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Building a virtual bridge

June 1, 2008
by Jess C. Jamieson, PhD and Tom Sebastian, MS, MPA
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Island-based providers use telemedicine technology to connect patients with psychiatric services

Access to psychiatric care is problematic in many locations, particularly in rural and other geographically remote areas. Without access to specialists, psychiatrically ill residents either remain untreated or the responsibility for evaluating and treating them falls to primary care physicians (PCPs). While that may be fine for some patients with mild or recent-onset illness, PCPs are among the first to emphasize the need for patient access to psychiatric specialists when illnesses are chronic, recurring, severe, difficult to diagnose, or life threatening, or when patients fail to respond to typical first-line treatment protocols.

As is typical of many states, 30 of Washington's 39 counties are designated rural. Review of several health plans' databases shows that approximately 19 of these 30 rural counties do not have a participating psychiatric specialist. San Juan County in northwestern Washington is among them. Comprised of 173 islands, San Juan County provides a snapshot of a national problem: a rural, isolated population with many residents living on a limited income and with a substantial number with undiagnosed or ineffectively treated psychiatric illnesses.

In 2007 three organizations in San Juan County came together to address this problem:

  • Inter Island Medical Center (IIMC) in Friday Harbor on San Juan Island serves the entire region's healthcare needs. IIMC is a primary care clinic and level V trauma center.

  • Compass Health has a clinic providing mental health and chemical dependency services in Friday Harbor. Compass Health regularly has flown a psychiatrist to Friday Harbor, but time and travel costs make this option untenable.

  • San Juan County Health & Community Services in Friday Harbor provides a wide array of direct public health services and referral to additional social services available in the community.

This consortium received a three-year federal Rural Health Care Services Outreach Grant to address five primary goals to increase residents' access to psychiatric services.


Develop and implement a videoconferencing-based system of psychiatric care for San Juan County residents. Equipment needs were identified by reviewing the literature and consulting with Compass Health's technology support provider, Advances in Technology. AIT has developed, installed, and maintained telemedicine technology throughout the Pacific Northwest. AIT and TelePresence Tech (TPT) created “3D TelePresence,” which allows both parties to have an experience much like a face-to-face encounter (For more about the technology, visit

Increase access and ensure sustainability by working with all health plans to make telepsychiatry a covered and reimbursable benefit. The project has meaningful value only if the services become self-sustaining. A substantial body of literature demonstrates telepsychiatry's efficacy, feasibility, efficiency, and acceptability. A major objective of this project is to have health plans pay for the service.

Provide and evaluate telepsychiatric services to 125 (estimated prevalence of need) San Juan County residents. All participants (patients and their families; IIMC physicians, nurses, and support personnel; and Compass Health's support staff and psychiatrist) were actively involved in the practice protocols' design so they would be clear and comfortable in their respective roles and responsibilities. The general principles underlying this process are below:

  • All San Juan County residents are eligible to receive telepsychiatry services, as clinically appropriate.

  • Prospective participants either are or will become IIMC patients.

  • A PCP evaluates prospective participants to determine their “medical necessity” of being referred to the project.

  • When medically appropriate, a telepsychiatry appointment is scheduled with Compass Health's psychiatrist.

  • An IIMC care coordinator orients patients to the telepsychiatry process and supports them throughout treatment.

  • The PCP makes all necessary medical information available to the psychiatrist.

  • Upon completion of treatment, the psychiatrist makes the findings/recommendations available to the PCP.

  • IIMC arranges appropriate patient disposition and follow-up.

Evaluate the community's perception of mental health issues and using telepsychiatry to address them. It is generally acknowledged that telepsychiatry services are well-received and accepted by participants. Promoting telepsychiatry throughout the community should help reduce stigma by showing that behavioral health problems can be treated successfully.

Evaluate the medical cost-offset of telepsychiatry services. A substantial body of literature shows that when previously unavailable mental health services are provided, overall healthcare expenditures are reduced—even when factoring in the cost of newly available psychiatric services. Yet studies have not examined whether this cost-offset, prevalent in studies of in-person psychiatric care, holds for videoconferencing services. The literature does indicate that telepsychiatry services are equal to in-person services in efficacy and satisfaction, so the cost-offset may hold for telepsychiatry as well.