Telepsychiatry - Week 7

It is week seven of telepsychiatry.  Things have been going reasonably well. I am as productive doing telepsychiatry as when I was sitting in an office. The constraints are becoming more evident as time goes by and I have the opportunity to confirm some of them with colleagues.   I have about 50-minute commute one way and doing telepsychiatry saves me that time every day. That is about 50 hours of time saved in the past 7 weeks. I also don’t have the additional expenses of purchasing food, coffee, and snacks at the workplace and that is a significant savings as well as the gasoline costs.

It is very convenient to sit in your office all day, click a tab, and immediately see your next patient. I do get notifications of people are running late but that is rare. The photo at the top of this post is what my desk looks like. The Mac Pro is the large monitor in the background. That is what I use for the telepsychiatry software. It is a high-resolution monitor with good sound quality but it is only as good as the monitor and sound quality on the other end. The small Dell laptop in front is what I use to access the VPN and secure networks and all of my previous notes. I only have access through this computer. The Surface Pro on the far right provides access to everything else I need including FDA package inserts, UpToDate, NLM searches, drug interaction software, an outside lab server that contains all the lab results on patients I am seeing, and the searches I need to locate a patient’s primary care clinic and psychiatrist. That is the information I commonly access during sessions with patients.  It turns out I am a lot faster with the additional computers than working on one computer in my office.

I have a number of documents that I present to patients in interviews that I have posted on this blog.  When I use web casting software for work related conferences, I have the option of posting material from Word, Excel, or PowerPoint right in the working field.  So far, I do not have that capability in my telepsychiatry software and I will be a lot more comfortable when I can do this. One of the critical documents is my standard list of psychiatric medications. It does prompt recall of many more medications than most people can recall spontaneously. 

I put up an earlier post on some of the limitations of telepsychiatry visits. I have had some further observations on that issue some of which have been confirmed by colleagues. Complex movement disorders for example are difficult if not impossible to assess in a telepsychiatry visit. The one I am thinking of was a combination of spasticity from a known neurological diagnosis, possible dyskinetic movements, and possible chorea. Asking a patient about their subjective experience of movements is useful to some degree but not absent an examination. I made the provocative suggestion to some colleagues that “telepsychiatry is not real psychiatry” to point out that there are both favorable and unfavorable consequences.

One of the unfavorable consequences is that telepsychiatry is not universally accepted by patients. With the recent security problems in a popular teleconferencing platform people are more aware than ever of this issue and how it may affect personal discussions with a psychiatrist. There seems to be a general belief that everyone accepts security risks as the cost of doing business but that is not true. There are some people who refuse telepsychiatry visits. There are others who go along but are obviously anxious about it and may not disclose sensitive material. It is an issue that should be explicitly discussed especially if the patient is obviously stressed or the information flow in the interview seems restricted. I had one colleague state that his practice of psychodynamic psychotherapy was going well with telepsychiatry visits. Another variable may be whether the psychotherapy started before telepsychiatry or not.

Even though it is a different kind of psychiatric assessment it does tend to expand the horizon. I started to think about seeing people anywhere in the United States or the rest of the world. I started to think about people I would see from rural Minnesota who would have to drive 150 miles to see me, until they eventually decided it was too inconvenient. Now I can potentially see them immediately right at their home. My mind wandered to the current pandemic and a recent story about depression and suicide in physicians who are on the front lines. I could potentially volunteer my time and help these colleagues.  A critical question is what are the barriers to that kind of practice or volunteerism? A good place to start is looking at an ideal telepsychiatry practice in the state of Minnesota. In that practice a very highly-respected psychiatrist has been a consultant to several southern Minnesota counties for years and has provided their psychiatric care. He has a very well-defined model that includes seeing patients only in clinic settings after they had been roomed and their vital signs have been determined. He has nursing and clinical staff on the other end who know the patients well.  He also sees everyone in his practice on an individual basis every year. His computer system and software are state-of-the-art and high definition. I have seen him give two presentations on his practice, but until the pandemic it never thought I would be using that model.

For now, I will consider a pared down model that would allow volunteer psychiatrists help their colleagues in the current and subsequent pandemics. The first consideration is licensing. Currently physicians are licensed in their own states and that license is not typically allowed treatment in a neighboring state. The only exception I am aware of is licensing through the Veterans Administration for physicians working in that system of care.  A central licensing body or state waivers could potentially bypass state licensing in this situation. It would also allow a large number of retired or semi-retired psychiatrists to volunteer their services. Some of those psychiatrists have let their licenses expire or in some states there is a active but retired status.

The second issue is malpractice. One of the deterrents to opening a private practice or transitioning to a private practice prior to retirement is malpractice insurance and tail coverage. Tail coverage is malpractice premiums that carry it on in retirement, until the window for civil litigation has expired. That would typically involve a two or three year malpractice premium payment during retirement with no associated income. Some states make an exception to malpractice insurance for volunteer physicians. I would argue that consultation to front-line physicians is a priority not only in terms of medical care but also national security. I would suggest that volunteer psychiatrists in this model should be indemnified by the federal or state government.

The third problem is centralized documentation. All clinical encounters should be documented - even in the case of free volunteered care and those records need to be confidential. I would argue for a central authority that would record and house those records. Ideally there would be access to an electronic health record so that any necessary prescriptions could be routed to the appropriate pharmacy.

All three of those prerequisites are considerable obstacles to a volunteer psychiatric workforce. The United States has a government facilitated private system of care that is dominated by large healthcare companies. Their networks are largely expensive and exclusive. The Veterans Administration is a good example of a government run system with its own information technology and networks. It may be a potential system for the addition of the elements necessary for a volunteer telepsychiatry workforce in the event of national emergencies. One of the issues made apparent by the current pandemic is a lack of public health readiness in the country. A volunteer telepsychiatry workforce may seem like a good idea right now but what happens when the pandemic ends? I would suggest that the infrastructure and volunteers could still be effectively used in areas where there were shortages of psychiatrists or after natural disasters when care for people with ongoing mental illness is disrupted. In order for that to occur, there need to be substantial changes in government philosophy and creating systems that are more people centric than business centric. The system like the one I am suggesting would not survive as a football for the two-party system.

If I think of an ideal science-fiction approach to telepsychiatry the possibilities increase greatly. I can envision a time where psychiatric appointments can occur anywhere or when a psychiatrist posts their availability online and see people who sign in. My current system displays all of the necessary legal documentation at the first visit. I think that all the details of what is necessary for telepsychiatry informed consent are still not clear at this point. Standard wrist worn activity monitors at some point could post the relevant vital signs in the physician’s software. Billing and payment is always an issue. In the past 20 years I have not really seen any progress in that area. There is no reason why a physician visit should not be as easy to pay as buying a mocha at a coffee shop.

I have some concerns about abuse of the format. It would be fairly easy to set up a prescription mill to prescribe stimulants, benzodiazepines, and opioids. Those operations certainly exist today and there are many ways to get those drugs from nonmedical sources. Confidentiality is a potential problem. If there is a telepsychiatry visit at home are there going to be other people listening or recording what occurs on the patient end? That does not occur in an office setting but I see it as a potential problem if the patient end of the visit is at home rather than a clinic.

Those are some of my thoughts after week seven of telepsychiatry. Despite the limitations I do think it is effective. If it wasn’t, I would have stopped by now and in this era of a pandemic of uncertain length - retired.

George Dawson, MD, DFAPA