Running head: NURSING INFORMATICS: PATIENT ENGAGEMENT 1

Nursing Informatics: Patient Engagement in Telemental Health

Christina M. Collins

Delaware Technical Community College - Terry Campus

NUR 410 Nursing Informatics

February 13, 2018

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Nursing Informatics: Patient Engagement in Telemental Health

What is Patient Engagement? Patient engagement is the healthcare team and the patient

working together to improve overall health (Health Information & Management Systems Society

(HIMSS), 2018). When a patient engages in their healthcare, they are more likely to follow the

care plan provided which leads to less frequent visits to the doctors, which in turn leads to a

reduction in healthcare costs.

One particular area extremely important for patient engagement is mental health care. If

patients do not have the proper engagement early on, the opportunity for treatment can be lost.

According to the National Alliance on Mental Illness, many people who seek mental health care

drop out. 70% that drop out do so after their first or second visit. Engagement in mental health

care not only takes into account the patient and the healthcare team, but the patient’s family,

culture, and community (NAMI, 2016). It takes a village to reach recovery for those who have

mental illness.

In our ever-changing world of technology, many options have opened up for those who

have mental illness. Not only can an individual visit their therapist face-to-face, they also have

the ability to have phone conversations, email, instant message, and video sessions.

In Australia they have e-mental health funded by the government. The clinic is called

MindSpot and provides online assessments and treatments as routine clinical services to adult

Australians with anxiety and depression (Titov et al., 2015). A study was conducted to see

whether online cognitive behavioral therapy (iCBT) was as effective as face-to-face cognitive

behavioral therapy (CBT) for anxiety and depression. The study showed that effective treatment

for anxiety and depression could be delivered online with outcomes comparable to clinical trials

and with benchmarks of face-to-face CBT treatment (Titov et al., 2015).

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This study is important because often times those with mental illness do not seek help

because they do not know where to go, they do not have transportation to the office, or maybe

they do not want others to see them going into a therapist office, so the option of online

counseling gives individuals the opportunity to seek help right from their home and potentially

their insurance may cover the cost. It is a win-win situation and a way to get many individuals

who suffer with mental illness engaged in treatment and hopefully recovery.

The article “Telemedicine’s Potential Ethical Pitfalls” discusses ethical dilemmas in

telemedicine such as patient privacy and patient-physician relationship. The patient-physician

relationship is paramount to healthcare. One of the most important aspects of the patient-

physician relationship is the face-to-face connection, which fosters and builds trust. It is

important for quality healthcare. If a patient is confident in the care that the doctor provides they

are more likely to cooperate with their care. Patient privacy is also a major concern with

telemental health services. Telemedicine and technology may give rise to unwanted intrusion

into a patient’s medical profile without their knowledge.

Telemedicine has the potential to open up a promising realm of patient care but ethical

issues must be addressed in telehealth and telemedicine just as it has always been a priority when

providing quality healthcare to patients. As the article “Telemedicine’s Potential Ethical

Pitfalls” points out, as long as a strong patient-physician relationship is kept, patient privacy

maintained, patients receive treatment that fits and addresses their needs, and the goal of the best

possible outcome for the patient is upheld; telemental health will provide many opportunities for

improved healthcare and patient engagement.

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Current Workflow

The current problem that our office would like to improve is engaging patients after their first

visit for a therapy session. Currently, the practice only sees clients face-to-face for their therapy

visits. Often after the clients first visit they do not return to continue their treatment plan. There

are many reasons why the clients do not return after their first visit. Examples are:

 Stigma with mental health

 Transportation issues

 Poor reminder system

 Comfort with therapist

 Lack of understanding of how the therapy will provide benefits for their

mental health.

The current workflow process is as follows. A client will be referred to the office by their

doctor, by a friend, or found the practice through some form of advertisement. The client will

schedule an in-office first appointment. The client will come to the appointment. During the

initial visit, the client will fill out medical and screening paperwork. After filling out all

necessary paperwork, the client waits in the waiting room. While the client waits, the healthcare

practitioner reviews the client’s chart. The patient will then have about a 45-minute session

where the therapist assesses the client’s mental health history, past medications, and completes a

diagnostic review. During this session the client and therapist are building their relationship and

trust. Once the session is complete, the client goes to the checkout desk to schedule a future

appointment. Currently, the only therapy modality available is face-to-face sessions. To make

sure the client returns for their next appointment the office staff will call the client the day before

their appointment and remind them of the time and date of the upcoming appointment. On the
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day of the appointment when the client shows up this is an excellent sign that the client is

making an effort to be a part of their treatment plan. It is also likely at the moment there are not

any significant barriers to prevent the client from returning to future appointments. The client

then has their therapy appointment with the therapist and the workflow process continues

provided the client continues to follow the treatment plan and comes to scheduled appointments

If the client does not show up to their therapy session, the front office will call the client

to find out why the client missed the appointment and offer to reschedule their session. If the

client comes to their therapy session they will see the therapist and progress can be made. If the

client does not arrive for the appointment, the office will call the client to follow-up and ask

about any barriers to making the appointment and how they can contribute to the client’s success.

The problem with the current system is if the client has barriers to attending their therapy

session they do not have any alternatives. Introducing other modalities of therapy can increase

patient engagement into their current treatment plan.

Workflow Process Improvement

To improve the current workflow process, increase patient engagement, and reach more

clients within the practice with more frequency, the practice will add additional services using

telemental health. The proposed change to improve the workplace process is to find out if the

client is eligible for additional services other than face-to-face therapy sessions. To be eligible,

the therapist must determine based on their diagnosis whether telemental health services would

be beneficial and the client must have the equipment necessary and/or available resources to

participate. If the client states that they are only comfortable with face-to-face sessions than the

current workplace process would continue. An additional step of providing all clients with a web

address will be added, clients can use an online scheduler for faster service or convenience.
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If the client is eligible for the new telemental health modalities they would fill out a

survey which would determine which services the client is willing to use for therapy. Once it is

determined which telemental health service the client would like to utilize they will be scheduled

for a videoconference, instant message, phone, and/or email session, all of which are provided

through a secure and private system. The client will be given an information packet, which will

detail how to communicate and access through each service provided. The client will also be

given the online scheduling information. The new appointment reminder system can remind

clients of their appointments through text, email, and phone. Each client will receive a reminder

phone call from a staff member 4 to 5 days before his or her appointment and they will receive a

text/email reminder one day prior to the appointment. Following a finished therapy session, the

client will receive a phone call from the office scheduler to set up the next appointment. The

client can also go online and use the online scheduler to make appointments when it is

convenient for them. If the client misses the telemental health appointment, the schedulers will

follow-up to find out why the client was unavailable for their appointment and to offer any help

to make sure all appointments be attended. During the follow-up call the office will attempt to

reschedule the missed appointment. If the scheduler is unsuccessful, the client will be provided

with the website address and given the option to schedule online at their convenience.

The initial investment to add telemental health services, a new reminder system, and an

online scheduler program will seem very expensive. Over time the benefits of this financial

investment will provide fewer missed appointment, increased client participation in their care,

increased client satisfaction, and more effective operations for the office staff.

The text message reminder system can improve missed appointments by 25%. Not only

will the client benefit, but the practice benefits as well. Missed appointments leave gaps in
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service for the therapist and it is a financial loss to their business. Missed appointments that are

rescheduled can lead to overbooking at future dates, which can be harmful to the clients who do

not miss their appointments because their session is rushed or late, which can lead to client

dissatisfaction.

Utilizing telemental health modalities such as video conference, email, instant chat, and

phone give a client who may not have a car the option to have a session from their home. The

positive benefits for the client are decreased anxiety trying to find transportation, time saved

traveling, and the convenience of reaching out to the therapist at a time that most suits them.

Therefore, if a client has a set back in their treatment, they will have the ability to reach out to

the therapist sooner than if they would have to schedule a face-to-face visit. If a client feels

valued, appreciated, and heard they will be more likely to cooperate with their treatment plan,

which is great for the client’s ongoing mental health.

Improving the workplace process makes the current process more efficient for the

customers, as well as improves workplace satisfaction. Telemental health services increase

access to mental health services, gives the customer more options of convenience, and more

clients are retained.

The policy put in to place to help ensure patient engagement occurs after the first visit is

the patient reminder system and appointment cancel

Workflow maps can assist in the design of hospitals and patient care technologies

because it takes an in-depth look at how the workplace process is utilizing the current resources

and provides opportunities for growth and development. The business can flourish with

improved processes, but most importantly the patients benefit from efficient and safe care, which

leads to the highest quality of health possible.

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References

Health Information and Management Systems Society (HIMSS). (2018). What is

patient engagement? Retrieved from http://www.himss.org/library/patient-engagement-

toolkit

Mehta, S. J. (2014) Telemedicine’s potential ethical pitfalls. Virtual Mentor, 16 (12),

1014-1017. Retrieved from http://journalofethics.ama-assn.org/2014/12/msoc1-

1412.html

National Alliance on Mental Illness (NAMI). (2016). Engagement: A new standard for

mental health care. Retrieved from https://www.nami.org/About-NAMI/Publications-

Reports/Public-Policy-Reports/Engagement-A-New-Standard-for-Mental-Health-

Care/NAMI_Engagement_Web.pdf

Titov, N., Dear, B. F., Staples, L. G., Bennett-Levy, J., Klein, B., Rapee, R. M., ... Nielssen,

O.B. (2015). MindSpot clinic: An accessible, efficient, and effective online treatment

service for anxiety and depression. Psychiatric Services, 66, 1043-1050. Doi:

10.1176/appi.ps.201400477