Jay H. Shore, MD, MPH, returns to the Psychcast, this time to conduct a Masterclass lecture on using telepsychiatry in a regulatory environment that is quickly changing because of the physical distancing forced by the COVID-19 pandemic.

Dr. Shore is director of telemedicine at the Helen and Arthur E. Johnson Depression Center at the University of Colorado at Denver, Aurora. He also directs telemedicine programming at the medical center’s department of psychiatry.

He disclosed serving as chief medical officer of AccessCare Services and receiving royalties from American Psychiatric Association Publishing and Springer.

Take-home points

Practicing telepsychiatry has administrative, technological, and clinical considerations.

• Administrative concerns include licensure, prescribing, billing, and establishing a procedure and protocol, especially about emergencies.
• Technological considerations include choosing software, understanding HIPAA compliance during the current COVID-19 crisis (and afterward), and incorporating a virtual clinic workflow, such as scheduling and billing.
• Clinical considerations include understanding how to manage a hybrid relationship with patients and tailoring your clinical style to teleconferencing, such as reading body language through video and directing the environment as the clinician.
• Basic dos and don’ts: The clinical space for teleconferencing of both clinician and patient must be private and secure. Every person in each room must be introduced. The webcam should be placed on top of the computer screen that so eye contact is maintained, and the clinician’s head should take up two-thirds of the screen.

Administrative considerations

• To practice telepsychiatry, typically psychiatrists must be licensed in the state in which the patient is located, with some exemptions within federal systems. During the COVID-19 pandemic, however, many states have waived this requirement. Inform your malpractice company that you are now participating in telepsychiatry to ensure that you are covered. During the COVID-19 crisis, the federal government has waived the Ryan Haight Act to allow the prescription of controlled substances without an initial in-person visit.
• Tips for dealing with an emergency: The psychiatrist should establish the physical location of the patient at the start of every appointment and document how to get a hold of them if the connection is lost. It’s helpful to know how and when to contact local emergency services; 911 is often a local call based on the GPS of the cell phone. American Telemedicine Association and American Psychiatric Association guidelines suggest using a patient support person. That person would either be a family member or close friend who is onsite during the event with whom you have preconsent to contact the clinicians if an emergency occurs.

Technological considerations

• Telepsychiatry services should have a procedures and protocol document to outline scheduling, billing, documentation, and how to address psychiatric emergencies. For telemedicine, the videoconferencing software must be HIPAA compliant. During the COVID-19 emergency declaration, the Department of Health & Human Services’ Office for Civil Rights will exercise “enforcement discretion” and, in most cases, waive penalties of HIPAA enforcement for clinicians who are serving their patients in good faith.
  • Use only technologies such as FaceTime or Skype if you are unable to make adequate connection with HIPAA-compliant technology.
  • Take your in-person operational workflow and try to replicate it virtually. Make sure that people’s responsibilities are clearly delineated.

Clinical considerations

• “Hybrid relationships” are increasingly more common with in-person and virtual interactions from videoconferencing, patient portals, email, etc. In hybrid relationships, there are both physical and virtual spaces. The physical space provides immediacy, often more trust, and clear boundaries. The virtual space often is convenient and provides a sense of physical and emotional space between clinician and patient, with advantages and disadvantages. The virtual space means rendering care to the patient in their home and gives insight into their environment. The virtual space can also decrease stigma because the patient does not have to seek care in a physical clinic. Sometimes, more small talk than usual about the environment is helpful to bridge that virtual gap. Use more active inquiry into emotions or body language if these are not clearly communicated over videoconference.
• Dos and don’ts: Make sure that the lighting is good. Use the picture setting, so you can monitor your body language during the session.
  • Make sure you are not too passive during the session. Be proactive. Animate yourself a little more than you would in person.
  • Ask patients questions about their environment.
  • Have a lower threshold for asking how patients are doing. More active inquiry can prove helpful.

References

American Psychiatric Association Telepsychiatry Toolkit: https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit

American Telemedicine Association: https://www.americantelemed.org/

Joint guideline on telepsychiatry from APA and ATA: https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/blog/apa-and-ata-release-new-telemental-health-guide

State licensure exemptions: https://www.fsmb.org/siteassets/advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in-response-to-covid-19.pdf

HHS HIPAA information: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html

Ryan Haight Act information: https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/ryan-haight-act

Yellowlees P and Shore JH. Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals. Arlington, Va.: American Psychiatric Association Publishing, 2018.

Show notes by Jacqueline Posada, MD, associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. She has no disclosures.

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