Telepsychiatry Revolution Amid COVID-19 Outbreak

If you are a psychiatrist or patient, chances are there has been a transition to telemedicine for outpatient services. With the COVID-19 pandemic creating chaos for patients and psychiatrists alike, many systems worked frantically to implement telemedicine platforms. As the world of technology moves at ever increasing speeds, we as physicians must keep up. There is a saying barrowed from motivational interviewing that goes “meet the patient where they are at.” Of course, I’m not talking about where they are in the process of change, but rather we can meet the patients literally where they are at. This provides convenient access to psychiatric care for patients who cannot make it to the office. 

The current situation is terrible, but it provides us new opportunities to learn and grow. If there is one thing I learned in my residency training, it’s how to be flexible and role with the punches. I have learned over the last several years that resistance to the reality of a situation will lead to unhappiness. While I miss the deep personal connections with my patients during in person visits, I have learned that most of that experience can be maintained through telepsychiatry. 

Telepsychiatry is becoming more common, and many younger psychiatrists are making a career out of it. In the past, telepsychiatry required patients be seen in places such as the primary care clinic, now we are able to see patients in their homes. With most patients having access to a smart phone, they are able to complete the consultation in their car, or while on break at work. For busy people such as physicians who need a psychiatric consultation, the convenience of telepsychiatry is unparalleled.   

Here are some of the questions I had after I found out I would be doing telemedicine visits. 

Are We Compromising Patient care?

One of my biggest concerns moving to a telemedicine platform is the quality of patient care. It’s important to consider, since one of the most therapeutic aspects of a psychiatric consult is the physician patient relationship. Countless articles have detailed the importance of physician patient relationship in treatment outcomes. I believe it influences treatment outcomes even more in psychiatry than other specialties. Multiple studies in the literature have shown that telepsychiatry is just as good as in person visits for many psychiatric disorders including depression, anxiety, and PTSD. If you work with children, it may even be a clinical advantage to use telepsychiatry. Most child and adolescent patients actually prefer using technology to interact, and doctors’ appointments are no different. 

Is telepsychiatry HIPAA Compliant? 

It’s important to remember that not all video-based systems are HIPAA compliant. The ones we are most familiar with (Facetime, google hangouts) are not HIPAA compliant. There are a number of companies that offer telemedicine platforms that do comply with HIPAA regulations. Skype for business is a HIPPA compliant product but the free version is not for example. The companies that offer HIPAA compliant services will provide you with a Business Associate Agreement (BAA). It’s basically a document that indicates the data transmitted over the service is confidential. The company agrees to provide the service and cannot look at any of that data transmitted over the platform. Ensuring you have the BAA in place will confirm HIPAA compliance. 

How does State Licensing Work?

In order to use telepsychiatry you have to be licensed within the state that the patient is located in. For example, if you are licensed in Florida and the patient is located in South Carolina you would need a license in the state of South Carolina. However, the physician is allowed to be located anywhere in the world.  

Are There Limitations to Medication Prescribing?

For routine psychiatric medications, these can be electronically sent to the pharmacy like an outpatient visit. The one caveat to be aware of is prescribing controlled substances such as stimulants and benzodiazepines should not be done via telepsychiatry. Careful monitoring of patients on these medications necessitates the need for in person follow up. The legal guidelines are not clear at this point, so it’s best to avoid prescribing controlled substances. 

What About High risk situations?

Another area of concern is what to do in the event that a person is suicidal or needs emergency care. These situations are rare, but they can happen, and you need to be prepared. It’s a misconception that someone has to be in the room with the patient during the consult. This is not true, however it’s prudent to have a person you can contact in the event of an emergency. This can be a friend or family member who lives close to the patient and can reach out quickly. You should also get a list of the local police departments in the area where your patients are residing. This is a last resort but may be required in some situations. To summarize you should have the patient’s address, phone number, a friend or family member’s contact information, and the local police departments number. This should be enough information in the event you need to alert emergency services. 

What Is The Out of Pocket Cost to Physicians?

One issue that may be more important to the private practice psychiatrist is the equipment required to start telepsychiatry. In many cases the equipment required is already possessed, a laptop computer with built in speakers, camera, and microphone will likely be enough for most practitioners to get started. You can purchase higher end microphones and cameras which may be important to psychiatrists who plan to continue using telepsychiatry after COVID-19 however, it’s not required. The take home point is a basic laptop computer will cover most physician and patient needs. 

How Do I Get Vital Signs?

Blood pressure, pulse, height and weight are usually recorded on every patient, at every visit. A simple way to get around this issue is having the patient purchase a blood pressure cuff from the store, which is relatively inexpensive. Have the patient perform the blood pressure check while in the session and show you the monitor. This will allow you to record pulse and blood pressure easily. Many patients will have a scale in the house, and if not one can be purchased. 

What about Urine Drug Screen and Routine Labs?

This is a simple situation to handle and much like regular outpatient visits the patient can be sent to LabCorp or Quest diagnostics for these tests. Other examinations like the Abnormal Involuntary Movement Scale (AIMS) test for patient’s taking antipsychotics can be easily completed with telepsychiatry. 

Final Points:

In conclusion, I do not think telepsychiatry will replace all in person psychiatric evaluations and follow ups. However, it does provide a convenient option for busy patients with time constraints, and those who are more comfortable communicating electronically. I have embraced the change and I really have enjoyed the process of transitioning to telemedicine. 

I would love to hear any thoughts on telemedicine from the patient or physician perspective. Please, like comment, and subscribe to the blog. 

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