HIPPA Violations

Case: Implementing Tele-Psychiatry in a Community Hospital Emergency Department

Westend Hospital is a midsize, not-for-profit, community hospital in the Southeast. Each year, the hospital provides care to more than twelve thousand inpatients and sixty thousand emergency department (ED) patients. Over the past decade, the hospital has seen increasing numbers of patients with mental illness in the ED, largely because of the implementation of the state’s mental health reform act, which shifted care for patients with mental illness from state psychiatric hospitals to community hospitals and outpatient facilities. Westend ED has in essence become a safety net for many individuals living in the community who need mental health services.

Largely considered a farming community, Westend County has a population of 120,000. Westend Hospital is the third largest employer in the county. However, Westend is not the only hospital in the county. The state still operates one of three psychiatric facilities in the county. Within a five-mile radius of Westend Hospital is a 270-bed inpatient psychiatric hospital, Morton Hospital. Morton Hospital serves the citizens of thirty-eight counties in the eastern part of the state.

Westend Hospital is fiscally strong with a stable management team. Anika Lewis has served as president-CEO for the past fifteen years. The remainder of the senior management team has been employed with Westend for eight to thirteen years. There are more than 150 active or affiliate members of the organized hospital medical staff and approximately 1,600 employees. The hospital has partnered with six outside management companies for services when the expertise is not easily found locally, including HighTech for assistance with IT services.

In terms of its information systems, Westend Hospital has used Meditech since the 1990s, including for nursing documentation, order entry, and diagnostic results. The nursing staff members use bar-coding technology for medication administration and have done so for years. CPOE was implemented in the ED four years ago and hospital-wide two years ago along with a certified EHR system.

The Challenge

Westend Hospital has seen increasing numbers of mental health patients in the ED over the past decade. For the past three years, the ED has averaged one hundred mental health patients per month. Depending on the level of patient acuity and availability of state- or community-operated behavioral health beds, the patient may be held in the ED from two hours to eight days before a safe disposition plan can be implemented.

The ED mental health caseload is also rapidly growing in acuity. Between 20 percent and 25 percent of the behavioral health patients are arriving under court order (involuntary commitment). The involuntary commitment patients are the most difficult in terms of developing a safe plan for disposition from the ED. The Westend Hospital’s inpatient behavioral health unit is currently an adult, voluntary admission unit and does not admit involuntary commitment patients. The length of stay for involuntary commitment patients in the ED can be quite long. In some cases, it may take three to four days to stabilize the patient on medication (while in the ED) before the patient meets criteria for discharge to outpatient care. Approximately 40 percent of the mental health patients in the ED, both involuntary commitment and voluntary, are discharged either to home or outpatient treatment.

The psychiatrists and the emergency medicine physicians have met multiple times during the past six years to develop plans to improve the care of the mental health patients in the ED. Defining the criteria for an appropriate Westend psychiatrist consultation remains a challenge. The daily care needs of the mental health patients boarding in the ED are complex. The physicians have not been able to reach an agreement on this topic. Senior leaders have suggested that tele-psychiatry may be a partial solution to address this challenge.

Tele-psychiatry as a Strategy

Westend Hospital has chosen to consider contracting with a tele-psychiatry hospital network to provide tele-psychiatry services in the ED. The network has demonstrated good patient outcomes and is considered financially feasible at a rate of $4,500 per month. This fee includes the equipment, management fees, and physician fees. The director of tele-psychiatry in the hospital network has verbally committed to work very closely with the Westend Hospital team to ensure a smooth implementation.

Technology to support tele-psychiatry uses two-way, real-time, interactive audio and video through a secure encrypted wireless network. The patient and the psychiatric provider interact in the same manner as if the provider were physically present. The provider performing the patient consultation uses a desktop video conferencing system in the psychiatric office.

Tele-psychiatry as a solution to the mental health crisis in the ED was not immediately embraced by the medical staff members. They did agree to the implementation of tele-radiology four years previously. However, the most recent revision of the medical staff bylaws to support telemedicine explicitly states that the medical executive committee must approve, by a two-thirds vote, any additional telemedicine programs that may be introduced at the hospital. The medical staff leaders wanted to preserve their ability to maintain a financially viable medical practice in the community as well as protect the quality of care.

The idea of tele-psychiatry was introduced to portions of the medical staff. The psychiatrists realized that tele-psychiatry could relieve them of