Question 1

How can I combat Zoom fatigue symptoms?

Accepted Answer

Videoconferencing and remote professional services are now a regular practice in many industries. However, these remote calls can lead to feelings of fatigue.

If you find yourself exhausted by all of the video calls in your life, here are a few tips:

* **Schedule “no meeting” blocks of time.**  Make sure there are parts of your day when you are away from a screen.
* **Avoid multitasking.**  When you are on a call, focus on the business of the call.  Avoid pulling up a second window to read emails or conduct other work.  Multitasking during calls leads to a loss of productivity and difficulty remembering what occurred in the meeting.
* **Limit the number of calls.**  Do what you can to cut down on your overall number of calls.  Group calls with separate people or teams together where feasible and appropriate.  If a video call is not actually necessary, resolve the issues via phone, email, or a collaborative document.  Do not default to a video call for every type of meeting.  If you are meeting a stranger for the first time, such as a networking connection, for example, video calls can feel personal and invasive; start with a phone call.
* **Take breaks.**  If your call lasts more than an hour, it is important to take breaks.  Get up and walk around, use the restroom, get a glass of water.  Everyone will have more energy and remain more productive as a result.
* **Turn off your self-view.**  Video call programs like Zoom default to displaying your own video as well as others on the call.  Staring at your own face can be distracting and increase stress and anxiety.  Hide yourself from your own view so you can focus on the other people on the call.
* **Limit on-screen stimuli.**  In addition to hiding your face and keeping other windows closed, do what you can to limit what you see on-screen.  Encourage people to take calls in front of plain backgrounds instead of a room full of objects.  Seeing five different rooms full of furniture can cause disorientation and increase mental fatigue.

Learn more in our complete article, "[Videoconferencing Fatigue and What to Do About It](https://www.orbithealth.com/videoconferencing-fatigue-what-to-do/)."

Question 2

What is Zoom Fatigue, and why does it occur?

Accepted Answer

As the COVID-19 coronavirus pandemic continues into its second year, people have become accustomed to handling most or all of their personal and professional interactions remotely.  Videoconferencing has become a normal part of daily life.  Videoconferencing fatigue, now commonly called “Zoom fatigue” in reference to one of the most popular videoconferencing platforms, refers to the exhaustion caused by constant video calls.

While Zoom fatigue is not yet an official diagnosis, many psychologists state that the condition is both real and prevalent in the new pandemic era.

Constant video calls on any platform, including Google, Skype, Microsoft Teams, FaceTime, and other professional platforms can lead to fatigue.  People can start to feel extra irritable, less energized, constantly “on the clock” for work, confused or awkward during meetings, and isolated even while communicating with others.

There are scientific reasons for these feelings. Video calls can make people feel like they are always “on.”  People are hyper-aware of their appearance, their mannerisms, the sound of their voice, and they can begin to feel like they are “performing” in a way that is not true of in-person interactions.  The silence on the other end of the line when people mute their microphones, delays in response time, as well as the added effort necessary to identify nonverbal cues via video chat, contribute to stress and fatigue as well.

Video calls from home also allow us to become easily distracted.  When technology fails us--the WiFi goes out, someone’s camera or microphone fails to work, etc.--we can feel even more overwhelmed.

Learn more in our complete article, ["Videoconferencing Fatigue and What to Do About It."](https://www.orbithealth.com/videoconferencing-fatigue-what-to-do/)

Question 3

How can a provider start a telepsychiatry practice?

Accepted Answer

To start a telepsychiatry practice, you must be licensed by the state to practice, and meet the requirements of your practice. Ideally, you would have board certification in psychiatry.

You'll additionally need broadband, a desktop computer such as a Mac or Windows PC, along with a webcam. Ideally, you can use a dedicated microphone and speaker headset, to maximize your audio.

You need to ensure you have the right software. You need to ensure you have an electronic health record, a prescription system, and ways to receive and send messages. Your videoconferencing setup -- whether it's Zoom, Google Meet, or Microsoft Teams -- needs to be HIPAA-compliant, and you would need a signed business associates agreement (BAA). While you could create a telemedicine service from scratch, there can be costs for telehealth implementation. Costs include human resources (HR) time, but also marketing, malpractice and legal, along with additional training time.

Finally, you can join an existing group, like Orbit Health. Orbit Health offers full-time and part-time positions in adult psychiatry (outpatient, inpatient, partial hospitalization, and more), child & adolescent psychiatry, community psychiatry, emergency & crisis psychiatry, and forensic psychiatry/health. Partnering with Orbit Health is a faster way to implement telepsychiatry services than building your own services from scratch. Orbit Health provides telepsychiatry for facilities across the United States, with board-certified physicians and nurse practitioners licensed in all 50 states.

Whether you enjoy working from home or on-site, Orbit Health has multiple positions for psychiatrists, nurse practitioners, and more! [Here’s why people like working for Orbit Health](https://www.orbithealth.com/job-opportunities/) — where you can tell us about your job interests and apply to work with us.

Question 4

How can I improve the telehealth experience for those with hearing difficulties or who are deaf?

Accepted Answer

You and your team may treat persons who have hearing difficulties, whether they are hard of hearing or death. Consider the following in your workflow, such as involving staff to troubleshoot audio quality, involving a sign language interpreter, and sharing your screen:

* Check to make sure if the patient is understanding you. Have them repeat back what you said from time to time.
* If you have a telepresenter (a staff member on the patient side), they can tell you if its poor audio quality or if its good quality but the patient just can’t hear you because of their impairment. You can have the telepresenter repeat your words to the patient during your appointment.
* If the patient knows American Sign Language, you can easily include an ASL interpreter into the videoconferencing session as part of a group chat.
* Type out what you want the patient to know and screen share it with them. Make sure to use a big text so they can easily see the words. You can put your words in a Word document or the like, then click screen share. Problem solved!
* If all else fails, arrange for the patient to be seen in person. Usually this is not necessary as there are so many ways to ensure good quality of audio.  These days, audio via technology should not differ much from the audio in person.

Check out our full post on ["Telepsychiatry for the Hearing Impaired – Top 10 Tips."](https://www.orbithealth.com/telepsychiatry-for-the-hearing-impaired-top-10-tips/)

Question 5

What hardware and apps should I use for telehealth visits for those with hearing impairments?

Accepted Answer

If you see enough patients, you are bound to run into patients who may be hard of hearing or deaf. Persons with disabilities deserve great care. Effective communication is essential to ensure a high quality of care.

Consider using the following computer equipment, hardware setup, and apps, for your telehealth and telepsychiatry visits:

* Make sure that there is as little background noise as possible on both sides of the camera. This can be challenging in certain facilities that are inherently noisy, such as jails or inpatient units.  Its helpful to have a dedicated office for telepsychiatry that can be insulated against background noise.
* Use a high-quality microphone speaker on both sides of the telehealth session. These are easy to use and inexpensive devices.  You just plug and play, with a USB port.
* If the quality is still not good, you can connect the audio through the telephone while keeping video with the telemedicine platform.
* Provide the patient with headphones (noise cancelling preferred). This allows the patient to increase the volume and minimize the diffraction of noise.
* There are several closed-captioning apps on the market. Also, some videoconferencing platforms include closed captioning as an option.  Just be sure that these technologies are all HIPAA compliant.

Check out our full post on ["Telepsychiatry for the Hearing Impaired – Top 10 Tips."](https://www.orbithealth.com/telepsychiatry-for-the-hearing-impaired-top-10-tips/)

Question 6

What's the standard of care for telepsychiatry, compared to in-person care?

Accepted Answer

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
Circumstances of the care
Community in which care is being provided.
Notably, the applicable community is debatable in telehealth, as the doctor and patient care are in different geographic areas.

The prevailing opinion in telehealth circles is that the standard of care should be based on the location where the patient is located, however, this is not a hard and fast rule.  Each state has its own opinions about standards of care for telehealth and multiple jurisdictions can potentially apply.

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.

Telepsychiatry, more so than other specialties of telehealth, offers almost the same level of services as onsite psychiatry.  Therefore, the standards of care should be considered very similar.  In fact, some state medical boards [(such as the Medical Board of California)](https://www.mbc.ca.gov/Licensees/Telehealth.aspx) make it clear that the standard of care is the same.

In reality, what a psychiatrist can do remotely may vary somewhat from what can be done in person.  For example, a psychiatrist examining a patient remotely through video cannot physically touch the patient to assess for physical conditions such as cogwheel rigidity.  In these cases, psychiatrists rely on onsite staff or other ways of obtaining a reasonable amount of information to make a diagnosis and adequate treatment plan.

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.

Question 7

How do you optimize internet speeds, audio and video?

Accepted Answer

Internet Speed: Anyone can test the bandwidth by going to websites like speedtest.net.  Upload speeds of over 3mps are generally effective if there are not a whole lot of other programs running on the computer.  However, it’s probably best to shoot for higher speeds and your internet service provider can give you options.  If you can afford it, its best to have the highest speeds the company can offer.  Also, ask for “dedicated bandwidth” which some companies offer that prevents your neighbors internet usage to bring down your own bandwidth.  Also, keep in mind that other devices running in the same household can hog up bandwidth and reduce the quality of the telehealth connection.

Computer: Most computers these days have enough power for videoconferencing.   However, computers that have a minimum of 8 gigs of RAM and I7 processors provide a more reliable videoconferencing experience (you might be able to get away with using an I3 or I5 processor, but this sometimes results in a slow computer response).

Video: Most (but not all) computers these days have cameras that are adequate for videoconferencing.  If your computer does not have a good camera, webcams can be purchased cheaply ($50-100).  While 720p video mode (“HD ready”) may be adequate, it is helpful to have a 1080p resolution (High Definition).  
While video is important, appointments are more often impacted by poor audio.  Oftentimes, people run audio through their computers which is hit or miss.  For a better quality of audio, you can purchase a microphone/speaker combination device which can be plugged into the USB port of your computer.  This will make audio clearer and filter out background noise.

It is a good idea to do a test run with the patient, clinic, or hospital, prior to the appointment to determine what equipment is being used and to experience the quality of the videoconferencing appointment.  Look to make sure there is no pixilation, freezing, graininess, or blurry video.  Make sure the video and audio are in sync--- in other words, the audio is not lagging behind the video.  Make sure that the audio is clear and that you can easily understand what the other person is saying.  Both parties (patient and doctor) should be able to talk at the same time and still hear each other if the audio is working correctly.

Paying attention to and optimizing the quality of video and audio will improve the telehealth experience for everyone.

Question 8

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 9

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:** 
Effective communication is important in virtually any healthcare setting, and inpatient telepsychiatry is no different. Communication between the telepsychiatrist and members of the inpatient treatment team allows optimal coordination of patient care.  This includes:

* 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?"](https://ask.orbithealth.com/faqs/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 10

How do you prescribe long-acting injectables via telepsychiatry?

Accepted Answer

Prescribing long-acting injectables (LAI) is similar to that of prescribing any medication — determine the dose, frequency, and applicable dispensing location.

Many clinics and work settings allow you to arrange for the long-acting injectable to be provided at another clinic site or nursing site. For instance, the [Veterans Affairs' telehealth system](https://telehealth.va.gov) allows a prescriber to order the medication, and request nursing support at a specific clinic, through their electronic health record.

According to the [Pharmacy Times](https://www.pharmacytimes.com/publications/specialty-pharmacy-times/2019/2019-Asembia-Recap/New-Frontiers-for-Pharmacists-Administration-of-Long-Acting-Injectable-Antipsychotics), as of 2019, pharmacists can provide vaccinations in all 50 U.S. states and the District of Columbia. Only 44 states allow pharmacists to give long-acting injectable medications. Calling your pharmacy for options can help clarify what services are available.

And, according to the [National Community Pharmacists Association](https://ncpa.org/administration-long-acting-anti-psychotic-injectable), industry programs from pharmaceutical manufacturers of long-acting injectable atypical antipsychotic medications — such as Invega Sustenna — can help determine which locations can administer such medications. Recognized "Injection Centers" are networks of pharmacies and healthcare facilities that help provide these injections.

Need telepsychiatry for your organization?

Job opportunities