Telehealth solution for psychiatric assessment

Solution

 

Itransition delivered a comprehensive telepsychiatry solution for medical case processing, patient data management, remote psychiatric assessment, treatment recommendation delivery, and facility inpatient placement coordination. The system can be extensively fine-tuned with detailed facility configurations, user settings, and custom evaluation forms.

We designed the solution under HIPAA guidelines, ensuring the due protection of sensitive patient data. Our team hosted the solution on Azure, set up CI/CD pipeline, and thoroughly tested it to ascertain the solution was easy to use and maintain.

User roles and pipeline

Facility employees

• Source facility medical staff create medical cases and patient profiles, fill in dashboards with patient data, and prepare patients for remote psychiatric assessment.
• Inpatient facility medical staff review cases and patient information, make decisions on accepting patients for treatment, and communicate with the customer.
• Admins configure and manage their facility accounts and medical staff profiles.

Our customer’s employees

• Coordinators manage case processing, select suitable psychiatrists, and facilitate communication between different healthcare facilities.
• Psychiatrists remotely review patients’ medical cases, perform assessments, and fill in evaluation forms.
• Admins add new users, manage facility and user configurations, and oversee password resetting and creation.

Case creation

When a new patient arrives at the hospital and the medical staff concludes they require a psychiatric assessment, a source facility employee starts by filling in the primary patient information (name, phone number, DOB, address, etc.) in the solution. The system checks whether there is a patient profile with similar data and either offers to create a new one or redirects the user to the existing patient profile.

Disclaimer: Due to the NDA that we signed with our customer, we can not reveal the screenshots from the real systems. Hereinafter, we provide some similar screenshots created to offer the reader an idea of the solutions developed by Itransition.

Then, the medical staff creates a case on the particular hospital admission. They enter the contact details of the person responsible for managing the patient on the facility’s side. Itransition also developed the requests panel, where the medical staff specifies what type of telepsychiatry consultation service they require in each case (phone consultation, video assessment, etc.). This information helps coordinators select the most suitable psychiatrist for a certain case.

The medical staff can also add insurance information like payer codes, ID card scans, and insurance verification codes. If the patient already has insurance data, the system will ask the medical personnel to verify it to ensure it’s up-to-date. Admins can also add credited insurance payers with verification codes to help ascertain that the information provided by patients is accurate.

Our customer requested the addition of a notes feature to help users avoid rereading documentation in search of the necessary information. Itransition also enabled medical staff to upload patient files in PDF format with supporting notes attached to them.

Thus, the medical staff can provide documents related to the medical case, helping the certified psychotherapist form a thorough understanding of the patient’s psychological state.

Additionally, the medical staff fills in the vitals section on the case information page. In the section, they can also enter the results of the initial physical examination: blood pressure, pulse, blood oxygen levels, temperature, and respiration rate. These parameters provide insights into the functioning of the patient’s body, helping psychiatrists conduct remote assessments.

Case processing and patient assessment

After the medical staff finalizes the case, the system transfers it as a new request to our customer’s coordinators responsible for processing the case and facilitating communication between different hospitals. Apart from processing individual cases, the customer’s employees can filter through and access patient history to access all cases related to a certain patient.

The solution grants access to past cases, with the information on previous hospital admissions helping coordinators select the best suitable psychiatrist and potential inpatient facility.

Tracking and measuring case processing

Our customer wanted to streamline telepsychiatry services, reducing the patient wait time and ensuring they can receive due medical help as soon as possible. This is why they requested us to develop a system of statuses, covering all stages of case processing from creation to completion.

Itransition developed the case list dashboard with accumulated elapsed time, displaying all the active cases with their respective elapsed time. The case list dashboard provides coordinators with a 360-degree view of the current case processing pipeline and helps them efficiently manage it. They can also see a detailed case processing dashboard with a spreadsheet on the duration of the processing phase for a selected case. They can look at the two dashboards and easily find process bottlenecks both at the individual case level and for the whole case processing pipeline.

Patient history panel

Itransition developed a patient history panel with various fields intended to clarify the patient’s past and current state. Reviewing the case and its supporting documents, coordinators fill in the table with condensed data on the legal status, criminal charges, affinity to violent behavior, detected drugs and alcohol, factors precipitating a hospital admission, and medication. Furthermore, our team developed a system of tags to highlight the most acute conditions and major assessment-affecting factors. Itransition added the most common tags and also enabled the medical staff to add custom ones. Thus, the patient history panel with tags functions as a case summary, enabling users to access the most critical data at a glance.

Psychiatric assessment

Coordinators review the case and, depending on the request type, either assign a psychiatrist to it or move to the patient placement. Via their own dashboard, our customer’s psychiatrist takes the case and assigns it a relevant status. Then, the psychiatrist studies the data and documentation supplied by coordinators and the source facility. Once they are ready to perform an in-person consultation, psychiatrists update the case status and the system automatically alerts the source facility of the need to prepare the patient for the upcoming examination.

All types of in-person assessments are held via Zoom, with the solution automatically generating a meeting room accessible through the case panel. We decided on Zoom as the communication platform due to its HIPAA compliance. Moreover, Itransition took into account such factors as Zoom’s cost-efficiency and easier configuration as opposed to alternatives like Twilio Video and Jitsi Video Service. In addition, our customer has already utilized Zoom in their other workflows, so their employees were already familiar with the platform, which accelerated user adoption.

Filling in evaluation forms

Having performed consultations, psychiatrists access an evaluation form. When developing the evaluation section, our team aimed to combine flexibility and ease of use, ensuring psychiatrists can fastly and efficiently enter their professional conclusions on the solution. The evaluation form includes drop-down menus with general treatment recommendations (mental health inpatient, substance abuse residential, etc.) and details (e.g., single occupancy during inpatient treatment).

Itransition also developed the feature, enabling psychiatrists to type in free-form additional assessment notes or therapy and pharmacological recommendations. It was important for the customer to standardize the evaluation form, so Itransition aligned the available diagnoses with the latest editions of DSM (Diagnostic and Statistical Manual of Mental Disorders) and ICD (International Classification of Diseases) – leading classifications for health issues.

Creating custom evaluation forms 

Our customer wanted to move further the standardized assessment questionnaires, offering more flexibility to facilities and psychiatrists. Even though Itransition created default evaluation forms for each type of psychiatric assessment, we also developed a feature for designing custom evaluation forms.

Granting admins the ability to create tailored questionnaires helps ensure the solution fits in with the unique needs of a particular facility.

Admins can add custom questions to the standard evaluation form, leaving a field for a free-form written answer. In addition, Itransition developed a patient history question type that integrates with the patient history panel in the case dashboard. The type has preformulated questions and a set of possible answers psychiatrists can select from. Both the questions and the answers are aligned with the fields in the patient history panel. After a psychiatrist has selected one of the answers and finalized the evaluation, the solution retrieves data from the evaluation and automatically updates the patient history panel in the relevant patient medical case. The patient history questions help decrease the load on coordinators by ensuring the panel is at least partially auto-populated and updated.

The ability to create dependencies between questions further contributes to the flexibility of custom evaluation forms, as certain answers given by patients trigger the system to either display or skip additional questions. For instance, the psychiatrist’s assessment often entails suicide risk screening (ASQ toolkit). Depending on whether the patient answers affirmatively to the starting question regarding suicide ideation, the solution will either pull more questions, prompting the patient to describe their experience in greater detail, or omit the rest of the ASQ toolkit.

Patient placement 

Our customer wanted to streamline finding and contacting the most suitable inpatient facility to quickly secure a place for the patient and reduce travel and patient waiting time. 

Itransition developed a patient placement dashboard that compiles a list of potential mental health facilities based on a variety of parameters, displaying the most suitable ones first.

We also created an interdependent system of criteria that the solution utilizes to filter through facilities, including voluntary/involuntary patient placement, available beds, and more.

We then ensured the system would offer only the facilities that can provide treatment plans and types of patient placement recommended in the psychiatrist’s evaluation. Our team also aligned patient data with the types of patients that facilities are ready to treat, automatically discarding unsuitable ones. As an example, the facility might be unequipped to treat geriatric patients, so the solution will not suggest it to coordinators if the patient’s age is over a certain mark.

Expected travel time

The expected travel time feature was one of our customer’s key requests as decreasing the time it takes to transport the patient between facilities is one of the major challenges when connecting dispersed hospitals. Itransition enabled the system to calculate the estimated travel time between the source and potential inpatient facilities and offer the most geographically convenient ones first, reducing patient travel time. To leverage the feature, users need only to enter the facility’s address. We realized the feature via integration with Openrouteservice, an open-source routing API. Itransition’s team opted for this service as it consistently accurately assessed travel time and autocompleted addresses based on the location by leveraging user-generated and collaboratively collected free geographic data.

Call history and mass change

Having selected the most suitable inpatient facility, coordinators call it to inquire whether they are ready to admit the patient. As facilities regularly require time to make a decision, coordinators often need to contact them multiple times. Also, taking into account that coordinators usually process several cases simultaneously, our customer wanted to enable coordinators to manage the calls and their results. For this purpose, Itransition created call history and mass change features.

The call history feature allows users to store the data on calls pertaining to a certain facility or patient, including facility contact information, records about previous calls, and basic patient information. The call history helps coordinators easily track when and why they contacted a certain facility and when they should follow up with a call, decreasing the chance of accidentally forgetting about the call or missing crucial information. Coordinators can also add notes and log call results, which Itransition aligned with the case processing statuses and patient profiles. As an example, if the coordinator marks in the call history that the facility agrees to accept a patient, the case status and the patient placement activity log are automatically updated.

The call history feature is connected with the mass change functionality, which helps update statuses or additional information for multiple patient cases at once. When contacting facilities, coordinators often get information affecting the processing of multiple cases. For example, a potential inpatient facility doesn’t have beds available. With the mass change feature, coordinators can mark the facility as unavailable for inpatient placement for a certain period of time. The action will impact the patient placement dashboard for all the patient cases, as the facility will temporarily stop appearing as a potential facility in the dashboard.

Notification system

To streamline collaboration on cases across geographically dispersed facilities and psychiatrists, the customer needed an automatic notification system to alert users about relevant updates on the case.

The notification system accurately reflects all potential scenarios in the case processing pipeline and automatically sends notifications to involved parties only in each particular case processing phase.

Thus, the notification system keeps psychiatrists and medical staff from being overwhelmed with a large number of irrelevant notifications. To make the system more user-friendly, Itransition provided two auto-notification options – SMS and robocalls – through the integration with Twilio. Our team selected Twilio among other communication APIs as it’s highly reliable with the US numbers. Moreover, the product had an SDK which simplified and accelerated the development.

We added the confirmation popup feature, requesting users to validate seeing the notification by either answering the call or sending a short SMS. If the recipient does not validate the notification, the system will automatically make multiple attempts to reach the person and finally alert the group of coordinators to resolve the issue through personal contact.

Audit and reporting

Itransition developed a set of features that provide visibility into past actions, processed case studies, previous psychiatric evaluations, and more. Our customer wanted to have tools to easily assess the quality and speed of the provided telepsychiatry services. The audit log feature enables them to search, filter, and see all the actions performed by each user, providing insights into the activities pertaining to each case. It is available only to the customer and facility admins, so only a selected number of users have access to a large amount of sensitive patient data. Additionally, users are granted access to past cases so that they can analyze them.

Our customer also requested the reporting feature because they need to use data outside the system sometimes. Thus, Itransition implemented the feature for exporting the data on past cases, psychiatrist evaluations, case activity, audit logs, and case notes as PDF and CSV files. To make the reports easily accessible and digestible, we developed document templates, formatting the data displayed in dashboards to fit CSV spreadsheets and print-oriented PDF files.

Admin features

Our customer’s admins can add new users and access and edit information on the existing ones. To add new medical staff, our customer’s admins can either manually enter the data (name, work email, phone number, and facility) or import multiple users from a standardized CSV file filled by the facility and accelerate the process. Itransition also ensured users can get access to the solution by leveraging SSO with their internal facility accounts.

When adding new psychiatrists to the solution, our customer’s admins can select the types of patients psychiatrists are ready to accept for assessment. Thus, our team helped ensure our customer’s psychiatrists can deliver the best possible psychiatric services as they can specify the patients they are most skilled to work.

Merging patient records

Itransition created the merge records functionality to search for potentially duplicating patients. Our customer wanted to develop the feature because users sometimes accidentally create a new profile instead of updating the existing one. The merge records functionality helps achieve patient data consistency across geographically dispersed facilities. The system notifies admins about potential duplicates, highlighting the coinciding information, and asks admins to verify the merge. If admins approve the merge, the solution combines the records into a single patient profile.

Facility management

The customer’s admins can view, add, and edit facilities. Facility configuring enabled the customer’s and facility’s admins to set up what types of patients a facility can accept and the available types of treatment. The configurations also affect what hospitals the system will consider when compiling the list of potential inpatient facilities for each particular case.

HIPAA compliance

Itransition created the solution following HIPAA compliance requirements to achieve high standards of protection for health information and personal data.

Under HIPAA compliance requirements, data transfer should be secured, so we encrypted data in transfer.

To safely transmit PHI, the system uses HTTP over TLS (Transport Layer Security). To encrypt all data in the database, we employed TDE (Transparent Data Encryption) technology. Itransition also added a database backup mechanism as a technical safeguard, so that it would take system snapshots every day at the selected RPO (recovery point objectives) to ensure that it can be easily restored.

Since the solution runs as a web application, Itransition developed a set of measures to ensure web security. All sensitive data is also HTMLl-encoded to prevent such security breaches as XSS (cross-site scripting). Web security is further reinforced through the usage of CSRF tokens that prevent cross-site request forgery attacks.

Following HIPAA security regulations, all operations with PHI data are trackable and auditable on application and database levels, which grants full transparency into the accessed piece of data, the involved user, the action they performed, and its date and time. Itransition also enabled cloud services audit to create logs with records of any activity related to the hosting environment: who logged in, data accessed, settings updates, etc. Aligned with HIPAA standards, system logs are stored for 6 years.

Since the solution had to be integrated with external services, HIPAA affected our choice of available platforms. As an example, one of the reasons we selected Zoom was its HIPAA compliance. HIPAA stipulates that HIPAA-covered entities need to sign a business associate agreement (BAA) with third parties handling PHI. Thus, our customer signed a BAA with Zoom Video Communications to regulate PHI storage and transfer on Zoom servers.

We aligned the solution’s architecture with technical safeguards, outlining features for role-based access, permissions with varying degrees of access, password strength, and unique user authentication.

Our team developed a user identification system so that each user could be easily tracked throughout the system. Itransition developed the automatic sign-out to ascertain the system would automatically terminate the session after 15 minutes in case of user inactivity. The functionality helps prevent accidental PHI disclosure if the user leaves the platform on the monitor unattended.

Itransition developed the SSO functionality in compliance with HIPAA. When designing the SAML-based SSO, we wanted to provide facility admins an option to configure SSO for their facility themselves, without turning to our customer’s admins. To attain this objective, our team developed automatic dynamic detection of any changes made to the existing SSO configuration, prompting the system to reload and apply new configurations.

QA

Functionality
Our QA specialists checked the developed functionality in detail and validated it against the project scope and the elicited business requirements. 

GUI
Even though the UI was developed by professionals on the customer’s side, our team tested the interface to ensure it perfectly reflected the intended business features and integrated seamlessly with the backend.

Usability
The solution was intended to be used by a wide variety of healthcare professionals in a high-pressure and time-pressed hospital environment, so Itransition needed to ensure users could easily navigate it.

Security
Since healthcare solutions store a large amount of highly-sensitive medical data, Itransition performed security testing. Itransition tested such web application security measures as CSRF tokens and HTML encoding of sensitive data. Our team also ensured the system is protected against SQL injection attacks. We also thoroughly checked all user roles, ascertaining the system accurately determines the types of features and medical data available to each role, ensuring users can access only the data necessary for carrying out their job.

Cross-browser testing
Since the solution is used as a web application, it was important to ensure it would run smoothly in different browsers, so Itransition tested the solution on Google Chrome, Microsoft Edge, Mozilla Firefox, and Safari.

Process

Itransition’s team included a project manager, business analysts, frontend and backend developers, and quality assurance specialists.

The primary stakeholder on the customer’s side was a product owner with whom we discussed the project’s vision. The product owner acted as the main contact point for our team, clarifying business needs and approving requirements created by business analysts. Itransition’s team also consulted the customer’s IT director on the architectural and major technical decisions. Our project manager participated in the bi-monthly meetings with the stakeholders to provide strategic oversight of the project’s progress. To fully satisfy our customer’s needs for the solution, we also initiated additional meetings with the customer’s stakeholders on mission-critical business or technical decisions to ensure both the stakeholders and the team had a clear understanding of long-term project goals.

Itransition suggested Scrum as the project management framework, working in two-week sprints with demos after each sprint to demonstrate results to the product owner. Regularly showing the developed features helped create a fast feedback loop, quickly altering the features and introducing modifications. To ensure consistent project development and close collaboration among team members, we organized retrospective sessions and planning meetings after each sprint. Retrospective sessions allowed us to quickly fine-tune processes to fit changed project needs. Itransition was solely responsible for filling the backlog and selecting and prioritizing the most mission-critical items for upcoming sprints. This freedom helped us accelerate the development process since our team could shape the sprint scope with all project intricacies in mind.