Telepsychiatry in a private practice setting

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Telepsychiatry in a private practice setting

• OPOP conference, September 03 09, Ottawa

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Disclosure.

• I, Hugues Richard, perceive no conflict of
  interest with this presentation but present
  companies with which I have worked and consulted
  for
• Lundbeck Canada
• Ontario Telemedicine Network (OTN)

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learning Objectives

• 1. Discover the benefits and limitations of
  working with OTN.
• 2. Find out which patients do best, and if there
  are any contraindications.
• 3. Discuss the future of telepsychiatry and ways
  it can be improved.

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introduction

• My practice general psychiatry, adult,
  psychotherapy, trauma work, consultation liaison,
  community psychiatry
• Private office Stittsville.
• Meet my two assistants

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Isabelle and nina
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background
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Relevant clinical Exposure

• After closing my 18 year practice at Centre
  Alliance in Sturgeon Falls, in 2003 off site at
  ROH.
• Use of a studio at a local hospital, walking
  distance from my office then in Arnprior.
• Since November 08, videoconference equipment
  installed in my office.
• 8 visits done since, for the 2 centers I serve
  up North (Kirkland Lake Chapleau)

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Use of Videoconference for.

• Direct clinical work including consultation,
  follow up, psychotherapy even meditation!
• Indirect clinical service case discussion,
  treatment plan, team meetings
• Supervision/teaching
• CME

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Installation and implementation

• Governments third phase
• Easy process from administrative to technical
• One person assigned ? very helpful!
• Non intrusive behind the scene action

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apprehensions

• to lose control on appointments,
• To lack efficacy or accountability,
• To become impersonal,
• To be left to my own self.

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Apprehensions

• How is it going to work for new patients?
• Will I survive working 5 days in a row?
• How are the patients and staff going to react to
  this?

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My experience

• Smooth process booking, liaison
• Professionalism and reliability
• Excellent technical support on line (bridge), and
  in vivo

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My experience

• Consultations ? no problem! Nurse or case worker
  always present!
• Actually enjoying working from my office, feeling
  at home
• Integration of activities and technology from my
  own practice (EMR, fax, phone, instant messaging,
  cell, computer server, Skype)
• Less tired at the end of day/week

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My experience the technology

• Sound raise it or decrease it, or mute yourself
  off when you need to speak to your assistant
• Image ZOOM in or out, see yourself in
  interaction
• Distance? different perspective

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My experience

• NORTH
• 1 patient declined, preferring to wait to see me
  in vivo
• Negative perception from one agency clinical
  director who thought I was less available

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Benefits - physician

• Convenience
• Time saving
• Comfort
• Safety ( pandemic, road accidents)

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Benefits-physician

• Environment (?carbon footprint)
• No disruption in family life
• Available to my in vivo practice

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Benefits - PATIENTS

• Availability of service
• Convenience less driving, specially in winter, ?
  autonomy
• Cost
• In the North, videoconference used for teaching,
  health, already part of culture

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Benefits - patients

• SOME PATIENTS WILL SPECIFICALLY PREFER
  TELEPSYCHIATRY
• 1.Distance is perceived as protective
• 2. Control is maintained, can walk out easily
• 3. Neutral place
• 4. Those who enjoy technology or like novelty

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My experience

• 65 to 75 of patients who could have benefited
  from telemedicine chose one-to-one visits.
• Different with patients from the North all but
  one have used OTN.

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What do studies tell?

• Patients satisfaction close to one on one
  visits.
• More qualitative studies needed to support this.

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What do Studies tell ?

• Very accurate compare to in vivo
• The non verbal communication lacks compare to the
  verbal
• Most studies show that the main obstacles to
  telepsychiatry have to do with physicians and
  patients adjusting

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Limitations

• Delay to get a studio available turn around
  between one and two weeks, at least 48 hrs
• Registration at an agency makes it more public
• Having other people involved makes it very hard
  for some patients to trust (bridge, hackers, OTN
  government)

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Limitations

• No hand shake!
• Non verbal communication somewhat lacking (visual
  acuity and precision)
• Smell is absent ethylic intoxication for
  instance
• Patients who needs a very strong presence, such
  as Veterans suffering from traumas, many will not
  engage with a TV or a COMPUTER

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Limitations charting!!!

• I had not anticipated this one!
• Old chart not easily accessible
• progress notes better be at both sites!
• KL Citrix EMR unpractical
• ?impossible to write in the chart
• ?very long process to enter and retrieve info
  from the chart
• KL transcriptionists long distance

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Charting my solution

• Progress notes written on same lap top I use on
  site
• Consultations dictated to and transcribed by my
  assistant ?notes sent rapidly to everyone
  involved

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Clinical vignette 1 Mrs. C.

• In her 50s
• Referred for consultation
• Long past history of sexual molestation as a
  child
• Interpersonal traumas later on as an adult.
• Symptoms of dissociation with possible PTSD
• Resistant to treatment (psychotherapy and many
  different ads)

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MRs. C.

• Lives gt160 k from my office, but a studio is
  available 4 k from her
• Would you have offered her videoconference?
• She chose.

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Contraindications

• Patients who refuse this modality (informed
  consent needed)
• Violent / unstable / impulsive patients
• Patients requiring special monitoring when not
  available

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Contraindications

• Patients with specific symptomatology that could
  be exacerbated by the use of communication
  technology (Z with hallucinations for instance)

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Contraindications

• Patients with whom news must be shared in person,
  because it could cause significant emotional
  reactions (HIV test results)
• Patients who have hearing, visual, cognitive
  deficits that limit their ability to communicate
  via this technology

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Clinical vignette 2 Ms. D.

• In her30s
• Recently separated
• Referred to me by FP and SW for symptoms of
  depression and anger
• SW attends the session
• I have completed the assessment, at least thats
  what I thought But apparently not her!

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Clinical vignette 2 Ms. D.

• Starts throwing chairs around,
• Screams that shes had it nobody listens to her,
  and she is to kill herself
• SW is hysterical
• Me too !!!

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What have I learned ?

• Have phone and fax very close by if not in the
  studio
• Have certification forms at hand
• Have a coordinator of care on site
• Have triage done beforehand
• Patient realistic expectations
• Good rapport with ER staff

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Clinical vignette 3 Mr. F.

• A good story at last!
• 46 year old native, married
• Works as bus driver at local Casino
• Known to me since early 90s, in Sturgeon Falls
• Bipolar II Disorder, mostly hypomanic, on Lithium
• Panic Disorder without agoraphobia,
• Alcohol Dependence in remission.
• Obese
• Diabetes dx while on Olanzapine 12.5mg.

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Clinical vignette mr. F.

• 2003-2006, treated by FP and SW
• Comes back in 2006 in need of psychiatric report
  re drivers licence
• Booster sessions 3 to 4 times a year, travelling
  from Orillia to Stittsville
• Spring 08 father dies, depression triggered
• Dec 08 sick leave, Paroxetine started by FP

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Clinical vignette

• Telemedicine equipment recently installed in my
  office allows for weekly intensive sessions.
• Also use of Skype (once) and numerous emails.
• I talk with his SunLife case manager on phone

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Clinical vignette Mr. F.

• Trial of different drugs
• Lots of support to his wife, psychoeducation to
  both of them
• Grief work related to his dad and his inability
  to work and to function.
• Work on regression, and nutrition.

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Clinical vignette Mr. F.

• Patient on his own decided to see a Native
  Healer, and took Rescue remedy (BACH flowers)
• Good response to Seroquel XR 600 mg, Lithium
  1200mg, Modafinil 100mg bid.
• I also reluctantly raised his Clonazepam from
  .75mg AM 1mg PM to 2.5mg AM 2mg PM.

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Clinical vignette Mr. F.

• Presently back to work full time
• No need for hospitalization
• His wife is still with him

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Clinical vignette Mr. F.

• Excerpt from an email received July 16 09 In
  the Objibway language Meegwetch means thanks
  from the heart...
• I wish to live to the fullest and that is my
  choice
• You have helped me through a hardship so I say
• MEEGWETCH Dr Richard

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REcapitulation

• Telepsychiatry is very valuable in many different
  ways
• It has shown that it is an accurate way to assess
  and treat patients
• It offers psychiatric services to people who have
  no direct access to such services

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recapitulation

• For some patients, its their preferred way of
  treatment
• It is not for psychiatric emergencies
• It is not to replace one on one sessions
• It might be a cost saving treatment
• Obstacles are mostly from professionals

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Recapitulation

• To me, it is an exciting way to practice
• Without telemedicine, I would not have been able
  to serve the northern communities last winter.

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Future

• Need to know more about who are the best
  candidates
• Contraindications to be more precisely defined

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Future

• Need to improve the image quality to get more of
  the non verbal communication.
• Professionals need to learn more about the
  potential benefits from this medium.

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Bibliography

• A must
• Telehealth-clinical guideline and technical
  standards for telepsychiatry,
• Gilles Pineau, Khalil Mogadem, Carole St-Hilaire,
  Eric Levac, Bruno Hamel et al. (AETMIS 06-01)
  Montreal AETMIS 2006 xxii-72p.