Anyone have experience in telepsychiatry?

[MBK2003]

I interviewed at a child psych fellowship this week in a state that has a combination of a large rural population, FP's and Ped MDs who have experience prescribing SSRIs, anticonvulsants, and stimulants, and a shortage of child psychiatrists. They are using videoconferencing at the rural health centers to do initial consults, follow-ups, and consultations with the PCP for kids. They also say that this is how they manage pediatric neuro disorders because there's only one pediatric neurologist in the state. Anyone out there have experience doing it? Thoughts about pros/cons. I have a lot of interest in public mental health and rural populations, so it was a big selling point for me, but I'm wondering if other people out there have had more negative experiences.

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[Solideliquid]

So as a psychiatrist you will be evaluating patients over like a webcam or something? Sounds neat.

 

[Milo]

I've seen it work quite well at the VA, but that is an adult outpatient population, not kids. Also, a fair amount of that population have PTSD with a tendency to isolate out in rural areas.

So, coming in infrequently and having a video interaction as opposed to a one to one sit down is rather ego syntonic for them. Therapeutic? Well, that's harder to say.

 

[TheCat]

hey there-I know a adult pyshiatrist that I worked with for 2 weeks doing teleconferences ( seriously this is all she does and I basically sat in the corner during 2 weeks worth of these!) This was also at a VA and worked absolutely perfect for the population-everyone almost all had PTSD and lived somewhere prety secluded and for them it was the best option to have an isoltaed experience. So I think for certain populations it works quite quite well. As for kids though I dont know-and it takes a special person to perform them-it is borrrring I tell ya!
Also it isnot just a webcam-atleast the lady i knew-she had a really expensive technology set up where it was TV quality images produced back and forth on a pretty big screen (size of a good size TV)-so the image was perfect life like crystal clear-which I think makes one diff is you dont want a scratch blurry image like webcam!

 

[Milo]

seriously this is all she does

She's actually doing inpatient psych now.

 

[Poety]

I interviewed at a child psych fellowship this week in a state that has a combination of a large rural population, FP's and Ped MDs who have experience prescribing SSRIs, anticonvulsants, and stimulants, and a shortage of child psychiatrists. They are using videoconferencing at the rural health centers to do initial consults, follow-ups, and consultations with the PCP for kids. They also say that this is how they manage pediatric neuro disorders because there's only one pediatric neurologist in the state. Anyone out there have experience doing it? Thoughts about pros/cons. I have a lot of interest in public mental health and rural populations, so it was a big selling point for me, but I'm wondering if other people out there have had more negative experiences.

Where is this rural area? I'm seriously considering going to some of these places after residency to get my loans forgiven. what states have these rural programs set up?

 

[MBK2003]

Where is this rural area? I'm seriously considering going to some of these places after residency to get my loans forgiven. what states have these rural programs set up?

This was in Maine which like most states has a severe shortage of child psychiatrists. My understanding is that they have a more involved set-up that just a webcam. The faculty I spoke with said it takes time to get used to the 2 second lag, but he seemed to think the kids actually liked getting to use the equipment. Certainly it beats a 6 hr drive to and from the psychiatrist's office.

There are lots of ways we in psychiatry have not fully utilized the technology resources available to better serve the underserved populations. For example, how many times when you are managing stimulants in kids do you actually get the Connors back from the teacher? In our clinic it's like 10%, because it involved multiple steps that only the most organized parent/kid/teacher combination can successfully manage. Wouldn't it be much more efficient for the clinic to set-up a secure website where teachers get an e-mail in advance of the appt (think e-vite) directing them to the secure website for the student, log in, and complete an online Connors. You could link it with the clinic appt software and send teacher's e-mails one week prior to the scheduled appt, with reminders until the eval is completed.

This ultimately folds into the debate about licensing PhDs for RxP privileges in rural, underserved areas. I can think of lots of ways that psychiatrists can serve these populations via telepsychiatry and via consultation with PCPs. This is how more subspecialized fields like pediatric pulmonology and pediatric neurology are serving the same kids - they see the kids in person once, then communicate via phone/e-mail with the FPs/pediatricians on regular intervals and the PCPs manage the severe asthma, epilepsy, and sometimes even CF.

Just my 2 cents of course.

MBK2003

 

[Slikateer]

In reference to the last post, I could see how telepsychiatry can prove to be advantageous to a rural outpatient practice. We also have technology that can handle hi-resolution imaging and sound to do visual assessments and interviews, though getting the infrastructure up with the right bandwidth can be a challenge.

We are already using it in the urban setting in the context of ACT/AOT settings, where going to court could be a challenge with the traffic challenges, etc. Teleconferencing with the forensic psychiatrist has been used with good results.

Though I have to say the region where I work at is slow to accept technology so readily, so I was pleasantly it was being used at all. I would look into how it's being handled also in terms of billing i.e. do insurances accept teleconferenicing as a billable service, rate of payment, etc. And also research the state's legal rules on using this, as this varies widely from state to state.

 

[wolfvgang22]

Telepsychiatry is better than no psychiatrist. But I worry that telepsychiatry is going to cause rural areas to think it's "good enough" and stop trying to get actual doctors to be there in person. On the flip side, you can live in Europe and phone it in as long as you have a license in the state where the patient is sitting. So you can be on call all night for a hospital, but it's tea time for you. Institutions can pay a doctor living in a large city doing telepsychiatry less, due to that doctor not having to come out to the the boonies, but I don't think it is as good.

I see adolescents for medication management two days a week via telepsychiatry. But I don't much care for it on the whole, I think it reduces me even more to "just a prescriber." The cameras are often blurry and I have no control over the quality of equipment on their end, which is barely acceptable. We use polycom equipment. I find for me it is harder to see things like tics and non-verbal cues over the camera. There is a one to two second lag. I think it slightly impairs my ability to form a therapeutic alliance with the patient, as maybe they can't quite see or hear me as well as in person, either. It's just not as good as being there in person, like using Skype to talk to a family member miles away isn't as good as being in the same room. Maybe I'm old fashioned when it comes to interacting with patients. I end up relying heavily on the nurse on the other end to fill me in on things that are outside the camera's view that I would notice in person. One patient had been badly chewing on his fingers because of the stimulant he was taking, and I wouldn't have known without the nurse to tell me. The camera does pan and zoom, but not perfectly. There always has to be a nurse in the room, which is basically necessary when doing telepsychiatry in case the call is dropped, which happens once or twice per clinic. For me, telepsychiatry although valuable is a distant second best to seeing patients in person.

 

[whopper]

IT has it's limitations.

E.g. in the PES I work in, it's at a different physical location than our ER. If they have someone that they think might need to be sent to psych, but can possibly be avoided they have us do telemedicine.

The problem is that there's a loss with it. Several docs can't quit put their finger on it, but seeing the person upfront does make us feel better about the interaction. If I forget to ask the patient a question, I have to go through adruous and annoying process to re-link with the ER, and you miss the stuff you sometimes miss on an interview, that you only get by having the patient wait in the ER. E.g. I got a guy yesterday that has a delusion that EM fields will cause him to have seizures. During the intervew he was fine, but when we put him next to the TV he started freaking out. (Yes it was a real delusion, I am aware that some people truly are hypersensitive to ER fields. I put my beeper next to him with the battery taken out, not telling him the battery was removed, and told me he could feel the EM field around it and it was killing him. Yeah, I know he would've flipped out being next to a computer but the point it he only flipped out after the interview).

It was also used in the PES where I did residency so they could bug the telepsych doc to do 72 hour holds instead of the ones on call. The problem there was for some reason, some patients held it together in front of the camera, but would flip out once the cameras were off. Again-something you notice by having the patient wait around that is something you can't really do with telepsych.

 

[wolfvgang22]

I am aware that some people truly are hypersensitive to ER fields.

Sorry to possibly high jack the topic, but is there any evidence for that? Just curious. I've only heard that from the people who believe blowing on the dice will help them win a game, but then they were lawyers, so whatever. Maybe I can believe that a big power substation or MRI machine might somehow bother somebody, but a pager or cell phone? I don't know. Interesting.

The problem there was for some reason, some patients held it together in front of the camera, but would flip out once the cameras were off. Again-something you notice by having the patient wait around that is something you can't really do with telepsych.

Funny you should say that, this happened to me just this morning. Also, a different patient who has been "very happy and upbeat, doing great" around staff is so camera shy I would have thought he was severely depressed talking to him. He only says "yes" and "no" because "being on T.V." makes him nervous.

Sometimes I wonder about if patient video interactions with a remote physician should be recorded. What do you think?

 

[whopper]

Correction, I should've wrote EM fields.

And another correction. There has been studies on EM field hypersensitivity and in short the conclusion is it may exist or it doesn't exist. The WHO did studies, the UK's equivalent of the EPA also looked into it.

So it would've been a better statement for me to stay it may exist, not that it does exist.

Sometimes I wonder about if patient video interactions with a remote physician should be recorded. What do you think?

So long as the patient was aware it was recorded, I don't see why not. It's part of the medical record.

 

[gibits]

I've done this for a child psych rotation. It seems effective and simple if you have a good RN on the other side. It provides help to underserved areas which can also count as loan forgiveness as well. Worth considering for sure.

 

[whopper]

My sense so far is it's better than nothing, does have an appropriate use, but like you mentioned, there needs to be someone on the other side. This way, if the patient flips out only off camera, the other person can tell this and inform the doctor. I still think there's some loss to it vs seeing someone in real life. I'd also say it's likely alright to use it on patients that are doing relatively well and just need checkups. The problem there is sometimes even this patient demographic is doing very badly and you might need to have an in-depth interview to tease this out and talking on a TV hurts that.

Just used it again yesterday. Prevented someone from coming from the ER to the PES with a transportation cost of several hundreds of dollars.

 

[PistolPete]

It seems like tele psychiatry is useful, but still undergoing a growing process. In 10 years, technology should be sufficiently widespread, faster and more reliable that video quality should be amazing, dropped connections should be few, and current psychiatry residents who are Gen Y or later should have no problem feeling comfortable with using the technology. Or at least that's the hope! I'm optimistic.

 

[clusterF]

BUMP.

I am in the bay area and I have had a few patients ask me about this.
I have looked at ATA etc but almost all of the information is about rural telemedicine.
Is there a way to do telepsychiatry for private patients with insurance in their HOME or OFFICE?

Young patients have no difficulty with using telemedicine equipment. Why is this only for rural settings?

 

[notdeadyet]

Standard of practice in telepsychiatry is to have clinical staff on hand on the patient's end that you can contact to intervene if needed. Telepsychiatry works great for ED consults or outpt appointments in under served practices. Doing therapy over the net to someone in their home would leave you very exposed legally....


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[clusterF]

What are the legal risks?
How is it different from calling one of your patients on the phone since these patients are all local anyway?

 

[psych md jd]

"Is there a way to do telepsychiatry for private patients with insurance in their HOME or OFFICE?"

It can be done, given the right set of circumstances. I see patients in my office from my home.

Are you planning to see patients from your home or office?

 

[clusterF]

I would want to see patients in their homes. Where I am really seems less relevant (unless you have more info) although I would be in the office during regular hours and at home on evenings and weekends.

I am interested in learning why notdeadyet said that seeing patient's in their homes increases liability significantly. Why and how significantly are my specific questions. I haven't really been able to answer these questions vie the ATA site or other research.

 

[notdeadyet]

What are the legal risks?

If you are practicing and a patient due compensates or becomes suicidal, a mental health professional is on hand. This is also the case with the established telepsych organizations I've seen (staff is on hand at the patient's end). This is the standard of care in telepsych. I would be careful to check with my PLI to make sure they'd cover anything less.

I would not want to be in court and explain why I thought it okay to conduct therapy in an environment I had no control over. I talk to my patients on the phone, but I don't do anything potentially destabilizing like therapy. That's left for in person so that I can provide care if need be...

 

[clusterF]

I wouldn't do therapy. But it would be better to handle things like med management visits or actually be able to bill for the same things you call patients for.
For example, patient calls to say they are having a side effect. You video-conference them back and document a full visit. It is safer than a phone call.
Even the therapy destabilization can occur 5 minutes after they leave your office. Absolute control is never possible.

I would love to see more data on this.
http://www.ncbi.nlm.nih.gov/pubmed/10796678

 

[heyjack70]

Works in the prison setting because there are counselors and other staff on site with the patient. Though, I think something is lost using the tele psych interface. The connection between patient and doctor is not as strong/secure, in my experience. It is harder to pickup the visual symptoms of mental illness.

 

[whopper]

Agree with the above on legal risks. A problem psychiatrists face more often than other mental health providers is the counselors deal with the population that likes to boo-hoo over things that we psychiatrists would usually not consider hospitalizable. E.g. someone who hates their boss, upset with their husband's cheating etc. While these are terrible and stressful things, they are not on the order of someone wanting to purchase a gun and shoot the "demons" especially the guy that happens to go to his mailbox the same time of day.

We often-times have dangerous patients and even in private practice I would see a patient with a GAF below 30 about every few months. Resorting to telepsych only--you will get a dangerous patient sooner or later, and your ability to have them held for an emergency room evaulation will be extremely limited. If there was an investigation-either through the state medical board or a legal action, you bet your ass the question will come up that your use of telepsych may have limited your ability to fully see what was going on. If you are seeing them out of state, your ability to write for a 72-hour hold may possibly not be acceptable under the specific state's guidelines.

For these reasons, if you do telepsych, make sure you are following guidelines that are compliant with existing standards. Have safeguards in place such as someone being on the other side or the other person is at a known location so if you have to call 9-1-1 you can give them the patient's address.

 

[Indodo]

Agree with the above on legal risks.

We often-times have dangerous patients and even in private practice I would see a patient with a GAF below 30 about every few months. Resorting to telepsych only--you will get a dangerous patient sooner or later, and your ability to have them held for an emergency room evaulation will be extremely limited. If there was an investigation-either through the state medical board or a legal action, you bet your ass the question will come up that your use of telepsych may have limited your ability to fully see what was going on. If you are seeing them out of state, your ability to write for a 72-hour hold may possibly not be acceptable under the specific state's guidelines.

For these reasons, if you do telepsych, make sure you are following guidelines that are compliant with existing standards. Have safeguards in place such as someone being on the other side or the other person is at a known location so if you have to call 9-1-1 you can give them the patient's address.

Using video instead of phone visits is an interesting idea. The monthly ADHD refills, 1-2 week follow-ups for med changes in otherwise stable patients, discussing labs etc can be done quickly this way. A lot of routine med management and therapy could be done this way for stable patients. You can still mandate that your patients have to see you face to face at some minimum interval. In fact this would work best if the patients were geographically close to your office so if a crisis happened they could be seen quickly.

How the lawyers, medical board or anyone trying to make a buck from the legal aspect of psychiatry spins it is a different story. Nobody can convince me that a video visit isn't way better than a phone call, yet we call patients all the time.

 

[BobbyB]

Using video instead of phone visits is an interesting idea. The monthly ADHD refills, 1-2 week follow-ups for med changes in otherwise stable patients, discussing labs etc can be done quickly this way. A lot of routine med management and therapy could be done this way for stable patients. You can still mandate that your patients have to see you face to face at some minimum interval. In fact this would work best if the patients were geographically close to your office so if a crisis happened they could be seen quickly.

How the lawyers, medical board or anyone trying to make a buck from the legal aspect of psychiatry spins it is a different story. Nobody can convince me that a video visit isn't way better than a phone call, yet we call patients all the time.

in a malpractice suit, you just need to prove that you provided care equal to or beyond your peers

if you can show that your peers make phone calls for med management, then video conferencing is providing superior care to the patient. you just need to demonstrate that the video call is secure.

what do you think about using it to do evaluations at your clinic with you at another location and med management checkups or lab discussions with the patient being home and you at another location?

 

[Indodo]

I first laughed out loud, then was sad when I saw you are a medical student.
I bet you still believe the 4D's actually apply.

Although you are correct because, it is actually not what happens but what you can show/prove to the jury.
Anyways, back to the topic.

 

[heyjack70]

in a malpractice suit, you just need to prove that you provided care equal to or beyond your peers

if you can show that your peers make phone calls for med management, then video conferencing is providing superior care to the patient. you just need to demonstrate that the video call is secure.

what do you think about using it to do evaluations at your clinic with you at another location and med management checkups or lab discussions with the patient being home and you at another location?

The argument would be that the standard of care for medication management is an office visit and video conferencing is below that standard. I don't know any doctors that do actual med management over the phone, as in doing a diagnostic interview, starting a medication, or changing medications (e.g. SSRI to SNRI) over the phone. If so that's pretty risky.

 

[BobbyB]

The argument would be that the standard of care for medication management is an office visit and video conferencing is below that standard. I don't know any doctors that do actual med management over the phone, as in doing a diagnostic interview, starting a medication, or changing medications (e.g. SSRI to SNRI) over the phone. If so that's pretty risky.

then how are people doing telepsych? is their rationale that there is no mental health in the area so any care is better than none?

or is it only used when there is no change in treatment. any problems would warrant a visit to the clinic.

 

[Indodo]

The argument would be that the standard of care for medication management is an office visit and video conferencing is below that standard. I don't know any doctors that do actual med management over the phone, as in doing a diagnostic interview, starting a medication, or changing medications (e.g. SSRI to SNRI) over the phone. If so that's pretty risky.

Why is changing an SSRI to another SSRI or an SNRI always the wrong thing to do over the phone? How about lowering/raising a dose or refilling a medication?
I don't know what your definition of a diagnostic interview is, but I think that is pretty common over the phone. Unless you mean a full initial evaluation.

 

[whopper]

in a malpractice suit, you just need to prove that you provided care equal to or beyond your peers

No longer true in several courts though this is erroneously being taught in many medschools.

The geographic standard of care is what was taught in medschool at least while I was in one.

A new standard that has emerged and is replacing it in most local courts is the reasonable practice standard. Instead of asking the question, "did the doctor's care meet or exceed the standard in the geographic location," instead the question is asked" is this the action of a reasonable doctor?"

There are significant differences. A neurosurgeon could literally be the only doctor providing his type of care within several counties. He could argue he is the standard of care because he is the only person in the geographic area. Therefore nothing he does violates the standard of care. That or another realistic scenario- a neurosurgeon could be one of only a few people that are likely practicing within several counties, and he and his close colleagues can dictate the standard. One of those colleagues could be used as an expert witness to say the guy did nothing wrong.

Another problem with the geographic standard is professional societies that have long been used by the Supreme Court for advice and guidance (and therefore this applies to ALL US Courts) have stated specific guidelines need to be followed no matter the locality. So if a bunch of doctors in a locality coincidentally don't do lithium labs, the APA and medical textbook guidelines still apply to them.

Getting back to telepsych, something I might do is be more liberal with allowing for it once the patient has established themselves as trustworthy for safety. E.g. no first evaluation can be done via telepsych. Only allow it once you feel comfortable in knowing the patient's case and know they have good enough insight to seek help if truly suicidal.

 

[heyjack70]

Why is changing an SSRI to another SSRI or an SNRI always the wrong thing to do over the phone? How about lowering/raising a dose or refilling a medication?
I don't know what your definition of a diagnostic interview is, but I think that is pretty common over the phone. Unless you mean a full initial evaluation.

It's not something I would do. If a patient is doing poorly enough to warrant starting a new medication or changing medications, they should be seen in the office as opposed to handling it over the phone. This is my opinion, there are plenty of opinions out there. My concern is that if there is a bad outcome, you are going to look like a lazy doctor in the eyes of a jury.

You can't do a diagnostic interview or a followup psychiatric interview with mental status examination over the phone because you cannot see the patient. You cannot comment on their affect, behavior, energy, appearance, etc. A phone evaluation is lacking.

 

[Indodo]

But when you call someone over the phone, you are using your diagnosing skills correct?
Also, this is mostly hypothetical. Most telepsych occurs where the patient is in another clinic somewhere.

But, I don't think what a jury might do should be how you approach everything. I think that generally leads to poor practice patterns and eventually you will end up in front of a jury.


For example, I facetime almost everyday with family and friends. The quality of audio and video is amazing. A mental status exam could be done very easily.
On the other hand, you could also argue that psychiatrists must have 20/20 vision when seeing patients. Don't ever take off your glasses!

 

[heyjack70]

But when you call someone over the phone, you are using your diagnosing skills correct? True, but I think the medium of a telephone call is lacking when we're talking about effective diagnosis and risk assessment.
Also, this is mostly hypothetical. Most telepsych occurs where the patient is in another clinic somewhere.

But, I don't think what a jury might do should be how you approach everything. I think that generally leads to poor practice patterns and eventually you will end up in front of a jury.
I also agree with this in the context of our routine medical work, but when discussing new ways of delivering care I think it's prudent to move forward with caution. IMO.

For example, I facetime almost everyday with family and friends. The quality of audio and video is amazing. A mental status exam could be done very easily.
On the other hand, you could also argue that psychiatrists must have 20/20 vision when seeing patients. Don't ever take off your glasses! Like you said, it's mostly hypothetical, if I was a plaintiff's attorney and the doctor had poor vision, or was blind (I have met a blind psychologist), I would absolutely try to leverage that in a lawsuit. Since we're throwing out examples, how about a color blind pathologist. I'm sure they're out there. Do you want to be the pathologist on the witness stand unable to identify the nu

 

[digitlnoize]

We do a LOT of telepsychiatry at my residency program. During PGY-2, we cover all the hospital consults (ED and Floor) across town on tele psych. During PGY-3 and on, we cover lots of State CSB's for outpatient med management, basically doing about 3 hours a week in PGY-3, and more in our child clinic.

There's been a lot of research done into tele psychiatry efficacy. Enough to say that it's equal to in-person modalities. That being said, this is IF it is done in a controlled setting, like a hospital or a CMHC-type clinic, which is what we do. I don't know that it would be defensible doing it through Skype from your bedroom in your boxers, haha.

Overall, I've found it pretty easy and not much different from an in-person eval. The hardest consults were the delirium and the one or two times I encountered catatonia on tele psych. In those cases, you're kinda hampered, trying to teach the local hospitalist how to do a Bush-Francis over the phone...fun times. Other than those few cases, most bread and butter ED admission (SI, psychosis, etc) or CMHC follow up med management visits are fairly straight forward and perfectly fine to do through telemed in a controlled environment. As others have said, I feel for the doc who is on the other end of the line with a patient who kills themselves at home while on telemed. That would suck.

Finally, I'd like to point out that we are NOT the only ones doing telemedicine. Neurologists are now doing freaking stroke consults via telemed. If they can do a stroke eval and decide to give TPA or now, I think we can do a med management visit.

 

[Indodo]

I just think to the first cell phone. They were a joke. Telehealth has been around since the 90s. Only about a decade after the cell phone. It's coming.

 

[marcbarton]

All telehealth portals have to be hipaa compliant (money grab?). I don't think Skype is hipaa compliant but they are actually more securely encrypeted than most "hipaa compliant" sites. my recruiter is pretty knowledgeable on telepsychiatry matters. Don't need to promote his company but you can call him at 978-513-7637

 

[clusterF]

Hipaa requires that a business associate agreement be signed for those handling PHI. When data is transmitted through Skype, they are handling PHI if it is medical data.

http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/businessassociates.html