The Unofficial Rules of Telepsychiatry Practice: Mastering Telepresence

There are lots of factors that contribute to a successful telepsychiatry practice—a robust telehealth platform, adherence to federal and state regulations, and, as Terry Rabinowitz, MD, professor of psychiatry and family medicine, Larner College of Medicine, University of Vermont, reminds us: well-practiced telepresence.

In this podcast, Dr Rabinowitz provides an overview of both the official and “unofficial” rules of providing virtual mental health care that clinicians should keep in mind for their practice.

Make sure you listen to Part 2: Remaining Mindful of Patient Safety When Practicing Psychiatry via Telehealth! In the meantime, visit our Telehealth Excellence Forum for more expert insights.

Read the Transcript: 

Terry Rabinowitz, MD: Hi, I'm Terry Rabinowitz. I am a psychiatrist at the University of Vermont Medical Center, and I'm a professor of psychiatry and family medicine at the Larner College of Medicine at the University of Vermont. I've been at the University of Vermont since 1996.

Brionna Mendoza, Associate Digital Editor, Psych Congress Network: What are some of the rules and regulations surrounding virtual care that mental healthcare clinicians should be aware of?

Dr Rabinowitz: I think there are official rules and unofficial rules that you have to keep in mind when you're performing telepsychiatry or just general telemedicine consultations. A couple of the important ones are you need to make sure that you have the appropriate credentials to do those visits. So, if you're seeing someone in a different state, the general rules are that you have to be licensed in the state where the patient is, not where you are, in order to perform that evaluation. However, with the pandemic, some of those rules were lifted, and so it's always important to know what the existing rules are.

This is also true for insurance purposes. So, some providers have 24/7 malpractice insurance coverage for them wherever they are, as long as they're doing something that's within the scope of care based on their medical or surgical specialty. But some insurers require that they specifically know that you're performing, or doing telemedicine consultations, and some insurers may not cover you for those kinds of encounters. So very important that you know what your coverage is.

The unofficial rules are a little bit different, and they have to do with telemedicine etiquette, or telepresence as we call it. That is, how do you behave when you're performing these consultations. And I think it's incredibly important to remember that there is a distance between you and that patient, so it's easy for you as a provider to get distracted. If you've got things on your desk just outside of the visual field, but they can be distracters, you want to make sure that you're not distracted by them. That includes not only inanimate objects, but if you've got a dog, and you're doing your consultation from home, or a little child, or a spouse, or a partner. If there's someone in another room, even though they may not hear what you're doing, your consultation may be affected by extraneous sounds. So very important there.

The other thing, and it's something that I forget from time to time, I hope I'm not today—face the camera. Look into the camera, and remember that the camera is not generally at the same position as the eye contact you would make with the person's image on your computer screen. So right now I'm looking into the camera on my laptop computer. But if I were to look into my own eyes, or your eyes, I would be doing that, and you would see then, that my vision, my eye contact is lost. And that can affect the consultation significantly, because a patient might interpret that you're no longer paying attention to them. And they may take offense to that, feel like you’re really not paying attention.

Another thing to keep in mind is that when you do have to break eye contact, because as is the case for me, for instance, and for many other providers, I'm not only looking at the patient, but I also may have their electronic medical record open on another portion of my screen. I will tell them in advance, "I'm going to face away from you for a minute, so I can look at your medical record. It doesn't mean that I'm not paying attention to you, but I have to move my eyes to another part of my computer screen." Then I'll do it. And I'll actually almost overemphasize that, so that they know I'm doing it. I'll say, "Oh, yes, I'm reviewing your medications now. I see the last notes from your visits with your other providers." And then I'll say, "And now I'm back." And so there's that built-in continuity    and anticipatory thinking that a patient might find that break from eye contact problematic.

The third rule is to be as comfortable as you can possibly be with the telemedicine approach, so that your patients are comfortable as well. I've been doing telemedicine for a while, so I'm pretty comfortable with it. But if you're newer at providing this type of care, make sure you keep the eye contact, make sure that you don't fidget, make sure that you are well-groomed, that the background isn't too distracting. All these things fall under the category of telepresence, how do you behave when you are doing a consultation. And be able to roll with the punches, so if you suddenly start to lose your transmission, don't look especially flustered, just roll with it. Tell your patient, "We're going to lose contact, or contact is broken up a little while. I tell them, too, "If this doesn't improve, I will do the rest of my consultation with you by telephone." And I make sure I have their number to call or that they have my cell phone number to call, so that we can continue the consultation with as little interruption as possible.

Terry Rabinowitz, MD, is a professor in the Departments of Psychiatry and Family Medicine at the Larner College of Medicine, University of Vermont, and medical director of the Psychiatry Consultation Service at the University of Vermont Medical Center. He has been a member of the Academy of Consultation-Liaison Psychiatry (ACLP) since 1993. He is the founding Chair of the ACLP Telepsychiatry SIG. He is a member of the Board of ACLP and Chairs the ACLP Membership Committee. He serves on the Editorial Board of JACLP. He has been the Principal Investigator or Co-Investigator on government-funded projects in both the US and Canada, including an Office for the Advancement of Telehealth (OAT)-funded project to develop and implement a regional telehealth resource center (the Northeast Telehealth Resource Center, NETRC) whose mission is to help fledgling telemedicine programs develop into independent telemedicine services.  His research interests include design, implementation, and testing of psychiatric assessment instruments; psychiatric assessment and treatment of persons with cancer; ECT and the somatic therapies; and development and evaluation of telemedicine services.

Dr Rabinowitz received his MD degree from the Case Western Reserve University College of Medicine and completed Psychiatry residency training at McLean Hospital and fellowship training in Consultation-Liaison Psychiatry at Massachusetts General Hospital. He has been at the University of Vermont Medical Center and the Medical College since 1996.