Telepsychiatry: Prescribing Stimulants, Group Therapy, and Future Advances

(Part 1 of 2)

In a live Q&A session at the recent Psych Congress Regionals virtual meeting, Psych Congress Steering Committee member Steven Chan, MD, MBA, answers questions from the audience about the benefits of telehealth, prescribing psychostimulants remotely, and the future of the practice.

In this excerpt from the session, Dr Chan also discusses best practices for carrying out group therapy sessions via telehealth.

Saundra Jain, MA, PsyD, LPC moderated the “Ask the Experts” discussion with Dr Chan addressing best practices for providing telehealth care.

In part 2, Dr Chan and Dr Jain converse about note taking, burnout, and how to set standards with patients for telehealth sessions.

Related article about this session: Keeping Telepsychiatry HIPAA Compliant

Read the transcript:

I'm. Hello again, everyone. I am so excited about this next session. It's my pleasure to welcome all of you to this exciting new session that we're calling, “Ask the experts at Psych Congress Regional's.” We’ll be with Dr Steven Chan, a leading expert in the area of psychiatry.

Now, before we get started, let me introduce our first guest expert, Dr Steven Chan. Dr Chan is a clinical informatics and medical director for addiction consultation and treatment at Palo Alto VA Health and is on faculty as clinical assistant professor affiliated with Stanford University School of Medicine. Dr Chan is co-investigator on clinical research in areas of telehealth and digital health. Dr Chan is a sought-after national speaker whose ideas, thoughts, and research have been featured at Fortune 500 companies such as Google, Publications such as JAMA, Telemedicine and E Health, US News and World Report, and Wire, and on other media outlets, including The Washington Post, Wired, PBS, and NPR's Ideastream.

So with that said, Steve, it is so wonderful to have you with us this afternoon. Thanks for joining us.

Dr Steven Chan: Oh, it's a pleasure. Thank you, Saundra, for the warm welcome.

Dr Jain: Absolutely. All right. I want you to know, there are so many questions. How about this one? Because it is relevant. And throughout this 2 day Regional meeting, we've been talking about COVID-19 off and on. But the question is this: “How has the transition to telepsychiatry as a result of COVID impacted your practice, Dr. Chan?”

Dr Chan: Yeah, you know, so many folks have had the ability to reduce no-shows and increase access to telepsychiatry/telehealth through using video technologies, but also with the ability to use other messaging and communication platforms, we've been able to do more. And I think that it's really opened up people's eyes on the potential for these technologies.

Myself, personally, I've been able to keep in touch with a lot of the folks we serve. I myself work in a substance use disorder clinic, and we've been able to maintain people's buprenorphine, naltrexone, and other medicines during a difficult time when so many services have been suspended: transportation services, car services, that sort of thing. We've been able to continue with mail-out buprenorphine and such.

And not only that, but our group services, group therapy, and classes by our stunning team of psychologists and social workers—they've really kept things going for the folks that we serve. And we've continued an intensive outpatient program, but also a residential program when there were a lot of restrictions within our region to continue doing video services within residential rooms or wherever someone is stationed. We've been able to keep in touch through these video visits as well as Internet screenshare, too.

So, it's been a remarkable time for some digitization during this really difficult time.

Dr Jain: And I think you're right during this difficult time. Can we only imagine just for a moment what it might have been like these last 16 months or so had we not had the benefits of telehealth? So, I'm glad you walked us through that, Steve.

So, all right. Here's a really practical question regarding the telepsychiatry model. This clinician wants to know, “what are the guidelines for seeing patients that are taking psychostimulants when you're using telehealth, telepsychiatry specifically? How do you monitor blood pressure, heart rate, weight, when it's remote?”

Dr Chan: You know, there are some health systems that will actually ship kits with technology to patients. If you are in one health system or if you're practice, let's say you have a serious practice that will provide this equipment to patients, you can provide a blood pressure cuff, heart rate monitor, a weight scale. Sometimes these technologies can be connected so that they will actually report to the patient's smartphone.

So that's one approach. Another approach would be, if your electronic health record software is linked to multiple other health systems, such as if you're using EPIK, or certainly the VA's own internal system, you can query other health systems for their records and see the vitals on all of the labs that results that might come up.

You can also ask the patient to report it themselves by if their technology is infrastructure not in place, having the camera or smartphone pointed to their display so that they show the blood pressure monitor or the weight scale. Or, if they're at a pharmacy, some pharmacies will have this equipment available for them to use. And then finally working with the primary care provider who automatically recorded these measurements. And if they are recording it, then you can ask the patient to report it or the primary care provider to do so.

So, there are a variety of ways to work around not having someone in person when you want to get these values for adjusting stimulants or our eyes or other such medications.

Dr Jain: Very, very good to know. All right. Oh, here's a good question. So they're wondering, Steve, how do you think telepsychiatry might change or evolve after our clinics allow face-to-face appointments-transitioning back? Do you even think that will transition back to face to face? Will it be a hybrid? What do you think that's going to look like?

Dr Chan: You know, you can hit the nail on the head with that word “hybrid”, and I think that you will have a much more flexible range of options in terms of your practice. So, some clinics will allow a blend of both.

Some clinics may actually designate times where it's just telehealth and just in-person. It really will be up to the provider team and the administrators to come together and discuss these options together so that, you know, it works for both staff and for patients, too.

And we're also going to see folks who are shifting entirely to just telepsychiatry telehealth. Did you visit technology? And a lot of people appreciate that because you don't have to deal with real estate or office rentals or commute times. And then some folks want to have flexibility of living in a place where maybe their parents or other family members are for a variety of reasons. So, I think that work from home, remote work, and telehealth technologies are going to—already have—opened up a lot of possibilities for where we can work.

Dr Jain: As you were talking about that, it reminded me that probably one of the more common questions at the beginning with several of my patients in private practice is, are we going to do sort of the online or are you going to be back in the office? And usually I found this quite remarkable. They have said when I've asked, “what is your preference, what would you prefer?” —because Austin is sort of a boomtown these days with lots of people moving here, so traffic is a problem—they are not wanting to deal with that. They're not wanting to have to try to schedule their appointments around the traffic flow. And they have found telatherapy to be very convenient and want to continue with it.

So, I think you may be I think you may be right, Steve. This may be a hybrid. That is a combination of what patients prefer, what our practices us individually, if we're in private practice, kind of how we see this developing as things begin to and continue to open up.

Dr Chan: And you imagine that the treatment for anxiety? No commuting.

Dr Jain: An immediate, successful intervention. Now, you also mentioned earlier on as we began this conversation about group therapy and we have a clinician who really is asking for you to maybe take a deeper dive on that, asking about what are the specifics, how do we carry out group therapy and make that viable via telehealth?

Dr Chan: Sure. You know, with group therapy, I think it a bit similar to any sort of cultural norms that you wanted to find, you want to think about the norms for telehealth and how you want a group to operate. So, for instance, knowing that people for education policies and such. So let’s start with education. You want to educate your patients, but also the staff members on how to meet, how to move people between rooms in case you need someone to take a time out.

You want to have the ability to have host controls so that you can rename people if they forget to change their name or even worse, maybe have an inappropriate name. So, you want to have software that has all of these abilities, but not just that, but thinking about the possibilities for patients to access your services.

So, some software will allow people to dial in by phone. And that can have implications, right? Because sometimes the video feed may cut in and out.

Do you want the video to always be on? Will you be allowing people to not have the video on in case they're shy or if they have other things that are going on in their lives? So you want to set those norms up ahead of time and in the shape of your policies.

The other things to consider too are whether it's appropriate to have specific people. For instance, I've had colleagues who would run substance use disorders, support classes and groups. They actually have a check-in process at the beginning of the day so that they can check in to see what people’s active use are and if they’re actively intoxicated. During this check and process, there are no other patients or there are fewer patients. So, they can then at that time assess intoxication and then give codes for the day so that they can access the groups.

So, there are a variety of ways to structure group therapies in the virtual space, very similar to how you would also have gatekeeping and policies and norms for physical in person.

Dr Jain: Of course.

Reference:

Chan S, Jain S. Ask the Expert: Telepsychiatry. Presented at: Psych Congress Regionals; July 16–17, 2021; Virtual.