Question 1

Has research been done to prove telepsychiatry works? What’s the evidence base?

Accepted Answer

Yes, telepsychiatry is comparable to in-person visits. In fact, studies have shown that telepsychiatry is effective for diagnosing mental disorders across ages — children, adults, and the elderly — and across ethnicities. Across studies, telepsychiatry has shown to provide clinical outcomes equivalent to face-to-face visits. Plus, across studies, diagnoses, and demographics, patients generally achieve improved symptoms and improved quality of life.

In fact, telepsychiatry has advantages over in-person care. Video visits increase access to a psychiatric practitioner, and can assist with collaborative care. Even those in rural communities and remote areas of the world — in other words, geographies with sparse populations — can access specialty care with the help of telepsychiatry.

Telepsychiatry is cost-effective. A study limited to the cost of providing clinical service has shown 10% reduction in cost per patient, when telepsychiatry was used versus in-person care. In the majority of studies, telepsychiatry is more cost-effective.

And both patients and providers are satisfied with telepsychiatry video visits. Patients feel they get along with their provider

Sources:

Hubley, S., Lynch, S. B., Schneck, C., Thomas, M., & Shore, J. (2016). Review of key telemental health outcomes. World journal of psychiatry, 6(2), 269.
Hilty DM, Ferrer DC, Parish MB, et al. The Effectiveness of telemental health: A 2013 review. Telemed J E Health 2013;(19):444-454.
Janca, 2000. Telepsychiatry: an update on technology & implications. Curr Op Psych 13: 591-7.
O'Reilly R, Bishop J, Maddox K, Hutchinson L, Fisman M, Takhar J. Is telepsychiatry equivalent to face-to-face psychiatry? Results from a randomized controlled equivalence trial. Psychiatr Serv. 2007;58(6):836-43.
Bashshur, R. L., Shannon, G. W., Bashshur, N., & Yellowlees, P. M. (2016). The empirical evidence for telemedicine interventions in mental disorders. Telemedicine and e-Health, 22(2), 87-113.

Question 2

Is telepsychiatry subject to specific guidelines and laws?

Accepted Answer

Orbit Health psychiatric professionals strictly adhere to the federal and state guidelines that apply to their practices. Additionally, different states may implement and apply different guidelines specific to telepsychiatry.

For example, telepsychiatry practitioners must carefully follow laws that regulate prescriptions for controlled substances. This is done by a rule called the “Ryan Haight Online Pharmacy Consumer Protection Act of 2008,” enforced by the DEA (Drug Enforcement Agency).

The Ryan Haight Act requires a practitioner to conduct in-person medical evaluation before they can prescribe a controlled substance. Some exceptions apply for systems like federal healthcare providers at Indian Health System.

With the COVID-19 public health emergency, an in-person medical evaluation is not feasible. This is where telepsychiatry has a protective advantage for clinical staff and for patients. For instance, the DEA will allow prescriptions to be issued for audiovisual telemedicine communication.

Question 3

Should groups be based on demographics, location, culture, or perhaps topic-focused?

Accepted Answer

The more group members have in common, the easier it is for them to develop bonds.

However, in today's world, there are so many ways you can categorize people. People of the same race may have vastly different attitudes and values, for instance.

But more than anything else, people bond over shared experiences. Also, people with different mental conditions may have great difficulty relating to each other, even if they share the same culture or race. Thus, it is important that a group be focused on a specific mental health condition.

Question 4

I need a psychologist

Accepted Answer

If you are an administrator seeking services for your healthcare organization or facility, please contact us through our website,https://www.orbithealth.com/contact-us/ However, if you are a patient seeking services for yourself or your family/friend, we cannot provide care directly to you. If this is a medical or mental health emergency, please call 911 or go to an emergency room immediately.

Question 5

Are psychotic patients appropriate for telepsychiatry?

Accepted Answer

There is no absolute contraindication for telepsychiatry and virtually any mental health condition can be treated via telepsychiatry. Generally, the concerns about psychotic patients becoming more paranoid or distrustful with telepsychiatry are overblown.

However, in rare cases, a patient may not be appropriate for telepsychiatry if they are truly fearful about a delusion that involves the camera or videoconferencing equipment. Does this mean that telepsychiatry is inappropriate or impossible to effectively treat such as patient? Not necessarily...

It is important to remember that psychotic patients can incorporate anything from their environment into their delusional beliefs. For example, a patient may be delusional that they are being held captive in a secret Nazi prison camp. This does not mean that they should be discharged from the unit out to the street. Likewise, a patient who has delusions about telepsychiatry does not necessarily fail to benefit from telepsychiatry.

Nevertheless, it is theoretically possible for a patient to be so paranoid about telepsychiatry that they become mute or refuse to participate in the telepsychiatry session. If that same patient is willing to converse with a psychiatrist in the facility, then perhaps onsite psychiatry may be a more effective option. This would be a clinical decision based on the case factors. Ultimately, if the treatment team feels that the patient fundamentally cannot benefit from telepsychiatry due to their delusional beliefs about that modality of care, then other arrangements should be made to provide care onsite.

In summary, there are certain clinical situations where a patient's mental status or condition may require that arrangements are made for onsite psychiatric care. However, this happens very rarely. Overall, telepsychiatry is an effective option in the vast majority of mental health cases.

Question 6

Is telepsychiatry appropriate for inpatient settings?

Accepted Answer

Telepsychiatry has been utilized in a variety of inpatient units with success and is an acceptable mode of delivering care in these settings. Both government and corporate health care organizations have embraced telepsychiatry for this purpose. In the early days of telepsychiatry, some administrators and providers were hesitant or skeptical about using telepsychiatry for inpatient units. Reasons given were mostly a subjective and vague concern about the ability of providers to appropriately care for severely ill patients without being on site, in person.

However, in recent years, as telepsychiatry has become more widely adopted, those concerns have diminished. Those who have experience with inpatient telepsychiatry have come to understand that providing care in this way is not substantially different that how it would be provided in-person. In fact, there are several advantages of telepsychiatry over onsite psychiatry in the inpatient unit:

Telepsychiatry allows inpatient units in underserved and rural areas to be adequately staff
Telepsychiatry allows the provider to work from the comfort of his home, rather than being forced to sit for long hours under fluorescent lights within a noisy, musty and uncomfortable inpatient unit.
Telepsychiatry gives providers opportunities to create any variety of schedule that works best for their lifestyle, including working during odd hours, weekdays, nights, part time, or full time. With telepsychiatry, shifts can more easily be modified and swapped to fit the needs of the providers.
Telepsychiatry allows the inpatient unit to supplement staff easily and efficiently. This is especially useful when facilities are running short on staff due to illness, surges in patient volume, or any other factors.
Telepsychiatry allows for 24/7 coverage of inpatient units, which is often hard to do when relying solely on in-person onsite coverage.

The Importance of Effective Communication:

Reviewing the treatment plan
Reviewing progress of the patient toward discharge goals
Addressing urgent and emergent patient issues
Relaying factors on the unit which may affect patient experience. For example, excess noise from other patients, physical plant issues (like plumbing or electrical issues in the unit), overcrowding on the unit, or hostile patients that are disrupting the environment for other patients.
Oftentimes, the way a patient presents to the psychiatrist may be different than how they behave on the unit. It is helpful for the psychiatrist to know how the patient is doing both on and off camera.

Efforts should also be made to establish adequate communication between the telepsychiatrist and the patient. Although communication with a severely mentally ill person can often be challenging, the telepsychiatrist should try to involve the patient in the treatment goals and plans as well as answer any patient questions and concerns.

**What about paranoid and psychotic inpatients? Are they appropriate for telepsychiatry? **

There is no absolute contraindication for telepsychiatry and virtually any mental health condition can be treated via telepsychiatry. However, there are certain clinical situations where a patient's mental status or condition may require that arrangements are made for onsite psychiatric care. For more information, please see the article "Are psychotic patients appropriate for telepsychiatry?"

In summary, telepsychiatry is an appropriate and effective way to provide care to inpatient facilities, especially when there is good communication.

Question 7

I need a psychiatrist

Accepted Answer

If you are an administrator seeking services for your healthcare organization or facility, please contact us through our website,https://www.orbithealth.com/contact-us/ However, if you are a patient seeking services for yourself or your family/friend, we cannot provide care directly to you. If this is a medical or mental health emergency, please call 911 or go to an emergency room immediately.

Question 8

What is the standard of care for telepsychiatry and/or telemedicine?

Accepted Answer

What is the Standard of Care for Telepsychiatry?

Telehealth is increasingly being adopted by providers, patients, hospitals, and clinics as a great way of providing access to much needed healthcare. Policymakers and lawmakers have generally fallen behind the current practice and therefore there can be some uncertainty around what standard of care should apply.

Moreover, “Standard of care” can be subject to interpretation based on several factors, including, but not limited to:

• Specialty or subspecialty, as it relates to the scope of practice of the provider

Notably, the applicable community is debatable in telehealth, as the doctor and patient care are in different geographic areas.

Each state may have its own opinions about standards of care for telehealth and multiple jurisdictions can potentially apply. In some, but not all states, the state medical board has language that states that standard of care for telemedicine is considered the same or similar to in person care.

As a provider, the best way to think about standard of care is to do what a reasonable and prudent provider do in similar circumstances. Reasonable and prudent care often depends on several components, such as:

• Patient case factors- although there are no absolute contraindications for telehealth, in rare cases the patient might object to the use of the technology for reasons such as paranoia/fear about being recorded or the technology being hacked, or difficulty keeping themselves in the frame of the camera due to cognitive issues. Also, if the patient is intellectually disabled and does not understand what is going on, perhaps thinking that they are watching TV.

• Setting to which care is being delivered- the environment is noisy, distracting, or not private, this can affect the quality of care provided.

• Types of technologies being used- if the technology does not allow adequate audio or video, this brings down the quality of assessment and treatment.

• Overall framework in which care is being provided- If telepsychiatry is conducted in the absence of other potentially important support for the patient

• Consent- consent requirements are determined by each state. Some states require specific verbal or written consent from the patient to conduct appointments via telehealth. Others do not have this requirement or have not opined on it.

• Limitations around AIMS testing. There are ways to conduct AIMS testing remotely, although the provider should be cognizant of potential limitations and this should be factored in the standard of care.

Ultimately, standards of care can be interpreted in a variety of ways, and telehealth makes it even more vague and sometimes confusing. Therefore, the provider should use their best judgment, considering clinical factors, their means to resources, and the overall nature of the care being provided.

Disclaimer- this article is our best effort to provide useful information and does not constitute legal advice. Please make sure to consult with entities such as state medical boards, their malpractice carrier, and potentially legal counsel prior to practicing healthcare.