1. Telemedicine Institute of
Oklahoma, PLLC
Overview of Telemedicine Needs and
Benefits, TIO Staff and Philosophy

2. Telemedicine Institute of
Oklahoma, PLLC
• The Telemedicine Institute of Oklahoma, PLLC (TIO)
was established in 2012.
• Mission: Provide high quality mental health services
to the rural populations of Oklahoma.
• TIO equipment inspected and approved by
ODMHSAS in Oct 2012.
• Practice established solely for the purpose of
providing mental health services via video
teleconference.

3. What is Telemedicine?
• The American Telemedicine Association defines
telemedicine as:
“the use of medical information exchanged from one site to
another via electronic communications to improve a patients'
health status”
• Allows health care professionals to
evaluate, diagnose and treat patients in remote
locations using telecommunications technology
• Developed by NASA to monitor and treat astronauts
while in space.

4. Why Telemedicine?
• Barriers exist that may prevent rural Oklahomans
from seeking care.
• Problems facing rural health care centers further
decrease access to care.
• Telemedicine can provide:
– Measurable improvement in patient care in terms of
accessibility and availability.
– Documented cost savings to clinics and patients that
participate in telehealth encounters.

5. Oklahoma’s Mental Health Needs
• Oklahoma in 2008-2009:
– 21.6% of Oklahomans experienced a diagnosable
mental, behavioral, or emotional disorder
– 7.4% of adults experienced at least one major depressive
episode
– 8.09% of youth aged 12-17 experienced at least one major
depressive episode
– Data derived from State Estimates of Substance Use and Mental
Disorders from the 2008-2009 National Surveys on Drug Use and
Health
• Over 1.27 million of Oklahoma’s population lives
in counties defined as rural (less than 50K)

6. The Problems
• Three factors may prevent rural persons with mental
illnesses face from receiving the mental health care
they need: accessibility, availability, and acceptability.
• These variables lead rural residents with mental
health needs to:
– Enter care later in the course of their disease than do their
urban peers;
– Enter care with more serious, persistent and disabling
symptoms; and
– Require more expensive and intensive treatment response
(Wagenfeld et al., 1994).
Derived from “Mental Health and Rural America: 1994-2005”, US Department of Health & Human Services

7. Accessibility
• Three significant components of access to mental
health services that put rural residents at a
significant disadvantage: knowledge, transportation
and financing.
– Patients need to know when one needs care and where
and what care options are available to address needs.
– The ability to travel to services and to pay for those
services if accessed is a significant barrier to rural persons.
– For rural Americans, the cost of health services (only
partially reimbursed by Medicare Part B; or at a discount
by Medicaid) may be too expensive—especially
prescription drugs.
Derived from “Mental Health and Rural America: 1994-2005”, US Department of Health & Human Services

8. Availability
• Lower access to mental health services is directly related
to lower availability or supply of mental health providers
(Lambert & Agger, 1995).
• The availability of rural mental health services and
providers is seriously limited in rural communities.
– Over 85 percent of the 1,669 Federally designated mental
health professional shortage areas (MHPSAs) are rural
(Bird, Dempsey & Hartley, 2001).
– According to the National Advisory Committee on Rural Health
(1993), of the 3,075 rural counties in the United States, 55
percent had no practicing psychologists, psychiatrists, or social
workers, and all of these counties identified were rural.
Derived from “Mental Health and Rural America: 1994-2005”, US Department of Health & Human Services

9. Acceptability
• Many Americans attach stigma to having or seeking
help for mental health or substance abuse problems.
• This is more of an issue in rural communities, as
there is less anonymity in seeking help.
• Ethnic minority individuals may be more hesitant to
enter treatment based on fear that the provider may
not understand their culture and traditions.
Derived from “Mental Health and Rural America: 1994-2005”, US Department of Health & Human Services

10. Rural Populations at Risk
• Rural populations often experience stress because of
the high poverty rates, high unemployment rates and
low educational opportunities.
• Demographics particularly at risk include:
– Women
– Children
– Elderly
– Veterans
Derived from “Mental Health and Rural America: 1994-2005”, US Department of Health & Human Services

11. These factors result in a loss of health services to
rural communities.
Problems Facing Rural Healthcare
Centers
• Limited availability of mental health providers
• Limited availability of outpatient services
• Decreased operating budgets
• Inadequate access to continuing education and
training

12. Availability of Providers
• It is estimated that approximately two-thirds of
individuals with symptoms of mental illness receive no
care at all.
• Of those who do receive treatment in rural
areas, approximately 40 percent receive care from a
mental health specialist and 45 percent from a general
medical practitioner (Regier et al., 1993).
• The availability of mental health services and the number
of mental health providers in rural areas is severely
inadequate .
• The availability of specialty mental health services
(e.g., neuropsychology, geriatric) is even lower than that
of general mental health services.
Derived from “Mental Health and Rural America: 1994-2005”, US Department of Health & Human Services

13. Availability of Providers (cont.)
• Primary care physicians and other general medical
practitioners are often the first-line mental health
providers for rural residents.
• Primary care physicians may not be adequately trained to
identify and treat mental illness and behavioral disorders
(Ivey, Scheffler & Zazzali, 1998; Little et al., 1998;
Susman, Crabtree & Essink, 1995).
• Law enforcement is often responsible for responding to
mental health emergencies in rural jurisdictions
(Larson, Beeson & Mohatt, 1993); they generally do not
have the training or experience recognizing mental illness
and/or providing triage or stabilization assistance to
individuals in immediate crisis.
Derived from “Mental Health and Rural America: 1994-2005”, US Department of Health & Human Services

14. Decreased Operating Expenses
• Fiscal realities have resulted in declining operating
budgets for many rural hospitals, health clinics, and
medical practices.
• Priorities for care are focused on acute needs and
outpatient services are often eliminated completely
or in part.

15. Access to Training
• It is difficult for many rural providers to stay abreast
of emerging mental health treatment and medication
protocols, especially in those areas served solely by
primary care physicians.

16. A Solution
• Treatment using telemedicine can address gaps in
care for rural populations.
• Treatment using telemedicine can provide:
– Improvement in Patient Care
– Cost Savings
– Improved Patient Satsifaction

17. Improvement in Patient Care
• Telemedicine can provide:
– Improved access to care;
– Provision of a higher level of care locally or in a more
timely fashion;
– Timely medication management;
– Improved continuity of care;
– Increased family involvement;
– Improved treatment compliance; and
– Better coordination of care.

18. Cost Savings
• Cost savings in out-of-pocket expenses for patients
have been well documented.
– As an example, the 866 mental health encounters
conducted over the Eastern Montana Telemedicine
Network from July 2002 – June 2003 represents over
$260,000.00 in out of pocket savings for patients. These
savings were based on travel cost and lost wages.

19. Patient Satisfaction
• Studies have consistently shown that the quality of
healthcare services delivered via telemedicine are as
good those given in traditional in-person consultations.
• In some specialties, particularly in mental health and
ICU care, telemedicine delivers a superior product, with
greater outcomes and patient satisfaction.
• Patients report high satisfaction with services provided
via telemedicine.
– On a patient satisfaction scale of 1-8, 1 being not satisfied and 8
being very satisfied patient receiving telemental health service
through the Eastern Montana Telemedicine Network reported
an average of a 7.0 satisfaction rating for 5 consecutive years.

20. Key Terms
• Distant Site: Location where the certified medical
professional is
• Originating Site: Location where the patient is.
• Telemedicine: The use of two-way, real time interactive
audio and video to facilitate the delivery of health care
services, including specialist referral, patient
consultation, remote patient monitoring, and
education/prevention.
• Telehealth presenter: Healthcare provider at the
originating site at time of interactive consultation
responsible for presenting the patient to the physician or
practitioner.

21. TIO Medical Staff
• Dr. Sarah Land
– ABPN Board Certified Psychiatrist
• Dr. Tracy Loper
• Dr. Peteryn Miller

22. TIO Philosophy

23. A Partnership
Originating
Site
Provides Emergent
Care
Provides Inpatient
Care
Provides Laboratory
Services
Distant
Site (TIO)
Provides Outpatient
Specialty Care
Provides Ongoing
Med Management

24. Authorized Originating Sites
• The office of a physician or practitioner
• A hospital
• A school
• An outpatient behavioral health clinic
• A critical access hospital
• A rural health clinic (RHC)
• A federally qualified health center (FQHC)
• An Indian/Tribal/Urban Indian (I/T/U) clinic or health
center

25. Originating Site Requirements
1. Providing a space for the patient during the consultation, including
Internet and other necessary telecommunications access.
2. Providing an appropriate certified or licensed health care
professional to present the patient to the physician or practitioner
at the distant site and remain available as clinically appropriate.
3. Providing client file to the physician or practitioner at the distant
site prior to the encounter, to include chief complaint, social-
family-medical history, medications, allergies, current diagnoses
and treatment plans.
4. Providing, operating, and maintaining all equipment and supplies
owned by the originating site to TIO standards.
5. Submitting facility site billing data to state agencies and insurance
providers.

26. TIO Responsibilities:
1. Providing for the scheduling of telemedicine
services.
2. Providing intake procedures to include, but not
limited to client orientation and consent forms.
3. Distributing prescriptions for Schedule II Controlled
Substances to clients as appropriate and with
providers signature as required by law.
4. Providing, operating, and maintaining all equipment
and supplies owned by TIO.

27. TIO Responsibilities (cont.):
5. Ensuring that all physicians and providers hold a current
medical license and/or certification to provide mental health
services, is Medicaid and Medicare registered, possesses a
National Provider Identification (NPI) number, and holds and
maintains medical malpractice liability insurance for the
provision of telemedicine services.
6. Complying with all requirements for provider credentialing
and privileging as required by the originating facility and in
compliance with CMS and the Joint Commission.
7. Submitting consultation billing data to state agencies and
insurance providers.

28. Partnership Advantages
• Behavioral healthcare that is accessible and
affordable to a large number of patients
• Increased scope of services that can be offered to
rural populations
• Reduces the number of mental health crisis visits to
the ER
• Better discharge options
• Routine monitoring and medication checks of at risk
patients

29. Process
• Signed contract between Rural Healthcare Provider and
the Telemedicine Institute of Oklahoma.
• Originating site provides requisite hardware, software
and network equipment, as necessary.
• Originating site equipment is inspected and approved by
ODMHSAS, as necessary.
• TIO provides a licensed health care professional for
patient consultation.
• Rural Healthcenter provides presenter to escort patients,
perform initial review of patient status, and conclude
patient visit.
• Originating site and distant site submit for costs.

30. Guidelines
• Requirements derived from Oklahoma Health Care
Authority Policies and Rules
• https://www.okhca.org/xPolicy

31. APA
• The American Psychiatric Association supports the
use of telemedicine as an appropriate component of
a mental health delivery system to the extent that it
is in the best interest of the patient and is in
compliance with the APA policies on medical ethics
and confidentiality. (American Psychiatric
Association, www.psych.org, August 14, 2003)