Dr Erin Morrison webinar slides (2)

Best Practices in Psychiatry and Long Term Care:TELEPSYCHIATRY

Erin Morrison, MD

What is Telepsychiatry?Telepsychiatry, also known as e-psychiatry, is the application of telemedicine to the specialty field of psychiatry.

Telemedicine is the use of telecommunication and information technologies in order to provide clinical health care at a distance.

Tele mental health care is the use of tele-communications technology to provide mental health services to individuals in communities or locations that are underserviced, typically as a result of geographic isolation. •Examples: providing health workers in remote areas with continuing education on mental health topics, videoconferenced consultations on routine and urgent mental health cases using a "virtual" case management team, and providing direct mental health care services through two-way interactive systems. One of the most controversial telemental health care applications is providing treatment services over the Internet directly.

Wikipedia, The Free Encyclopedia

1American Telemedicine Association

Provider and patient identity

and location

Patient appropriateness

Informed consent

Physical environment

Collaboration with treatment

teamMedical issues

Emergency management

Technical guidelines

Challenges and Benefits

Elements of Video-Based Mental Health

Services1

Provider + Patient Identity and Location

1American Telemedicine Association

Verify patient identity and location

(must verify patient location for provider state licensure

rules)

Contact information for provider and patient should

be exchange in case of dropped sessions or for

routine questions

Expectations regarding contact between sessions should be addressed prior

to the first session

Patient Appropriateness

“To date, no studies have identified any patient subgroup that does not benefit from, or is harmed by, mental healthcare provided

through remote videoconferencing.”1

• Home care setting-must consider degree of patient independence and have more comprehensive emergency plan in place

• Supervised setting- more issues with privacy

Situation dependent, but possible in both:

• Psychosis• Panic disorder• Cognitive impairment (though may not be appropriate for

unsupervised settings)

Diagnostic considerations-telepsychiatry has been successfully employed in patients with:

Informed Consent Are there any differences?

Informed consent process is the same as for face to face care, but must ALSO include (if applicable):

Confidentiality limits in electronic

communication

An agreed upon emergency plan

(patients in settings without clinical staff

immediately available)

Process by which patient information will be documented and

stored;

Conditions under which telepsychiatry services may be terminated and a referral made to face-

to-face care

It is very important to use language the patient can understand when discussing technical issues (such as data encryption or technical failure of equipment)

Physical Environment

Rooms/environments should be comparable to a standard services room

Ensure privacy so clinical discussion cannot be overheard

Presence of attendants or family members is situation dependent and subject to patient consent:

• to assist with orientation• to tend to audio or visual sensory deficits• for patient comfort (a familiar caretaker often eases patient anxiety)

For cognitively impaired patients it is often necessary for an attendant to be present in the room:

Communication and Collaboration with the Patient’s Treatment Team

Essential in the geriatric population

The geriatric patient often has multiple medical problems needing a full workup (appropriate laboratories, radiologic, and other diagnostic procedures). This communication can require more effort when one or more members of the treatment team is located at a remote site, but can still be accomplished.

Some solutions:• schedule monthly phone/video treatment team meetings• ensure all available records for other providers are

available during session• ensure that the facility (or other providers) have contact

information for the telepsychiatry provider

Medical work up

Ordering or prescriptions/ laboratory

studies

Follow up of laboratory or radiological

studies

Management of medication side effects

Referrals available for face to face

care

Coordinating Medical Issues-Who Does What?

Emergency Management

Based on the facility’s emergency procedures

Technical Guidelines

1American Telemedicine Association

Technical Contingencies

Backup plans include calling the patient or facility via telephone and attempting to troubleshoot the issue. Sessions may be continued by

telephone (situation dependent).

Technology “breakdown”• Poor/no audio• Poor/no video• Dropped sessions

Backup plans• Discussed with patient before session• Alternate contact information

Privacy

Recognized encryption standards for transmission of video & audio

• Federal Information Processing Standard• Advanced Encryption Standard (AES)

Physical environment (facility limitations)

Appropriate security of medical records

1American Telemedicine Association

Challenges

Remote facilities and available internet speed Patients with sensory impairments - The patient

end would ideally have large monitors, good audio capabilities, and high bandwidth and video resolution to make sure there is a large and clear picture for the elderly

Increased reliance on facility staff, e.g.: to assist with patients with disabilities,

to give limited physical exams (AIMS test), and

occasionally track down or confirm medication/lab values

Overall Benefits - Options!

Choice of providers Transportation Scheduling

Bottom Line: Delivering services to patients who would otherwise go without

References

1. Coleman, M., Dennison, O., Drude, K., Goldenson, M., Hirsch, P., Kramer, G., … Zucker, M. (2013). Practice Guidelines for Video-Based Online Mental Health Services-DRAFT. American Telemedicine Association. Retrieved from http://www.americantelemed.org/practice/standards/ata-standards-guidelines