Telepsychology, Medication, and Collaboration Module

Introduction

The objective of the 2008 APA Survey of Psychology Health Service Providers was to gain a broad understanding of those psychologists providing health services in the United States. Prior research in this area has focused primarily on APA members, which presents problems for generalizability of the data to nonmember providers. This study attempted to address these limitations by including non-APA member participants.

Specifically, this brief report or module focuses on health service providers’ (HSPs’) use of telepsychology in providing services, proportion of client caseload on psychotropic medication and HSP actions regarding psychotropic medication, and collaboration with other professionals. Telepsychology refers to health services that are provided to patients/clients by a health professional in which parties are physically separated when the service is rendered. Various media, such as Internet chat rooms, videoconference, email and phone, are used as mechanisms to enable communication between the parties.

While the vast majority of responses to this particular section of the survey came from APA member psychologists, the data gathered from this effort will be valuable to the Association’s planning for the entire psychology workforce. As a whole, it is hoped that this research will provide a better understanding of HSPs’ behavior regarding telepsychology, psychotropic medication and collaboration. Furthermore, these data may indicate changes in utilizing technology to provide services by comparing these data to previous studies on telepsychology.

Methodology

The first part of the sample included 34,289 APA members identified as working as and/or trained as “health service providers” and holding a doctoral degree in psychology. In other words, the membership sample included members engaged in professional practice or potentially eligible to do so by merit of training or educational background sufficient for licensure in most jurisdictions.

Additionally, a roster of licensed, doctoral-level psychologists in the United States was purchased by CWS in April 2008, from a vendor able to compile a listing of individuals with state-issued professional licenses in psychology. The vendor culled duplicate entries across states and forwarded this list of 99,350 names and mailing addresses on to CWS. This list was then compared against the member sample of HSPs to remove duplicate records.

For the first wave in September 2008, an email invitation was sent to 23,818 members identified as licensed by one or more state licensing agencies/boards and having a valid email address on file with APA. Three follow-up reminders were sent to nonrespondents one week apart.

The second email distribution was sent in October to 10,471 members with unconfirmed licensure status (names not appearing on the purchased list) and valid email addresses on file with APA. Nonrespondents from this distribution received three followup reminders also spaced one week apart.

Third, 10,000 randomly selected licensed psychologists (members and nonmembers) were mailed a paper version of the survey along with a URL address to access the online version from an Internet-accessible personal computer. The paper instrument did not include questions pertaining to this telepsychology, medication and collaboration module. However, 83 of the 5,486 online responses received overall, which included 11 of the 1,296 online responses received for this module, were identified as originating from the general survey URL provided to those included in the paper distribution. As such, the respondents for this module consisted of APA members and non-members.

Only fully completed and submitted online surveys were included in analysis; data from partial or saved surveys were excluded. Four modules were randomly assigned across 5,486 members of the sample. This telepsychology, medication and collaboration module was completed by 1,296 participants. This brief focuses on the results from those chosen to participate in this section of the survey.

Given the exploratory nature of this study, only proportions and frequencies were reported; no distinction between members and nonmembers is implied beyond descriptive convenience.

Module Results

This module was quite broad in that it included a total of eight questions on four different topics.

• hours spent on various work activities (Table 2)
• use of telepsychology to provide health services (Tables 3-3b)
• client caseload on psychotropic medication and related actions (Tables 4 and 4a)
• collaboration with other professionals (Tables 5-5b)

In addition to these questions, Table 1 provides demographic characteristics for all respondents to this module.

Table 1 summarizes general demographic characteristics of those responding to questions in this module. Missing values were excluded prior to analysis. Consistent with other CWS studies, more than three fourths (78 percent) of respondents held a PhD while nearly one fifth (19 percent) indicated that they held a PsyD. Just under 4 percent reported an EdD. The median age for participants responding to this module was 54. Women were in the slight majority (54 percent) and 89 percent of respondents identified as white, not Hispanic. The largest minority group was Spanish/Latino/Hispanic (4 percent) followed by black/African American at 3 percent. Just over 2 percent had multiple races or ethnic backgrounds, while about 1 percent was Asian. The race/ethnicity categories for this module were consistent with the full population of those surveyed in this full effort, as well as the other sub-groups analyzed in the other modules. Less than 5% reported a disability. Among those that chose to respond to the sexual orientation item, 8 percent identified as gay, lesbian, or bisexual.

Table 2 breaks out the average number of typical weekly work hours by type of work activity for psychology health service providers' primary and secondary work positions. A large majority (84 percent) of respondents spent time providing direct client patient care in their primary position and 27 percent in a secondary position. Direct care had the highest mean number of work hours in both primary (22 hours, SD=12.59) and secondary (10 hours, SD=12.04) positions compared to other work activities. Over two thirds (70 percent) reported doing educational activities in their primary position, spending an average of 9 hours (SD=10.06) per week. In both primary and secondary work positions, basic and applied research had the second highest average number of typical weekly hours: 12 hours, SD=12.51 and 7 hours, SD=7.09 respectively. However, research was the least common activity among HSPs, with one fifth in their primary position and 3 percent in a secondary position reporting they conducted research in the past typical week. While this table gives an overview of typical weekly work hours by type of activity, there was substantial variation in the work hours as evidenced by the high standard deviations. HSPs' typical work activities and hours depend on numerous factors such as employment setting and position, whether they're working full time or part time, and the number of work positions they hold.

Table 3 shows health service providers' use of telepsychology in delivering health services. Telepsychology refers to health services that are provided to patients/clients by a health professional in which parties are physically separated when the service is rendered. Various media, such as Internet chat rooms, videoconference, email and phone are used as mechanisms to enable communication between the parties. Respondents were considered users of telepsychology if they indicated using at least one type of media as shown in Table 3a. A large majority (87 percent) said they use telepsychology, whereas only 13 percent never used telepsychology to deliver health services.

Table 3a shows the frequency of telepsychology use for different types of media.

Telephone

The telephone, including cell phones, was the most frequently used technology among respondents for providing direct health services. Eighty-five percent used the telephone, of which over a third (35 percent) used it once a week or more. Another 22 percent used the phone two or three times a month, and slightly less (17 percent) once a month. Just over a quarter (26 percent) indicated they only use the telephone to provide services several times a year or less.

Overall telephone use for providing health services in 2008 was similar to results found in a telehealth survey conducted in 2000, where 82 percent percent used the telephone (not including cell phones, which was asked separately) for individual, group or family treatment and assessment. However, there has been an increase in the frequency with which the telephone was used. In 2000, of those who used the telephone, most often use was less than monthly (46 percent), whereas in 2008, most (35 percent) provided direct health services via telephone once a week or more (Randall & Kohout, 2001).

Email

Email was the second most frequently used technology for health service providers with 45 percent of respondents indicating they used email to provide direct health services. Although just under half (47 percent) of those using email only used it several times a year or less, 22 percent used it once a week or more. Just under one third used email to provide services two or three times a month or once a month, 16 percent and 15 percent respectively.

In the span of eight years, there has been a large increase (32 percent) in the proportion of health service providers using email to provide health services. In 2000, email was rarely used for clinical practice with only 13 percent of respondents reporting any use of this technology for individual, group, or family treatment and assessment, and of those most often (71 percent) less than monthly (Randall & Kohout, 2001).

Listservs

Listserv technology was used much less than telephone or email for providing direct health services, yet it was more common than videoconferencing, podcasts, or chat rooms. Of the 13 percent of respondents who reported using listservs to provide services, 37 percent used listservs once a week or more. About the same proportion (39 percent) rarely used listservs — several times a year or less. Thirteen percent provided services via listservs two or three times a month, and the remaining 11 percent once a month.

Video Conference

Compared with the above media, respondents rarely relied on videoconference technology; only 7 percent used Internet videoconferencing and 6 percent non-Internet videoconferencing.

For those who used internet videoconferencing, over three-quarters (78 percent) only used it several times a year or less. Eight percent used it once a month, 5 percent two or three times a month, and 9 percent once a week or more.

Non-Internet videoconference was used somewhat more frequently than Internet videoconferencing. Yet the majority of users (67 percent) only indicated using non-Internet videoconferencing several times a year or less. Seventeen percent used it once a month, 6 percent two or three times a month, and 11 percent once a week or more.

Although videoconference technology is still rarely used in providing health services, it has tripled in use since 2000 where videoconference use was 2 percent for individual, group, or family treatment and assessment, and 1 percent for clients in crisis, routine treatment or assessment, or for clients not previously met face to face (Randall & Kohout, 2001).

Podcast

A large majority of psychology health service providers (97 percent) said they never use podcasts to provide direct health services. Of the 3 percent providing services via podcasts, about half (53 percent) only used them several times a year or less. However, one quarter (25 percent) used podcasts regularly — once a week or more. Nineteen percent used them two or three times a month, and 3 percent once a month.

Internet Chat Room

The least used media for providing services was an Internet chat room. Only 1 percent of respondents indicated they use chat rooms to provide direct health services. This is similar to results found in 2000 where chat-room/chat-channel was employed by only 1 percent of respondents for individual, group, or family treatment and assessment, and less than 1 percent for clients in crisis, routine treatment or assessment, and for clients not previously met face to face (Randall & Kohout, 2001).

Summary

Use of different technologies in providing direct health services varied greatly. Telephone was used by a large majority (85 percent) followed by email, which was used by about half of respondents. When telepsychology was used, it was most commonly employed several times a year or less, except for the telephone where most used it once a week or more. Listservs and videoconferencing were rarely used, and podcasts and Internet chat rooms were almost never used to provide services (see table 3a).

Table 3b shows the types of services that are provided when using telepsychology. It should be noted that respondents could select multiple options.

Most commonly (72 percent) respondents indicated they used telepsychology to schedule appointments; however, it should be pointed out that this would not be considered direct health services. Over half of respondents said they used telepsychology for communication in between sessions (65 percent), providing resources (63 percent), or to make referrals (62 percent), which may or may not be considered direct health services depending on the situation. For categories that are clearly direct health services, telepsychology was used by more than a third of respondents for consulting (37 percent) or psychotherapy (34 percent), about one fifth (21 percent) for counseling, and 17 percent for supervision. Six percent of respondents provided other types of services through telepsychology.

Table 4 indicates the distribution of the proportion of health service providers’ client caseload that was currently being treated with psychotropic medication. On average, half (50 percent, SD 27.9) of the client caseload was on psychotropic medication. Only 5 percent of respondents indicated that none of their clients was medicated and about 3 percent said all of their clients were on medication. About one in five respondents (19 percent) indicated that 20 percent or less of their caseload was on medication. Nearly half (47 percent) of respondents currently had 21-60 percent of their caseload on medication, and the remaining third (34 percent) had a caseload with 61-100 percent of clients on psychotropic medication.

Table 4a shows how often health service providers take certain actions for clients on psychotropic medication. Most commonly (90 percent), providers indicated they talk with prescribing physicians; two thirds did this somewhat often and 24 percent always.

Over half of respondents made recommendations regarding medication and/or provided information literature to clients about medication. Just over half (52 percent) said they would make medication recommendations somewhat often, and 5 percent always; however, 39 percent indicated not at all. For providing information about medication, 51 percent did this somewhat often, 9 percent always, and 35 percent not at all.

Psychology health service providers almost never prescribed medication for their clients. Eighty-three percent said they prescribe not at all and 16 percent indicated this question was not applicable. Less than 1 percent prescribed medication at all. Nineteen percent of respondents took various other actions regarding medication that did not fit into one of these categories. It is still the case that psychologists’ ability to prescribe is constrained by state laws.

Table 5 lists a large variety of professionals with whom health service providers collaborate. Collaboration could be with either individuals or groups, and it could also include one-time referrals or interactions with those working in the same practice or business.

The vast majority of respondents (93 percent) collaborated with other psychologists, closely followed by psychiatrists (89 percent). Over three quarters (79 percent) worked with primary care physicians and more than two thirds (72 percent) with social workers.

About half of respondents indicated working with nurse practitioners (51 percent), specialty care physicians (50 percent) or attorneys (49 percent). Nearly one third (33 percent) collaborated with clinical nurses, and over a quarter worked with court system personnel (29 percent) or physicians assistants (27 percent).

Just under a quarter (24 percent) of health service providers collaborated with probation officers and registered dietitians. Less than 20 percent of respondents indicated collaborating with: physical therapists (19 percent), EAP personnel (18 percent), law enforcement personnel (17 percent), alternative medicine practitioners (13 percent), and human resources (13 percent). Very few collaborated with personal trainers (3 percent), and 15 percent indicated that they collaborated with other professionals not listed. In sum, most psychology health service providers work with other psychologists and psychiatrists, but overall they collaborate with myriad professionals.

Table 5a ranks the types of activities/issues that were involved in collaborations with other professionals listed in Table 5.

Most health service providers (84 percent) collaborated for the provision of psychological services (e.g., if a primary care physician (PCP) refers a patient to someone for treatment). The second most common type of collaboration was making referrals for psychological services (72 percent).

Between 50 and 60 percent of respondents said they collaborated on the following issues: health conditions (59 percent), treatment adherence (56 percent), consulting on treatment approaches that can be used (56 percent), and medication suggestions (50 percent). Forty percent indicated they collaborated with other professionals on screening for mental health problems, pediatric issues, etc., and 37 percent on lifestyle changes.

One quarter (25 percent) of respondents collaborated on provision of training, and 22 percent worked with others for forensic assessment. Just 8 percent said they collaborated with other professionals on other activities or issues.

Table 5b analyzes how often psychology health service providers collaborate with other health care providers or other professionals. It is important to note that collaboration could include interactions with those in the same practice or business. Most often (34 percent) respondents collaborated once a week or more followed closely by daily collaboration (31 percent). About one in five respondents (19 percent) collaborated two or three times a month, and 8 percent each collaborated just once a month or several times a year or less. Almost no respondents (less than 1 percent) indicated that they never collaborate with other professionals.

Module Conclusion

Psychology health service providers' use of telepsychology to provide direct health services has increased over the past eight years with 87 percent using telepsychology in 2008. Most notable is the increased frequency in using the telephone and email to provide services. These and other media are used to provide a variety of services, most often to schedule appointments, communicate between sessions, provide resources, and make referrals. Yet over one third indicated they used telepsychology for consulting and psychotherapy. The increased use of technology in providing health services has important implications including ethical concerns such as confidentiality and liability, as well as quality of care, reimbursement and accessibility.

Another trend in health care has been the development of new psychotropic medications. The vast majority of health service providers had clients who were taking psychotropic medication, and these clients made up half of HSPs’ caseload on average. As would be expected, a large majority of providers talked with prescribing physicians regularly, and over half made recommendations regarding medication and/or provided information literature to clients about medication.

HSPs worked in many different types of positions and settings throughout the U.S. They also collaborated with a variety of other professionals, most commonly other psychologists and psychiatrists, followed closely by primary care physicians and then social workers. While these were the most common, respondents worked with a diverse range of professionals. The top activities involved in collaborations were the provision of psychological services and making referrals for psychological services. Over half indicated that they collaborated either on a daily basis or at least once a week.

In sum, health service provider psychologists were increasingly using technology in providing services, had many clients who were being treated with psychotropic medication and collaborated often with numerous other professionals in their work.