other contexts. Some mainstream program evaluation methods can also be used in (Tekian et al. 2015).

Table 3 Teaching and assessment methods for telepsychiatric (tp) education in relationship to competencies
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Assessment

There is no shortcut for observation, feedback, and evaluation in measuring the progressive acquisition of skills. The evaluation process includes adopting standardized measures, use of measures with specificity, timely, accurate and brief completion, and collection of data prospectively rather than retrospectively (Hilty et al. 2014). Kirkpatrick stresses that evaluation should include four different levels: (1) reaction, (2) learning, (3) behavior, and (4) results (Kirkpatrick and Kirkpatrick 2009). Level one evaluation assesses a participant’s reactions to setting, materials, and learning activities, ensuring learning and subsequent application of program content (Rouse 2011), and can be captured through satisfaction ratings. Level two of evaluation involves determining the extent to which learning has occurred, often employing performance testing, simulations, case studies, plays, and knowledge exercises (e.g., pre- and posttest). Level three attempts to determine the extent to which new skills and knowledge have been applied “on the job,” such as in the healthcare setting. Level four of evaluation involves measuring system-wide or organizational impact of training.

Assessment of TP clinical outcomes can inform program evaluation, particularly at Kirkpatrick’s levels 3 and 4 (Shore et al. 2013; Hilty et al. 2014).

As is obvious, these evaluations have moved beyond general satisfaction – to the issues of feasibility, validity, reliability, cost/economics, and clinical outcomes. In addition, effectiveness is favored above efficacy-only approaches (Hilty et al. 2013). Learners’ skills can be gauged through these program and systems-level variables, and simultaneously, learning to incorporate quality assurance and evaluation as an important TP competency.

TP Education via Relationship Building by eMH (e.g., TP Consultation to Primary Care)

TP is part of a much broader e-health and eMH movement. Since traditional in-person care may be costly, unavailable to many, and insufficient alone, many patients and caregivers are seeking e-health information and eMH services from nontraditional sources. The Internet provides all of us education, resources, social connections, and other meaningful activities – even for those with obstacles (e.g., geographic distance, physical immobility or agoraphobia) and generational preferences (i.e., teenagers who prefer technology-based communication) (Hilty et al. 2015a, e).

With regard to primary care, three levels of intervention are possible:

  • Low-intensity patient services include materials for psychoeducation, with tips for self-assessment (e.g., diabetes, depression, and self-help and support groups).

  • Mid-intensity options are informal online provider consultation, formal education programs, and asynchronous communication with providers (Odor et al. 2011).

  • High-intensity options are TP, Internet-based cognitive-behavioral therapy (ICBT) or in-person MH services with professionals (Celio et al. 2000; Clarke et al. 2005; Andersson et al. 2006; Christensen et al. 2006; Ritterband and Thorndike 2006; Ljotsson et al. 2007; Mucic et al. 2016a) .

Institutional Learning and Progress

This level of intervention requires a look at leadership, change management, and other factors. The main current barriers to TP are human factors related to providers, healthcare leaders, and other decision-makers. There are five categories of technology adopters: innovators (2.5%), early adopters (13.5%), early majority (34%), late majority (34%), and laggards (16%). Innovators and early adopters are more likely to make a leap of faith and thereby believe in a new technology or innovative process. This contrasts with the early majority, which has to be convinced by evidence that an innovation works well before they will use it (Nadler et al. 1999; Luo et al. 2006). Leaders in TP clinical care and education should consider how ready repetitive stakeholders are, in terms of adopting specific clinical, educational, and administrative aspects related to TP.

As a result, there are two approaches needed to implement TP widely within any health system. First, leaders need to acknowledge the generational leadership change that is starting to occur in healthcare providers, with younger providers being early adopters who should be included in leadership roles in these programs as clinical champions. The increasing body of evidence on the effectiveness of TP may be used to convince others of the necessity of TP adoption to move from theory to practice. Institutional competencies for TP may include: Patient-centered Care; Measurable Outcomes; Trainee/Student Needs/Roles; Faculty Clinical and Teaching Roles; Faculty Leadership Skills; Institutions and Institutions Within; Finance, Organizational Structure, and Funding; Change Management; and academic health center– community partnerships (Hilty et al. 2015b). From a technological perspective, there are relatively few barriers to the implementation of TP programs between clinics and health systems or to patients’ homes in the community. Such a platform could also facilitate e-curricula and TP training for programs, departments, and institutions, under a broader distance education approach.

A number of federal resources in the USA could be adapted to assist with telemedicine adoption, including telemental health with youth. This includes the Office for the Advancement of Telehealth (OAT)-funded Telehealth Resource Centers (TRCs). The TRCs span all states and provide assistance, education, and information to organizations and individuals who are providing, or interested in providing, healthcare at a distance. The TRCs also provide resources related to program development and evaluation, operations, reimbursement, legal and regulatory questions, marketing, training, and other concerns. The Center for Connected Health Policy (http://www.cchpca.org/) specifically addresses telehealth policy for the 50 states. The Substance Abuse and Mental Health Services Administration (SAMHSA)-HRSA Center for Integrated Health Solutions also has telebehavioral health training resources (https://www.samhsa.gov/).

Discussion

TP competencies related to skills, attitudes, and knowledge, which are stratified across levels, might help trainees, faculty, and other interdisciplinary clinicians across the world. Behaviors that reflect core competencies help with measurement and evaluation. An approach is needed to select, align, and contextualize teaching and assessment methods to achieve the desired outcomes. Development and use of competencies is an ongoing process, though (Harden et al. 1999; Holmboe et al. 2010). The first steps involve discussion, needs assessment, implementation, and evaluation from champions across administrative levels (Capobianco and Schultz 2007). Such TP competencies may help us to better meet access to care, trainees’ interests, and support patients’ rapid uptake of technology for care. Advanced competencies are suggested, but need further review and analysis. Faculty development for teaching, supervision, and evaluation is also needed (Litzelman et al. 1998; Skeff et al. 2007; McLean et al. 2008; Srinivasan et al. 2011).

The institutional context is critical to the uptake of technology-mediated healthcare. Stakeholders have to be convinced that technology significantly contributes to patient care and population health in order to gain buy-in. If only one group champions the value of TP, adaptation of new competencies is unlikely (Fairchild et al. 2004). Leaders adapting to changes related to eMH care may need to consider a change management plan to streamline clinical service delivery (Armstrong et al. 2004; Hatem et al. 2006) and consider building/upgrading an integrated e-platform. Such a course considers current and emerging infrastructure like wireless options. Start-up, ongoing, and context-specific funding is crucial and the use of TP could leverage clinical resources (i.e., specialists, interpreters, social workers) and offset costs.

Conclusion

TP is effective and it is moving into mainstream medical education due to its clinical relevance, many additional technologies that are shaping clinical care and increased interest from the current generation of psychiatry residents. Indeed, since TP is only part of a larger spectrum of clinical care based on how technology is now being used (the eMH care spectrum), competencies will grow in importance. TP competencies for trainees and clinicians grounded in healthcare, business, and andragogy will help learner objectives align with patient-based evaluation. Cross-sectional and longitudinal evaluation of nearly all participants is needed iteratively to improve the process. Exposure to TP care in training and opportunities for clinicians to train at the bedside or in interactive continuing education/medical education programs may yield a greater impact. Outcome, learner, and program evaluation that drives the training – rather than is tacked on to it – is needed .