Best Practices in Using Telemedicine for ADHD During the COVID-19 Pandemic

Abstract: Our American health care system is under an extreme strain placed upon by the Coronavirus (COVID-19) outbreak. The necessary precautions and safety measures undertaken have created roadblocks for individuals with psychiatric conditions to obtain care, and psychiatrists are exploring ways to best serve this population while complying with the medicolegal restrictions. Here, I will outline approaches to best leverage the use of telemedicine in a desperate time like this and discuss the most recent policy changes.

ADHD/NEUROPSYCHIATRIC DISORDERS

Attention Deficit Hyperactivity Disorder (ADHD) is a psychiatric disorder characterized by inattention, hyperactivity, and impulsivity-all falling on a spectrum of severity ranging from mild to debilitating.¹ Historically this was only diagnosed and addressed in children. However, it is being increasingly recognized in adults with a prevalence of up to 5%.²

Lack of appropriate identification and treatment, such as by non-physicians, can have profound consequences leading to impairments in all domains of life as a whole-not  just in academic performance.^3,4 Untreated ADHD is correlated with higher rates of unemployment and poor work performance, difficulties with relationships and eventual marital problems, increased antisocial and criminal behaviors, as well as increased traffic accidents among others.^5-8

In light of the recent COVID-19 pandemic, social distancing has been adopted as a proven strategy to decrease viral transmission and mitigate mortality, the implementation of which has unfortunately translated in cancelled appointments and delays in new patient evaluations as a tradeoff.⁹ Unlike with general psychiatric treatment, ADHD management vastly requires the stimulant class of medications-prescribing of which via telemedicine having been hindered by the Ryan Haight Act (RHA).¹⁰

Despite some provisions of the RHA allowing maintenance prescribing of controlled substances if a prior in-person exam has been conducted, the issuing of new prescriptions has been restricted. This is extremely unfortunate as studies have found ADHD diagnosis and treatment via telemedicine to be equally effective as in person services, especially when dealing with rural and disadvantaged patients.¹¹ As a broad category, telemedicine is the fastest growing means of healthcare delivery for mental health and in fact has similar outcomes and patient satisfaction ratings.^12,13

Delivery of services in rural and disadvantaged environments

Faced with a huge challenge this past week upon declaring the COVID-19 a national emergency,¹⁴ President Trump has taken commendable action in addressing an emergent deficit and an overall need for services:

1. Physicians are now exempt from the restrictions imposed by the RHA, granting us the ability to prescribe controlled substances without the requirement of an in-person medical evaluation as long as we are engaging in the practice of telemedicine in accordance to our professional practice and state law.¹⁵

2. Health Insurance Portability and Accountability Act (HIPAA) was waived, granting “enforcement discretion” and allowing the use of any videoconferencing modality, sometimes even audio only if that is all that is available, to deliver these vital services.¹⁶ It is important to note however that, if given the option, a HIPAA compliant videoconferencing should ideally be elected with this being a last resort.

3. Several states including mine (New Hampshire) have imposed requirements for parity in reimbursement for telemedicine. New Hampshire Governor Sununu¹⁷ released Emergency Order #8 requiring private insurers, Medicaid and Medicaid MCOs to pay for all telemedicine services of in-network physicians at reimbursement rates for in-person visits, waiving co-pays, deductibles and co-insurance for medically necessary treatment delivered via telemedicine. CMS also now has a similar policy for Medicare beneficiaries.¹⁸

4. Just recently, a 1135 waiver was issued for the requirement that physicians must hold licenses in the state in which they provide services as long as they have an equivalent license from another state.¹⁹ CMS has not had a chance to issue guidance on how to implement this, hence there may still be variability in how states currently regard such prescribing across state borders. Despite federal law being preemptive, it would still be precautious to consult with your state’s board of medicine to ensure full compliance.

These steps certainly represent an emergent response in a time of crisis, yet also a tremendous stride in enabling physician-delivered care to be supplied to patients in need, regardless of their geographical location or ability to physically present to a brick-and-mortar clinic. Keep in mind that the aforementioned changes are active only for as long as this emergency is in effect. Given that the overall situation is evolving by the minute, physicians are to stay up to date (a great resource is the

)²⁰ as well as be familiar with any preemptive state-specific laws surrounding telemedicine.

For the first time we are witnessing the full breadth of possibilities telemedicine has to offer, presenting the opportunity to showcase how we physicians can leverage it and deliver quality care on a national level to patients that are both in need and in remote areas. It is important not to deviate from the standard of care despite this emergency.

ADHD remains a clinical diagnosis which is more challenging in the adult population as collateral and a retrospective history is often required in the decision-making process. Additionally, appropriate treatment monitoring still includes an assessment of psychotropic efficacy, a review of the state Prescription Drug Monitoring Program, and any routine screening and monitoring parameters (or attempts to obtain such).

Have more COVID concerns and clinical tips? Email us at PTEditor@mmhgroup.com. We may share your stories, queries, or thoughts in a future editorial or even as a standalone piece. Check out our COVID-19 Resource Page for Psychiatrists.

Disclosures:

Dr Stanciu is Assistant Professor of Psychiatry at Dartmouth’s Geisel School of Medicine and Director of Addiction Services at New Hampshire Hospital, Concord, NH. He is Addiction Section Editor for Psychiatric Times. The author reports no conflicts of interest concerning the subject matter of this article.

References:

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington DC: American Psychiatric Association; 2013.

2. Fayyad J, De Graaf R, Kessler R, et al. Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder. Br J Psychiatry. 2007;190:402–409.

3. Waite R, Vlam RC, Irrera-Newcomb M, Babcock T. The diagnosis less traveled: NPs' role in recognizing adult ADHD. J Am Assoc Nurse Pract. 2013;25:302-308. https://pubmed.ncbi.nlm.nih.gov/24170594. Accessed March 19, 2020.

4. Arnold LE, Hodgkins P, Kahle J, et al. Long-Term Outcomes of ADHD: Academic Achievement and Performance. J Atten Disord. 2020;24(1):73-85.

5. Biederman J, Petty C, Fried R, et al. Impact of psychometrically defined deficits of executive functioning in adults with attention deficit hyperactivity disorder. Am J Psychiatry. 2006;163:1730-1738.

6. Barkley RA. Major life activity and health outcomes associated in attention-deficit/hyperactivity disorder. J Clin Psychiatry. 2002;63(Suppl 12):10–15.

7. Mohr-Jensen C, Steinhausen HC. A meta-analysis and systematic review of the risks associated with childhood attention-deficit hyperactivity disorder on long-term outcome of arrests, convictions, and incarcerations. Clin Psychol Rev. 2016;48:32-42.

8. Chang Z, Lichtenstein P, D'Onofrio BM, et al. Serious transport accidents in adults with attention-deficit/hyperactivity disorder and the effect of medication: a population-based study. JAMA Psychiatry. 2014;71:319-325. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3949159. Accessed March 19, 2020.

9. Johnson CY, Sun L, Freedman A. Social distancing could buy U.S. valuable time against coronavirus, Washington Post. March 10, 2020. https://www.washingtonpost.com/health/2020/03/10/social-distancing-coronavirus/. Accessed March 19, 2020.

10. PUBLIC LAW 110–425-OCT. 15, 2008. 122 STAT. 4820. Ryan Haight Online Pharmacy Consumer Protection Act of 2008. https://www.congress.gov/110/plaws/publ425/PLAW-110publ425.pdf. Accessed March 19, 2020.

11. Spencer T, Noyes E, Biederman J. Telemedicine in the Management of ADHD: Literature Review of Telemedicine in ADHD.J Atten Disord. 2020;24(1):3-9. https://journals.sagepub.com/doi/abs/10.1177/1087054719859081.

12. American Well, Telehealth Index: 2019 Physician Survey, https://www.americanwell.com/resources/telehealth-index-2019-physician-survey. Accessed March 19, 2020.

13. Lewei A, Lin D, Casteel E. et al. Telemedicine-delivered treatment interventions for substance use disorders: A systematic review. J Subst Abuse Treat. 2019:101;38-49.

14. The White House. Proclamation on Declaring a National Emergency Concerning the Novel Coronavirus Disease (COVID-19) Outbreak. March 13, 2020. https://www.whitehouse.gov/presidential-actions/proclamation-declaring-national-emergency-concerning-novel-coronavirus-disease-covid-19-outbreak. Accessed March 19, 2020.

15. US Department of Justice. Diversion Control Division. COVID-19 Information Page. https://www.deadivision.usdoj.gov/coronavirus.html. Accessed March 19, 2020.

16. OCR Announces Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency. March 17, 2020. https://www.hhs.gov/about/news/2020/03/17/ocr-announces-notification-of-enforcement-discretion-for-telehealth-remote-communications-during-the-covid-19.html. Accessed March 19, 2020.

17. State of New Hampshire. Emergency Order #8 Pursuant to Executive Order 2020-04. March 18, 2020. https://www.governor.nh.gov/news-media/emergency-orders/documents/emergency-order-8.pdf. Accessed March 19, 2020.

18. Medicare Telemedicine Health Care Provider Fact Sheet. Center for Medicare and Medicaid Services. March 17, 2020. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet. Accessed March 19, 2020.

19. Waiver or Modification of Requirements Under Section 1135 of the Social Security Act. US Department of Health and Human Services. March 13, 2020. https://www.phe.gov/emergency/news/healthactions/section1135/Pages/covid19-13March20.aspx. Accessed March 19, 2020.

20. Telehealth coverage policies in the time of COVID-19 to date. Center for Connected Health Policy. March 17, 2020.

. March 19, 2020.