•  Learning To Do Telemental Health
•  Donald M. Hilty, M.D.

There are many personal and professional experiences we can draw from to be a “good telepsychiatrist.” These include, but are not limited to: public speaking, acting on stage, coaching soccer, videoconferencing meetings, and news/television/broadcasting. The skillset – and equally important, the attitude and approach – involve basic communication skills with adjustments for the setting, audience and objectives of the event.

General Considerations

• Practice and self-observe (i.e., tape yourself doing a session and review it, but be mindful of local and state law regarding videotaping of telemental health sessions)
• Individual patient care: patient-centered, respectful, active listening, expressing empathy, culturally sensitive, use non-verbal behavior (e.g., eye contact) and replace things like handshakes with chit chat. If it is a consultation for a primary care provider, what are his/her expressed and implied needs in terms of outcomes, too?
• Group formats for care: introductions, engaging others to get involved, and giving directions or ground rules to provide structure.
• Public speaking: message preparation, presentation style, and content; methods of engaging small and large audiences; handouts if applicable for details.
• General preparation: planning of session (e.g., main goals, pre-reading chart, if available, summarizing knowledge), managing the session (e.g., people, room set up, dress, behavior style, voice projection, limited moving) and feeling organized. Consider an opening script for new evaluations.

Clinical Considerations

General Issues

• Maintain the standard of care and quality of service.
• Consider scope issues: consultant versus direct care roles.
• Informed consent: not just the documentation but the “green light” on engaging, in general; social chit chat at beginning helps, too.
• Pre-visit events, if available: level of interaction (e.g., toys for kids with a table; hearing limitations) patient attitudes or complaints, and sources of information.
• Time allocation: video interviewing takes longer than face-to face, and requires more concentration; add 5 minutes before end and consider what minor parts can be subtracted.
• The setting/room: both ends private/secure, announce anyone who is unseen to the patient, check lighting and check equipment.
• Check in with the client at the end of the session to see if they are Ok with the format.

Social communication reminders:

• “Less is more” in terms of interruptions and amount of information dispensed, just as in-person
• You: dress appropriately (i.e., no stripes that cause dizziness), and project voice and other gestures about 15% greater than in-person.
• Adjust to age (e.g., toys and table for kids; support person for older adults).

The clinical examination is virtually the same, with a few caveats:

• Cognitive examination: may require item substitution if clock drawing or sentence writing cannot be uploaded to see or held visually in the camera; again staff are better in assisting here so as to not answer questions for the patient.
• Physical examination: camera control at the far end enables easy wide angle, close-up, and focused viewing to detect tremors, micrographia, and other abnormalities but staff may need to be trained to check for extrapyramidal side effects (EPS) like cogwheel rigidity or rashes (Steven Johnson).
• We encourage family member to attend in general and when there is significant cognitive impairment, as this enhances patient acceptance. Families are very welcoming of TP interventions and are grateful for the extra time and effort put forth to facilitate a TP encounter.
• Before initiating, make sure there is an emergency protocol in place at the client site if a more restrictive level of care is warranted.

References

• Yellowlees PM, Shore JH, Roberts L, et al. Practice Guidelines for Videoconferencing-Based Telemental Health. Tel e-Health 2010;16(10):1074-89.
• Wootton R, Yellowlees PM: Telepsychiatry and E-Mental Health. United Kingdom, Taylor & Francis Group, 2003.