Telemedicine and Telepsychiatry
Telemedicine and in
particular, telepsychiatry has been looming on the horizon for a number of
years. Subspecialist services, for example, Child and Adolescent Addiction
Psychiatry have viewed telepsychiatry as a practical and pragmatic approach to
increasing the range of their services and addressing inequities in access
especially amongst patients living in smaller towns around the country. You can
listen to a discussion on this topic from members of the College of
Psychiatrists of Ireland here: https://www.irishpsychiatry.ie/blog/telepsychiatry-dr-john-hillery-and-dr-bobby-smyth-on-rte-radio-one-drivetime/.
Many services have found telepsychiatry
thrust upon them in recent months and have tried to rapidly adapt. While phone
calls and occasionally video conferencing have been used by staff members to
discuss clinical or team matters for decades the application of such
technologies to patient encounters is significantly less common. A helpful
review published online in 2013 in The American Journal of Psychiatry can be
found here:https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2012.12081064
There are several key
considerations:
- · Software / technical issues
- ·
Setting up an appropriate environment
- ·
Documentation
- ·
Clinical Indemnity
- · The patient’s perspective
Software
Many Psychiatry MDTs are
using either Microsoft Teams (https://www.microsoft.com/en-ie/microsoft-365/microsoft-teams/group-chat-software )
or Zoom (https://zoom.us/) to
facilitate MDT but there are varied approaches across the country.
There are a variety of
different software tools in use and some guidance from a HSE body on same: (http://www.hsedigitaltransformation.ie/content/mental-health).
More recently the HSE has
launched Attend Anywhere for Healthcare Provider video consultations: https://healthservice.hse.ie/staff/coronavirus/working-from-home/virtual-health/attend-anywhere-healthcare-provider-video-consultations.html
The HSE has also mentioned
some other software is acceptable to use in certain circumstances:https://healthservice.hse.ie/staff/coronavirus/working-from-home/virtual-health/virtual-health.html
Informal enquiry amongst
Senior Registrars across Ireland reported the following software in current
use:
·
Zoom https://zoom.us/
·
Skype for business / Microsoft Teams https://www.microsoft.com/en-ie/microsoft-365/microsoft-teams/group-chat-software
·
Siilo https://www.siilo.com/professionals
·
Blue eye https://hse.blueeye.video/login
·
Cisco Webex https://www.webex.com/
·
WhatsApp https://www.whatsapp.com/
And the following used in
General Practice
·
Nuahealth https://www.nuahealth.com/
(used in General Practice)
·
Doxy.me https://doxy.me/ (used in General Practice)
The College of Psychiatrists of Ireland has not issued (to my knowledge to this current date) specific guidance on the
technical aspects of patient video conferencing.
The Medical Council’s Guide
to Professional Conduct has a short section (43) on Telemedicine that is
essential reading for anyone engaging in this activity. https://www.medicalcouncil.ie/news-and-publications/reports/guide-to-professional-conduct-ethics-8th-edition.html
Setting up an appropriate environment
In ideal circumstances the
clinician implementing videoconferencing (VC) would have access to a reliable
software that meets the medico-legal requirements of their employer, reliable
broadband and a private, well-lit room with neutral background to conduct video
calls. An initial question will be whether you are conducting the session from
your normal place of work (e.g. your office in the Community Day Hospital) or
from home due to perhaps self-isolation issues. Practical considerations are
other household members consuming bandwidth concurrently (online gaming,
Netflix, YouTube etc. etc.) or the wi-fi signal being weak.
A rule of thumb would be to
dress and conduct yourself as you would in person during a VC review of a
patient. Paraverbal communication, body language and facial expressions are all
important in the psychiatry interview so video conferencing if reliable is
preferable to audio calls alone.
While family or pet
interruptions during BBC news interviews are humorous https://www.youtube.com/watch?v=Mh4f9AYRCZY they
are likely to be inappropriate for the clinical setting. For this and other
reasons I will discuss it is preferable to conduct clinical sessions from the
workplace rather than from home.
Documentation
As doctors our patient notes
should be up-to-date and accurate. The Medical Council’s Guide to Professional
Conduct and Ethics for Registered Medical Professionals: https://www.medicalcouncil.ie/news-and-publications/reports/guide-to-professional-conduct-ethics-8th-edition.html has
a specific paragraph with regard to telemedicine.
“If you are working in
out-of-hours services, or telemedicine, you should make every effort to ensure
that any notes you make about a patient are placed in the patient’s medical
record with their general practitioner as soon as possible (see paragraph 43).”
This would be another reason
why it is preferable to conduct telemedicine from your normal place of
employment rather than home as you have access to the clinical records.
Clinical Indemnity
Issues relating to clinical
indemnity will vary from clinician to clinician depending on their role and
responsibilities as well as the expectations from the service. One indemnity
service has published some brief advice for their members to consider: https://www.medicalprotection.org/uk/articles/covid-19-and-remote-consultations-how-we-can-help
In early March it looked
likely that Trainees in Psychiatry would be redeployed to other parts of the Health
Service due to exigencies https://healthservice.hse.ie/staff/coronavirus/policies-procedures-guidelines/redeployment-of-staff-during-covid-19.html but
to my understanding this has not happened to any great degree. This obviously
would have ramifications for an indemnity point of view.
The patient’s perspective
It has been difficult to
capture the patient’s perspective on telemedicine during COVID-19. Prior work
had suggest that telemedicine is in general effective and efficient with
patient satisfaction levels similar to those of face-to-face contacts: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5629741/
The Mental Health Commission
has made recent amendments to their tribunal procedure to allow remote
assessment of patients by the Independent Psychiatrist through WhatsApp: https://www.mhcirl.ie/File/guidancedoc_MHT.pdf therefore
maintaining their right to a legal and timely Mental Health Tribunal.
The Royal College of Psychiatrists have reported that while crisis and emergency assessments have increased, routine and elective assessments have reduced. They are anticipating a “tsunami of mental illness” due to COVID-19. While this doesn’t directly address patient’s perspectives on telepsychiatry we can infer that for multiple reasons uptake in telepsychiatry during this pandemic is insufficient: https://www.rcpsych.ac.uk/news-and-features/latest-news/detail/2020/05/15/psychiatrists-see-alarming-rise-in-patients-needing-urgent-and-emergency-care
Come back next week for part 2 of the Dr. Kevin Lally trilogy, covering the topics of medical education and postgraduate psychiatry training in pandemic times.
