Question 1

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."

Question 2

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

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) 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 3

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).

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 4

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 5

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 6

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 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, 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, 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.

Question 7

Does working for the federal government allow you to see patients via telepsychiatry, wherever you are?

Accepted Answer

Working for the federal government does not necessarily allow you to see patients via telepsychiatry, wherever you are. While there are no absolute contraindications to patients being assessed or treated using telemental health, you have to check with your supervisor — and any applicable administrative rules and trainings — for these rules.

Ask your supervisor about federal telework agreements, contingency plans for persons who appear in-person or who are unable to connect by video, and whether support staff are available to guide your patient in case of an outage.

Furthermore, telemedicine requires you to know which state a patient is located. You would need to follow that state's licensing laws and regulations. Usually, this means you must have a license to practice in that patient's state, have malpractice cover your practice in that state. Some states allow for a single state license to cover multiple states — the Interstate Licensure Compact, for instance — but not all states participate in this.

Resources, such as the American Medical Association Telehealth quick guide, can help you determine which laws apply.

Question 8

Can you get reimbursements for video devices for patients who don't have a computer or smartphone?

Accepted Answer

Getting reimbursements for video devices vary depending on your work setting. Look to your workplace's patient support services, local and state government funding programs, and federally-supported services.

Federal government agencies — such as the Veterans Health Administration (Veterans Affairs, or VA) — have instituted a "Digital Divide" consult that will contact patients, discuss their needs, and send them telehealth equipment such as Apple iPads with wireless services.

Comcast offers Internet Essentials, with affordable high-speed Internet wifi, a discounted laptop or desktop computer, for those who qualify for their low-income program.

The federal government has Lifeline, a "discount on monthly telephone service, broadband Internet service, or bundled voice-broadband packages purchased from participating wireline or wireless providers." Service providers like SafeLink Wireless, Assurance Wireless, TruConnect provide wireless devices, hotspots, and accounts. States such as California implement Lifeline as Your Call Wireless, providing phone services and cell phones.

Finally, large commercial organizations such as T-mobile, Verizon, and AT&T offer Lifeline services.

Question 9

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

Accepted Answer

Yes, telepsychiatry has been comparable to in-person care among inmates in jail, prison, and correctional facilities. Video visits with telepsychiatric evaluations are used used to treat inmates with a variety of psychiatric illness in a range of severity, including severe mental illness. Decades of studies demonstrates telepsychiatry’s usefulness.

Vacancies and staffing issues in correctional facilities can impact access to care. Physical space requirements, security requirements, and correctional work culture pressures discourage healthcare providers from working in the correctional facility environment.

Telepsychiatry fills these vacancies, can ease burden on clinicians and providers, and takes less physical space than having more personnel on-site.

With the adoption of telepsychiatry, inmates can be seen early in their incarceration. Patient satisfaction has been shown to be high in forensic psychiatric patients with remote video visits. Acceptability has additionally shown to be high amongst jail personnel.

A meta-analysis — a study of multiple studies — looked at telepsychiatry used in acute settings, including inpatient units. They showed that the quality of clinical interaction is similar to in-person face-to-face encounters, and that telepsychiatry has been cost-effective.

Sources:

Kaftarian, Edward. "Lessons Learned in Prison and Jail-Based Telepsychiatry." Current psychiatry reports 21.3 (2019): 15.
Salmoiraghi A, Hussain S: "A Systematic Review of the Use of Telepsychiatry in Acute Settings" Journal of Psychiatric Practice. 2015; 21 (5):389-93
Brodey et al, 2000. Satisfaction of forensic psychiatry patients with remote telepsychiatric evaluation. Psych Services: Oct 51(10): 1305-7.
Leonard S: "The Successes and Challenges of Developing a Prison Telepsychiatry Service" Journal of Telemedicine and Telecare. 2004; 10 (S1): 69-71
Zaylor C, Whitten P, Kingsley C: "Telemedicine Services to a County Jail" Journal of Telemedicine and Telecare. 2000; 6 (S1): 93-95

Question 10

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.