Please enjoy this excerpt from Optimizing Telehealth.
Episode 2: Strengthening the Telehealth Therapeutic Relationship
Dr. Shawna Wright is the Associate Director of the Kansas University Center for telemedicine and telehealth.
Dr. Allison Crawford is a psychiatrist and Associate Chief of Virtual Mental Health and Outreach at the Center for Addiction and Mental Health, and Associate Professor in the Departments of Psychiatry and Dalla Lana School of Public Health at the University of Toronto.
Dr. Marlene Maheu has written more than 40 peer-reviewed telehealth book chapters and journal articles and is the lead author of five telehealth textbooks. She enjoys giving telehealth keynotes, training, consulting and helping organizations meet their staffing needs. She's definitely a telehealth pioneer.
Dr. Maheu: Shawna, what are the provider related factors that support successful telehealth delivery from your perspective?
Dr. Wright: I know many colleagues after they stepped into telehealth and received some training, their adoption and comfort really improved.
Dr. Maheu: Allison, would you please talk with us a little bit about how to know if telehealth practice is appropriate for a specific patient or client?
Dr. Crawford: The most important term is Patient-centeredness. It really has to do with if you can meet the patient's clinical needs. From a technical point of view, you need to be able to have enough information to base your assessments and interventions. Do you have Appropriate Connection? Things like internet speed? Is there privacy for the patient and also for yourself? Can you clearly see and hear the patient? And can you safely assess the patient and do an intervention? I think these are the factors in assessing a patient’s environment. We all know from clinical experience how to do this, but thinking about how to do this in a virtual setting requires some adaptation.
Dr. Wright: I would like to point out that prior to the pandemic, most of what we knew about telehealth through research and practice was delivering telehealth in supervised settings, like a mental health center or a skilled nursing facility. Those supervised settings had another licensed or trained professional to support the client or patient on the receiving end. When we're reaching into the home or a place of work, those are unsupervised settings, which puts a higher burden on the provider to make sure all of these things are in check. One, so that we can deliver a high quality of care, and two, so that we can ensure safety and effectiveness in the care that we're delivering. There's a larger burden for the provider when we're reaching into the unsupervised settings.
Dr. Maheu: Shawna, could you talk a little bit about how to document what we're doing?
Dr. Wright: When we look at the factors that inform us if telehealth is appropriate, from the provider comfort to the patient or client comfort, the environment or the technology, we can document that we've made that assessment in a variety of places. Oftentimes, we'll start with informed consent. When we're providing an effective and efficient informed consent regarding telehealth, a lot of those factors are assessed and discussed with our clients. When we meet with patients in our regular care sessions, we can also continue that assessment. We might meet with a client who is living where they have good internet connectivity. They might decide to join us from their workplace or they might move to a new location. When that happens, we have to document if internet connectivity is strong enough to effectively deliver telehealth care. We need to be documenting any changes in the clients notes. If, for any reason, the use of telehealth causes us to step out of our normal and expected standard of care, we need to explain and justify that in our notes. If we run into any barriers or issues in our telehealth sessions, we need to document those in our notes. We need to identify how we work around those. For instance, if we're having some difficulty with an internet connection, we might decide to leave our video on with the platform, but connect through audio with a phone. And that way, we still have audio and visual connection, enough to check the boxes to bill for a telehealth appointment. But we'd want to document in the notes what steps were taken when barriers show up.
Dr. Maheu: We have a comment from Darby.
Darby: The idea of supervised versus unsupervised settings and the implications for telehealth I find interesting, because I've worked in a lot of clinics over the years, where we frankly struggle with confidentiality because of the closeness of offices and the lack of an appropriate barrier between the walls and so forth. Right now, I'm in my home, and there's no one else here. It's totally private. Whereas I could be in a clinic and it could actually be less confidential.
Dr. Crawford: I think that's a good point. I can see you right now by yourself, but I have no idea if there are 10 people surrounding you outside of the screen. We need to think about that for patients. I think it directly links to safety or at least it's one factor in thinking about safety. And I'm thinking about some clients I've worked with who actually don't live in safe situations, yet we're relying on them to tell us that they're alone and have privacy. When we prep patients, we also talk to them about how they can improve their privacy even if they can't insure it completely. So using a headset is one example or turning your screen to the wall. There are also international safety signs. For example, putting your thumb in front of your palm and tucking your fingers over is a sign that you need help. That's maybe an extreme example, but I think what you're saying is true. We all have to think about the configurations of our spaces, because where we are gives clients a felt sense of safety or not.
https://telehealth.org
