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
