TELEPSYCHIATRY
GLOBAL GUIDELINES 2021
Copyright © 2021 by WPA
These guidelines are the property of the World Psychiatric Association (WPA) and cannot be distributed or reproduced without the expressed consent of the WPA.
ISBN 978-1-4767-4660-9 (ebook)
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FOREWORD
In the face of a global COVID-19 pandemic, digital mental health is coming into focus more than ever. This global crisis offers the opportunity to advance our understanding of how to develop models of “traditional services with modern approaches” through digital technologies. These guidelines aim to help professionals at all stages of their careers along with service users, communities and policymakers to develop telepsychiatry (TP) services that are compatible with and augment existing mental health systems.
Wider understanding and the use of the new technologies allows many people with mental ill health to receive high quality treatment and care that otherwise remain inaccessible. Regulatory constraints, however, currently pose significant barriers to the broader adoption of TP within and across countries. The collaborative development of global TP standards along with policies and appropriate regulations opens the possibility of improved access to care: including the free choice of health care providers, even across national boundaries
For these reasons it is important to make a start in developing global guidelines for work in TP. The aim is to contribute to making TP accessible to patients and professionals worldwide through improving the possibilities for international collaboration in the field. Reaching a common understanding of the appropriate standards, policies and medico-legal requirements for TP, while considering its constant technological and methodological upgrading, is likely to make a crucial contribution to reducing global disparity in access to care.
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We trust that the WPA Global Telepsychiatry Guidelines will be a useful source of information for practitioners, policy makers and communities. We hope this document will also pave the way to increased international collaboration in this work and inspire a movement towards easier collaboration and access to care within and between countries across the world.
Prof. Helen Herrman Prof. Afzal Javed Prof. Norman Sartorius
DISCLAIMER:
All reasonable precautions have been taken by the World Psychiatric Association (WPA) to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the WPA be liable for damages arising from its use. The views expressed by the author, or expert group do not necessarily represent the decisions or the stated policy of the WPA.
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TABLE OF CONTENTS
FOREWORD i
PREFACE V
INTRODUCTION 1
TELEPSYCHIATRY EXPLAINED 2
ADMINISTRATIVE ASPECTS OF TP SERVICE PROVISION 4
Legal and Regulatory 4 Licensure and Malpractice 4
SCOPE OF PRACTICE 4
Prescribing Medication 6 Written and Spoken Information followed by Informed Consent 6 Billing and Reimbursements 6
OPERATING PROCEDURES/PROTOCOLS
Culturally Competent Care 7 Quality Improvement and Performance Management 7 Patient-Provider Identification 8
CLINICAL SETTINGS FOR TP PROVISION 9
Clinically Supervised Settings 9 Clinically Unsupervised Settings 9 Common Requirements 10
TECHNICAL REQUIREMENTS 11
Videoconferencing 11 Videoconferencing Applications 11 Integration of Videoconferencing Equipment into other Systems and Technology 11 Physical Location and Room Requirements 12
CLINICAL ATTENTIVENESS 13
Patient Selection 13 Setting Selection 13 Management of Hybrid Patient-Provider Relationships 14
Ethical Considerations
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SPECIFIC POPULATIONS AND SETTINGS 16
Child/Adolescent Populations TP 16 Geriatric TP 16 Substance Use Disorder Treatment TP 16 Inpatient and Residential Settings TP 16 Primary Care Settings (“Shared Care Model”) 17 Rural TP 17 Cross Cultural TP 17 International TP 17 Team-based Mental Health Care (TP Consultation between a Healthcare Worker and a Psychiatrist) 18
SUMMARISED GENERAL RECOMMENDATIONS 19
REFERENCES 20
APPENDIX 1: STANDARDS OF REMOTE CONSULTATION CLINICAL PRACTICE AND
PROFESSIONAL BEHAVIOUR 23
APPENDIX 2: LIST OF ABBREVIATIONS 23 APPENDIX 3: TELEPSYCHIATRY PATIENT SATISFACTION QUESTIONAIRE 29 APPENDIX 4: TELEPSYCHIATRY PROFESSIONAL’S SATISFACTION QUESTIONAIRE 29
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PREFACE
PROF. DAVOR MUCIC
‘Before anything else, preparation is the key to success.’ (A. Bell)
This document was borne of curiosity, creative thinking, and a passion for collaboration and knowledge-sharing with colleagues worldwide. It is the product of two decades of effort to promote, innovate and develop telepsychiatry (TP). During a passionate journey through various TP applications, I discovered an almost unlimited potential waiting to be applied in clinical practices around the world. At the same time, obstacles such as legislative issues and concerns around the quality of care and patient safety also came to the fore. It quickly became clear that in order to realise the full potential of TP, these obstacles must be overcome. While there is still much work to do on the first obstacle, these guidelines seek to address the second – providing useful and useable procedures to ensure a high quality of patient care.
We live in a world where digitalization is not a temporary phenomenon. Broad implementation of e-Mental Health (eMH) is without doubt an inevitable process. Under the umbrella of eMH, TP remains the longest-established and best-documented application of all – it is a tool with demonstrated benefits and a proven track record. With proper preparation and thoughtful risk management, TP is an invaluable tool for allowing greater access to an increased quality of care.
The current pandemic has only confirmed the need for increased international collaboration in mental health care – and it is technology that can facilitate this. Telepsychiatry, like many other eMH applications, is rapidly growing and constantly changing. Technological advances, evolving needs at both patient and doctor level, and a shifting regulatory landscape make it difficult to know where digitalization in mental health care will finally settle. What is clear is that collaboration will be key.
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This document, a result of curiosity, creativity and collaboration, aims to provide a starting to point that can be built upon as the exciting area of telepsychiatry evolves.
I would like to express my gratitude to Prof. Helen Herman, Prof. Afzal Javed, and Prof. Norman Sartorius respectively, who have recognized the need for such a document. Furthermore, many thanks to colleagues from e-mental health expert group: Donald Hilty, Jay Shore, Peter Yellowlees, Toshi Furukava and Helen Christensen, each of whom have provided advice and guidance throughout the writing process.
Finally, a big thank you to Catherine Devine and Andrea Pound, without whom this document would suffer under my limited English skills.
Peer reviewers of this document were:
Jay H. Shore, MD MPH
Professor and Director, Telemedicine Programming,
Department of Psychiatry, University of Colorado Anschutz Medical
Campus
Donald M. Hilty, MD MBA
Veterans Affairs Northern California Health Care System
UC Davis Department of Psychiatry & Behavioral Sciences, School of Medicine
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INTRODUCTION
Using videoconferencing within the healthcare system to assess and treat patients is not new. It was first used in psychiatry in 1959. Since then, many services have been developed and primarily serve geographically isolated populations. This is known as telepsychiatry (TP).
Within the last three decades, in line with internet expansion, TP has been applied to the majority of psychiatric patient populations via a variety of applications (see under “Specific Populations and Settings”). In countries where TP is well-established, guidelines and protocols for use are developed and frequently updated.
This WPA guideline aims to provide advice to those wishing to establish or upgrade the use of TP during the current COVID-19 emergency. It provides general, high-level advice and it is important that due consideration is given to local laws and regulations where necessary.
In practice, TP consultation must be as similar as possible to an in-person meeting. The WPA Telepsychiatry Global Guidelines provide a framework to ensure a quality TP service in addition to patient and provider satisfaction. TP requires flexibility and tolerance by professionals and the application of common sense.
Competent TP skills, attitudes, and knowledge are necessary in order to provide TP that is high quality and equivalent to, or sometimes even more effective than, traditional in-person care.
In addition to this guideline, an online TP competency course that may help trainees, faculty, and other interdisciplinary clinicians across the world will soon be available through WPA.
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TELEPSYCHIATRY EXPLAINED
Many of the recommendations and requirements of TP are similar to the common rules and good practice for in-person consultations. We repeat them here in order to prevent potential misunderstandings and improvisations related to the new communication mode.
TP is the use of videoconferencing for the provision of mental health care. It primarily uses internet- based communication technologies to allow for interactivity, with offline options less frequent in clinical practice. In a broader context, the use of other media, such as e-mail, text messaging (SMS), telephone communication in real-time, and chat via web-based platforms, may also be understood as TP. This may be used, for example, within a “hybrid model” of care when combined with in-person contact.
Setting up a standardised TP service requires a number of prerequisites and considerations which are itemised in Table 1.
PREREQUISITES AND CONSIDERATIONS WHEN SETTING UP A TELEPSYCHIATRY (TP) SERVICE:
1. The need for services and whether TP is an option.
2. The sustainability of the service.
3. The patient population, model of health service delivery, and services to be offered.
4. The required infrastructure.
5. Legal and regulatory issues reviewed and identified.
6. Management strategies for the service.
7. Appropriate equipment and technological specifications.
8. Quality and clinical outcome indicators should be developed.
9. Rapport, confidence, and collaboration with staff at the patient site should be fostered.
10. Informedconsentandassentproceduresshouldbeestablished.
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11. Thephysicalsettingshouldbearrangedandthevirtualrelationshipshouldbeestablishedto produce an optimal clinical encounter.
12. Themethodofconductingtheassessmentshouldbedetermined,includingwho,ifanyone, should be present with the patient.
13. Proceduresforprescribingmedicationsshouldbeestablished.
14. PatientsandfamiliesshouldbeinformedaboutproceduresforcarebetweenTPsessions,
including procedures for emergency or urgent care.
15. Animplementationplanwhichshouldincludestafftrainingandaddresslongterm sustainability.
Table 1. Basic Principles for establishing a standardised TP service
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ADMINISTRATIVE ASPECTS OF TP SERVICE PROVISION
While the needs of the patient should always be the priority, TP providers must also comply with program requirements, professional requirements and regulatory requirements.
LEGAL AND REGULATORY
TP must adhere to the relevant country, state/province, and local laws, regulations, and policies/procedures relating to TP practice. These include, but are not limited to, licensure and malpractice, mandated reporting, informed consent, documentation, legal technology-related mandates, scope of practice, and requirements for billing/reimbursement.
Additionally, TP providers should:
§ Practiceinaccordancewith,andeducateotherson,adherencetoTP-relevantlegaland regulatory requirements
§ Applyandadaptin-personstandardstoTP
§ Attendtocontextualandoverarchingjurisdictionalissuesinareasonableway
§ Inlinewithlocalregulations,payattentiontoprivacy,confidentiality,data protection/integrity and security.
LICENSURE AND MALPRACTICE
All the requirements of in-person care – i.e. ethical codes or other standards and guidelines – should also be followed when working “remotely” – i.e. via technology. The clinician is expected to legally and professionally serve each individual, regardless of the website or technology used.
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Challenges in this area are primarily related to different rules and regulations in different states, provinces and countries. Each patient and provider location must be considered individually. This is of key importance, as the location of both the patient and the practitioner in remote consultation may have an impact on legal aspects of TP. So far, most countries regulate the TP practice depending on where the patient is located. As long as the patient is within the borders of their own country, he/she is subject to the local regulations.
If the TP provider is located in another country they must be certified in the country where the patient is located. Accordingly, the provider must be aware of the regulations valid in the country where the patient is located. However, the local licensure may be an obstacle to international collaboration and expansion of the scope of the services. Another interesting development in Greece is that the majority of TP consultations are stored using cloud technology. For such arrangements, the consultation adheres to the rules and regulations valid in the country where the ‘cloud server’ is located. Accordingly, the TP provider must be certified in the country where the cloud server is located i.e. not where the patient is located. Since COVID-19 occurred, the health insurance companies in Greece have been reimbursing the mental health providers by following the legislation valid in the location of the doctor, though.
There is a rapidly growing tendency for patients to reach out to TP providers located in other countries. Language, the doctor ́s specialty and cost associated with the service are the main parameters that influence a patient`s choice of the provider. For example, if a practitioner speaks the same language, has the required expertise and is cheaper than those locally he/she will be chosen even when located in another country. A broader international framework may need to be established that operates globally. The first step may be the creation of regional licensure regulations, which could pave the way for globalized legislation enabling expanded international collaboration and increased access to care regardless of national borders.
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SCOPE OF PRACTICE
TP providers must ensure that the standard of ‘remote’ treatment is equivalent to ‘in-person’ treatment. TP providers should be aware of local rules and regulations related to online services and, if necessary, incorporate them in their guidelines for clinical TP practice. Professionals need to keep up to date with technologies, research, and legal issues in the following areas:
PRESCRIBING MEDICATION
Each state/province or country articulates standards for prescribing medication. These standards should be maintained by following the local regulations.
WRITTEN AND SPOKEN INFORMATION FOLLOWED BY INFORMED CONSENT
The information about the TP service must be simple and easy to understand for patients and their caregivers/family members. This will ensure the service meets expectations and that the therapeutic service is delivered in a manner that is supportive of evidence-based care.
The consent process should include discussion of circumstances around session management, so that if a patient can no longer be safely treated through distance technology, he/she is aware that services may be discontinued.
BILLING AND REIMBURSEMENTS
Billing and reimbursements are dependent on the local regulations and vary from country to country. For more details, refer to specific regulations.
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OPERATING PROCEDURES/PROTOCOLS
Clear consensus related to roles, responsibilities, and communication between the sessions and procedures around emergency issues is necessary when establishing a TP service. The following aspects of the standardised TP service are important to maintain the same level as one might expect from “in-person” services:
CULTURALLY COMPETENT CARE
Cultural competency is an important prerequisite in the establishment of standardised TP services. Providers should familiarise themselves with the cultures and environments in which they are working and may use site visits and cultural facilitators to enhance their local knowledge when appropriate and practical.
QUALITY IMPROVEMENT AND PERFORMANCE MANAGEMENT
Effective quality and performance management processes aim to collect data about the activities, characteristics, and outcomes of the TP service. This data is used to answer questions about the acceptability, participation levels, and the short- and long-term impact of the proposed service(s).
Recommended evaluation areas include:
§ Patientsatisfaction,providersatisfaction,andprocessofcare(e.g.no-shows, coordination, and completion of treatment).
§ Communication (e.g. rapport).
§ Reliability/validity (e.g. assessment and treatment vs. in-person).
§ Specific disorder measures (e.g. symptoms).
§ Cost (e.g. length of service, travel, hard and software).
§ Administrativefactors(e.g.facilitymanagementandteamstaffing).
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PATIENT-PROVIDER IDENTIFICATION
At the beginning of a TP session:
§ Allparticipantsofthevideoconferencemustbepresentedandidentifiedtoeachother. § Thefollowinginformationmustbeverifiedanddocumented:
– The name of the patient.
– The name and credentials of the provider.
– The location of the patient during the session.
– Contact information for the patient, provider, and other relevant support people (both professional and family).
– Expectations of potential “between-session-contact” must be discussed and verified with the patient.
– Provisions for the management of mental health emergencies, both during and outside sessions. It is crucial to establish protocols related to collaboration with patient site staff to either assist or initiate commitments.
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CLINICAL SETTINGS FOR TP PROVISION CLINICALLY SUPERVISED SETTINGS
These are patient locations where other medical or support staff are available in real-time to support the TP sessions. For example, hospitals, elderly homes, prisons, GP clinics, rehabilitation institutions, and so forth. It is crucial to create emergency protocols, including an explanation of roles and responsibilities in potential emergency situations. Outside clinic hours emergency coverage and guidelines for determining when other staff and resources should be brought in to help manage emergency situations are important to determine and inform the patient about. Clinicians should be aware of safety issues related to any patients displaying strong affective or behavioural states and, upon conclusion of a session, must understand how patients might then interact with remote site staff.
CLINICALLY UNSUPERVISED SETTINGS
These are patient locations where other medical or support staff are not readily available in real- time to support the TP sessions, e.g. private home, working office, and so forth. When providing a TP service in clinically unsupervised settings, it is critical to identify where the patient is located should the following situations occur:
§ Patientrequiresreferraltothenearestmentalhealthinstitutionortoalocalpsychiatristfor in-person consultation.
§ Toinformthelocalpolice/ambulanceservicesforemergencyinterventiontosaveapatient’s life (attempted suicide) or someone else’s life (homicidal attempt).
§ Mandatory reporting of certain diseases is tied to the jurisdiction where the patient is receiving services and may be a requirement under the law.
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COMMON REQUIREMENTS:
The following prerequisite requirements are applicable to both clinically supervised and clinically unsupervised settings:
Clinicians.
TP professionals shall uphold the following:
§ Professionalclinicalstandards,protocols,policies,andprocedurestodelivercareofequal quality as provided through in-person care.
§ Ethicalnormsandlawssimilartothoseappliedtoin-personcare.
§ Haverequisiteskills,attitudes,andknowledge–adaptedfromin-personcareandspecific to the technology used (e.g., video, mobile health, other asynchronous). Involved clinicians should receive preliminary training in the operation of the equipment, such as the WPA online TP competency course.
Patients.
Patients must voluntarily participate in TP consultation(s) after undergoing a consent process that explains the use of telepsychiatry and the service/clinic procedures and processes for during and after session communication.
• Technology
Any technology used must fulfil requirements related to the safety of patient data and privacy
according to local state laws/regulations.
• Care Coordination
Providers should establish appropriate processes for coordinating patient care internally
within their services and to external organisations and providers.
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TECHNICAL REQUIREMENTS VIDEOCONFERENCING
§ TPprovidersandorganisationsshouldselectvideoconferencing equipment/applications/platforms in line with its required verification, confidentiality, and security parameters.
§ Sufficientbandwidthandscreenresolutionisrequiredtoensurethequalityoftheimage and/or audio received is appropriate to the services being delivered.
§ Abackupplanorsetofplans(e.g.telephone)mustbeestablishedpriortotheTPsession commencing in case of technical disruption to the session, such as a power outage or network issues.
VIDEOCONFERENCING APPLICATIONS
§ Intercompatibilityofthevideoequipment/software/platformisofutmostimportance when choosing the equipment. Lack of intercompatibility limits the communication possibilities between all potentially involved parts. The producers of the video equipment are already aware of it. Awareness and ongoing efforts may result in major improvements related to intercompatibility without compromising patient and data safety and security.
INTEGRATION OF VIDEOCONFERENCING EQUIPMENT INTO OTHER SYSTEMS AND TECHNOLOGY
§ OrganisationsshouldensurethetechnicalreadinessoftheTPequipmentandtherelated environment. They should also have policies and procedures in place to ensure the physical security of TP equipment and the electronic security of data.
§ Incaseoftheuseofavideoplatform/app,itisrecommendedtoincorporateitintothe existing electronic patient journal (EPJ)/Electronic Health Record (EHR)/Electronic Medical Records (EMR) system.
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§ IncaseofofflineTPconsultations,theinterviewermustbeappropriatelytrained,andthe recording of the interview should be stored and/or shared following national standards to protect individuals’ medical records and other personal health information.
PHYSICAL LOCATION AND ROOM REQUIREMENTS
The location of the patient, as well as the TP professional, are considered as clinical space. Both locations must ensure privacy and be a safe and comfortable space for the patient.
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CLINICAL ATTENTIVENESS PATIENT SELECTION
There are no absolute contraindications to patients being assessed or treated via TP. However, providers should always assess and consider how best to provide care and services across a range of technologies and settings (in-person vs. virtual) based on the individual’s case needs.
Providers should also consider whether there are any medical aspects of care requiring physical examination. If the provider cannot manage the medical aspects for the patient without being able to conduct initial or recurrent physical exams, this should be documented on the record and arrangements made to perform physical examinations onsite as clinically indicated.
SETTING SELECTION
Providers should assess and consider how best to provide care and services across a range of technologies and settings based on the individual case needs.
§ ClinicallyUnsupervisedSettings:
In professionally unsupervised settings, the patient must take a more active and cooperative role in the treatment process than in other settings. Patients need to be able to set up the videoconferencing system, maintain the appropriate computer/device settings, establish a private space, and cooperate for effective safety management. Health care professionals should be aware of the following disadvantages/limitations related to clinically unsupervised settings:
– Limited opportunity for somatic examination.
– Limited ability to read the body language.
– The risk of the patient recording the sessions and publishing them on the Internet.
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– Poor bandwidth/unstable internet connection that may have an impact on the sound and picture quality.
Given these limitations, it is important that TP providers consider the appropriateness of the TP service for each individual patient. Factors to consider include:
– The patient’s cognitive capacity.
– Their history regarding cooperativeness with treatment professionals.
– Their current and past difficulties with substance abuse.
– Their history of violence or self-injurious behaviour.
– The geographic distance to the nearest emergency medical facility.
– The efficacy of the patient’s support system.
– Their current medical status.
– The patient’s location.
§ ClinicallySupervisedSettings:
The provision of TP services in professionally supervised settings has the same requirements
as in-person consultations.
MANAGEMENT OF HYBRID PATIENT-PROVIDER RELATIONSHIPS
The TP interview can be the only mode of contact between the patient and the psychiatrist. This is more prevalent in rural areas due to distance. A TP interview can also be in addition to in-person contact. All communication with the patient should follow clear policies describing the boundaries around ways in which patients can communicate with a provider and which content is appropriate to share over different technology platforms.
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ETHICAL CONSIDERATIONS
TP professionals must maintain the same level of professional and ethical standards as in-person care in the provision of care via TP.
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SPECIFIC POPULATIONS AND SETTINGS CHILD/ADOLESCENT POPULATIONS TP
The procedures for the assessment and treatment of youth must be modified to address the developmental status of the patient. The examination room should be set up with age-appropriate equipment required for specific levels of interaction. It should be of adequate size to enable activities that allow the child to engage with the accompanying person and provider.
When providing TP services to young patients, it is critical to conduct an assessment of the appropriateness of “remote” care. This includes the safety of the patient, the availability of supportive adults (and their mental health status), and their ability to respond to any urgent or emergent situations.
GERIATRIC TP
Interviewing techniques should be adapted for patients who may be cognitively impaired, find it difficult to adapt to the technology, or have visual or auditory impairment. Cognitive testing may be provided via videoconferencing but might need to be modified for use via video. The inclusion of nurses, other mental health clinicians and social workers is often helpful. Inclusion of family members should be undertaken as clinically appropriate and with the permission of the geriatric patient.
SUBSTANCE USE DISORDER TREATMENT TP
Local laws and regulations around prescription of controlled substances involved in Substance Use Disorder treatment must be followed. Collaboration with onsite staff is necessary to monitor ongoing treatment as clinically indicated.
INPATIENT AND RESIDENTIAL SETTINGS TP
TP enables integration of the mental health professionals into inpatient and residential care settings. Remote providers should optimise use of patient site staff for help with TP consultations
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and case coordination, as clinically indicated. In addition to clinical care, it is helpful to participate in treatment team, quality/process improvement and other meetings by video.
PRIMARY CARE SETTINGS (“SHARED CARE MODEL”)
A patient may receive the treatment from a remote mental health specialist while located at a local General Practice (GP). The TP “shared care” model refers to the provision of mental health care from a distance and includes clinical work with the patient, educational (i.e. supervision) and administrative activities. Using it, general practitioners and TP specialists discuss patient treatment, which increases the information and knowledge available to each participant. TP is used for collaborative, stepped an integrated care models.
RURAL TP
Rural hospitals may connect to behavioural and mental health specialists through TP. Accordingly, a remote located psychiatrist can assess and/or treat patients in rural hospitals or rural located GP’s. Some rural programs provide case management services through TP to improve patient outcomes.
CROSS CULTURAL TP
Ethnic minorities access assessment and treatment via interpreters or via a third language that is common for both the patient and the professional. Use of TP may eliminate the need for an interpreter and enable remote connection between the patient with limited abilities in one language and a bilingual professional with a respective cultural and even ethnic background. This is known as the ‘ethnic matching’ model. It may lead to more precise and detailed description of patient symptomatology (as the patient feels at ease and better shares the story), minimise risk for misinterpretation/misunderstanding, and enable better diagnostic and subsequent treatment.
INTERNATIONAL TP
Bilingual resources are precious in assessment and/or treatment of ethnic minorities i.e. refugees and migrants, with limited language proficiency. If/when the bilingual resources are not readily available within the country borders, technology may help to build the bridge over geographical as well as cultural boundaries. International collaboration via TP may be used to get a qualified “second opinion” from colleagues with a relevant cultural and linguistic background. Further, international expertise may be brought via TP to local health workers as a part of education, supervision, and scientific collaboration.
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Considerations related to international TP are primarily based on licensure and national laws and regulations related to the location of the patient and the professional respectively. It is common that the patient cannot be treated if not located within the same country boundaries as the professional. Conceptualization of the visit with the doctor “up in the cloud” then may cause future changes in these regulations.
TEAM-BASED MENTAL HEALTH CARE (TP CONSULTATION BETWEEN A HEALTHCARE WORKER AND A PSYCHIATRIST)
Healthcare workers, such as Nurses and Allied Health Professionals, can initiate TP consultation for both independent and supported assessment.
The collaborative TP consultation initiated by the healthcare worker can also be part of the assessment of persons for assisting the law enforcement agencies or persons in-charge of the institution in the evaluation of persons with mental illness.
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SUMMARISED GENERAL RECOMMENDATIONS
Regardless of settings and/or patient populations, it is recommended to:
1. Adapt best practices for in-person care and make adjustments for the technology used to ensure quality of care and the therapeutic relationship.
2. Assess a patient’s previous exposure, experience, and comfort with technology/videoconferencing. The TP provider should be aware of how this might impact initial TP interactions.
3. Create emergency protocols, including explanation of roles and responsibilities, in potential emergency situations.
4. Conduct an ongoing assessment of the patient’s level of comfort with technology over the course of treatment. (Refer to Appendix 2: ‘Patient Satisfaction Questionnaire’.)
5. Conduct an ongoing assessment of the other users’ level of comfort with technology over the course of treatment (Refer to Appendix 3: ‘Users TP Satisfaction Questionnaire’.)
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REFERENCES GUIDELINES
1. American Telemedicine Association. Practice Guidelines for Videoconferencing-Based Telemental Health, 2009. Available online: http:/www.americantelemed.org/docs/default- source/standards/practice-guidelines-for-videoconferencing-based-telemental- health.pdf?sfvrsn=6.
2. American Telemedicine Association. ATA Practice Guidelines for Video-Based Online Mental Health Services. Telemed J E-Health 2013; 19(9): 722-30.
3. Shore JH, Mishkind MC, Bernard J, et al. A lexicon of assessment and outcome measures for telemental health. Telemedicine Journal and E-Health, 2013; 20(3), 282-292.
4. American Telemedicine Association. Practice Guideline for Child and Adolescent Telemental
Health, 2017. Telemed J E-Health. Available online: https:/higherlogicdownload.s3.amazonaws.com/AMERICANTELEMED/618da447-dee1- 4ee1-b941- c5bf3db5669a/UploadedImages/Practice%20Guideline%20Covers/NEW_ATA%20Children%2 0&%20Adolescents%20Guidelines.pdf.
5. American Psychiatric Association and American Telemedicine Association. Best Practices in Videoconferencing-Based Telemental Health, 2018. Available at: https:/www.psychiatry.org/psychiatrists/practice/telepsychiatry/blog/apa-and-ata- release-new-telemental-health-guide.
6. American Psychiatric Association. Resource Document on Telepsychiatry and Related Technologies in Clinical Psychiatry, 2014. Available online: Resource-2014-Telepsychiatry- Clinical-Psychiatry.
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7. American Psychiatric Association. Resource Document on Telemedicine: Synchronous Video- conferencing in Psychiatry, 2017. Available online: resource-document-telemedicine- synchronous-video-conferencing-in-psychiatry-2017.
8. Suresh Bada Math, Narayana Manjunatha, C Naveen Kumar, Chethan Basavarajappa, BN Gangadhar (2020). Telepsychiatry Operational Guidelines-2020. Pub; NIMHANS, Bengaluru- 560 029.
COMPETENCIES
1. Hilty DM, Chan S, Torous J, et al. A framework for competencies for the use of mobile technologies in psychiatry and medicine. JMIR Uhealth Mob Health 2020; 8(2) http:/mhealth.jmir.org/2020/2/e12229/.
2. Hilty DM, Torous J, Parish M, et al. A literature review comparing clinicians’ approaches and skills to in-person, synchronous and asynchronous care: Moving toward asynchronous competencies to ensure quality care. Telemed J E-Health, In Press
4. Hilty DM, Maheu M, Drude K, et al. The need to implement and evaluate telehealth competency frameworks to ensure quality care across behavioral health professions. Acad Psychiatry 2018; 42(6): 818-24.
5. Zalpuri I, Liu H, Stubbe D, et al. A competency-based framework for social media for trainees, faculty and others. Acad Psychiatry 2018; 42(6): 808-17.
6. Maheu M, Drude K. Hertlein K, et al. An interdisciplinary framework for telebehavioral health competencies. J Tech Behav Sci 2018; 3(2): 108-40; correction 3(2): 107.
7. Hilty DM, Armstrong CM, Luxton DD, et al. A framework of sensor, wearable and remote patient monitoring competencies for clinical care and training: Scoping review. J Tech Behav Sci, 2020 In Press
3. Hilty DM, Crawford A, Teshima J, et al. A framework for telepsychiatric training and e-health: Competency-based education, evaluation and implications. Int Rev Psychiatry 2015; 27(6): 569-92.
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8. Mucic D. Training in Telepsychiatry. In: Edmond H. Pi, Tan Chay Hoon and Marc H.M. Hermans (Eds). Mental Health and Illness Worldwide. Education about Mental Health and Illness, Springer publisher, 2018.
OTHER
1. Hilty DM, Rabinowitz TR, McCarron RM, et al. An update on telepsychiatry and how it can leverage collaborative, stepped, and integrated services to primary care. Psychosom 2018;59(3):227-250.
2. Shapiro ML, Miller J, White K. Community transformation through culturally competent nursing leadership: application of theory of culture care diversity and universality and tri- dimensional leader effectiveness model. Journal of Transcultural Nursing, 2006;17(2), 113-118.
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APPENDIX 1
STANDARDS OF REMOTE CONSULTATION CLINICAL PRACTICE AND PROFESSIONAL BEHAVIOUR
General Recommendations:
§ ThefollowingshouldbeavailabletoeachparticipantoftheTelepsychiatrysession:
– Concise and easy-to-understand printed protocols on operating the video
equipment.
– A list of dial-in numbers for virtual call rooms and relevant IP addresses.
– Contact information for the technical support person and/or “Helpdesk” must be readily available in each video room.
§ When booking the patient in the Electronic Patient Journal ( EPJ)/ Electronic Health Record (EHR)/Electronic Medical Records (EMR) system, remember to include the purpose of the consultation.
§ Test the equipment and become familiar with the use of remote control (if using a stand- alone camera) or command buttons on the video platform prior to the first video call.
§ Ifyouareusingavideoplatformwithanotherhealthworker(i.e.withoutthepatient)make sure you have two monitors for the purpose of easy access to EPJ/EMR/EHR.
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Before the TP Session:
§ Inform the patient both verbally and in written form about TP before the initial remote interview.
§ PriortocommencementofthefirstTPsession,thepatientmustgivewrittenconsentwhich states that he/she/they may at any time interrupt the remote session and have the opportunity to meet the doctor in person.
§ The patient’s explicit consent is required to record the remote consultation for educational purposes (supervision or clinical case presentation) or an asynchronous TP session aimed for diagnostic clarification/second opinion.
§ Consider the background that will be captured by the camera. Personal photos and other items you would not display in your office should be relocated out of the camera’s view. You may need to remove books from the camera’s view. Some titles on the bookshelf behind you may create a distraction for patients.
§ Sitinthecentreofthepicturewithaneutralbackgroundsothisdoesnotinterferewiththe consultation. The patient’s view of you should be similar to that of a seated news anchor on television.
§ Ensure the room is well lit and the video image is clear. Avoid backlighting. This will create a shadow on your face.
§ Establishavideoconnection5minutesbeforethesessioncommencestoadjustthepicture on both sides and exchange information with medical staff related to the patient interview.
§ Muteyourmicrophoneuntilthesessionstarts.
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Be Prepared:
§ Maintainprofessionalismatalltimesprior,during,andaftertheappointment.
§ Thepurposeofthemeetingshouldbeclear.
§ Ensureyouhavethenecessarymaterialstorecordnotesduringthemeeting.
§ ThedurationoftheTPconsultationshouldbetheequivalenttoanyotherin-personsession, whether it is an initial assessment, medical follow-up, psychotherapy, or another type of meeting.
Beginning of the TP Session
§ Remembertoun-muteyourmicrophone.
§ All participants on both sides of the video conference must be presented and identified to
each other.
§ Introduceanyadditionalpeopleintheroomtoboththepatientandtheprovider.
§ Confirm the patient’s identification (name, national insurance/social security/ Medicare/ number, etc.).
§ Confirmthelocationofthepatientduringthesession.
§ Confirmthepatient’ssoundandpicturequality.
§ Exchange contact information for the provider, the patient, and any other relevant support people, both professional and personal.
§ Discussandverifyexpectationsofpotential‘betweensessioncontact’. 25
§ Establishprovisionsformanagementofmentalhealthemergenciesforthesessionandalso how to handle any emergency between sessions.
§ Ensuretheroomisquietandprivate:
– Test the noise level of the room in a practice session.
– Sometimes unnoticeable noises, such as the air conditioner running, can be amplified by microphones.
– Others in the area may need to be asked to keep the noise level down.
– Silence all phones and other devices prior to starting a session.
§ Privacy should be afforded by the location. Sessions should be conducted behind closed
doors.
§ Provideanoverviewandpurposeofthevideomeetingandconfirmthetimeallocated.
During the TP Session:
§ Attempttomaintaineyecontactwiththepatientthroughouttheconsultation.
§ Whentakingnotesduringtheconsultation,explainthisandthereasonsforittothepatient.
§ Itcanbedifficulttoreadpatientbodysignalsovervideo.Observethebodylanguageofthe patient and also pay attention to your own body language.
§ Keeptrackoftime.Allowtimeattheendofthemeetingforthepatienttoaskquestions.
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At the End of a TP Consultation:
§ Discussandagreeonthenextsteps. After the TP Session:
§ Provide the patient with the opportunity to provide feedback on the session (i.e. Questionnaire). Address any technical issues encountered during the instant session right away.
§ Noteanyfollow-upappointmentswiththepatient.
§ Remembertoturnoffyourequipment,closeyourtelepsychiatryplatform,oratleastmute
your microphone after a session concludes.
§ Ifrequired,andifinlinewithlocallawsandregulations,medicinesmaybeprescribedonline.
Recommendations for TP Sessions Within Clinically Unsupervised Settings:
§ Usethecomputerordevice’sbuilt-inmicrophonefunctionratherthanheadphones.Thiswill ensure the session is as similar to an in-person consultation as possible.
§ Remindthepatientthatnorecordingofthesessionisallowed.
§ Havetheemergencyplanready.
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APPENDIX 2
LIST OF ABBREVIATIONS
TP – Telepsychiatry
EPJ – Electronic Patient Journal EHR – Electronic Health Record EMR – Electronic Medical Records ID – Identity, Identification
GP – General Practice
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APPENDIX 3
. TELEPSYCHIATRY
. PATIENT SATISFACTION QUESTIONNAIRE
Name: ________________________________ Diagnosis: ________________________________
No. of telepsychiatry sessions:
Medicine: Antipsychotic
Antidepressant Tranquilizers Other
______________
Earlier psychiatric treatment (please circle): Earlier telepsychiatry experiences (please circle):
YES NO YES NO
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YES
(to a high degree)
YES
(to some degree)
NO
(only to a less degree)
NO
(not at all)
Don`t know
Did you receive enough information prior to commencing telepsychiatry?
1.
2. Do you perceive ‘contact via TV’ as uncomfortable?
3. Did you feel safe under telepsychiatry contact?
4. Were you satisfied with the sound quality?
5. Were you satisfied with the picture quality?
6.
7.
8
9 Would you prefer contact via a translator in future?
10.
Did you achieve your goal via telepsychiatry / could you express everything you wanted to?
Would you be interested in continuing with telepsychiatry contact if possible?
Would you recommend the method to others (e.g. if direct contact is not possible)?
What telepsychiatry related benefit(s) do you perceive?
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Is there something you would change or improve?
Further comments or suggestions.
11
12
OBS. Question no 9. is only for Cross-cultural TP participants that otherwise will be assessed and/or treated via translator assistance.
________________________________________________________
(Date and place)
________________________________________________________
(Signature)
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APPENDIX 4
. TELEPSYCHIATRY
. PROFESSIONAL’S SATISFACTION
QUESTIONNAIRE
Name: ________________________________ Function: ________________________________
No of telepsychiatry sessions within the current course of treatment:
______________
Previous telepsychiatry experience (please circle):
1.
2.
3.
4. Do you perceive ‘contact via TV’ as uncomfortable?
5. Is the video equipment user friendly?
YES NO
YES
(to a high degree)
YES
(to some degree)
NO
(only to a less degree)
NO
(not at all)
Don`t know
Did you receive enough information prior to commencing telepsychiatry?
Did you have concerns or reservations when you were first introduced to telepsychiatry?
Has your attitude towards telepsychiatry changed after completing the current course?
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6. Were you satisfied with the sound quality?
7. Were you satisfied with the picture quality?
7. Could you assess the patient as in-person?
8. 9. 8 10.
11
12
Could you provide the treatment to the same level as in-person?
Would you be interested in continuing telepsychiatry contact with the patient?
Would you recommend the telepsychiatry to the colleagues?
What telepsychiatry benefit(s) do you perceive?
Is there something you would change or improve; any potential disadvantages you perceived?
Further comments or suggestions.
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________________________________________________________
(Date and place)
________________________________________________________
(Signature)
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