Dr. Avrim Fishkind: Moving Beyond the Basics of Telepsychiatry

A session being presented at the virtual 2021 American Psychiatric Association (APA) Annual Meeting will go beyond the basics of telepsychiatry and explore equity and ethical issues related to the practice and examine the future of telemedicine, including an array of digital tools.

In this Q&A, presenter Avrim B. Fishkind, MD, discusses some of the topics he will address in the session, which is being held at 4 p.m. on May 1.

(This interview has been edited for clarity.)

Q: Why did you choose to speak on “Equity, Ethics, and Future Directions in Telepsychiatry" at this year's APA meeting?

A: I've done a lot of talks for the APA before, and most of them focused on the basics of telepsychiatry. I think we're past that now.

I think because of COVID we're just long past the worry about essential aspects of telepsychiatry and we need to move on to the more interesting aspects of telepsychiatry and e-health in general. That's why I picked these particular topics.

Q: Has the recent growth in telepsychiatry usage increased access for everybody, or only for certain groups?

A: The equity disparities are very remarkable in populations that you would expect, mostly Latinx populations and African American populations. Also, Indian reservation populations.

That's mostly due to lack of cell phones, computers, and other devices. Also, lack of broadband in many of those areas, and the affordability of broadband. There is quite a bit of disparity, and then COVID brought that out very clearly, once everybody had to use telecommunication.

Q: Aside from access, are there other issues of equity related to telepsychiatry adoption?

A: There's the ability to pay. Unlike vaccines, which are being given away, nobody decided they were going to give away money to help all of these students. In fact, we still don't know yet what's actually happened with students, with people who needed medical procedures, with all of the people who were not able to do elective surgeries.

Contrary to popular belief, a lot of elective surgeries are for pain, mobility, and other problems. Those were delayed as hospitals filled up with COVID patients. All of the telemedicine related to all of the elective pieces of medicine, those were not included.

We had a very specific number of items—infectious disease, psychiatry, internal medicine— mostly on the ambulatory side, where we use telemedicine, but a lot of the hospital-based telemedicine decreased vastly. People didn't have that kind of access.

A lot of the previous facility work that might have been done by a psychiatrist and other people visiting nursing facilities also decreased because of COVID. People were afraid, concerned. Not all facilities were capable of handling telemedicine. Some were. Some were not.

Q: What are some of the ethical issues facing mental health providers who are using telehealth?

A: People worry about very specific things. The most questionable part of our practice when using telehealth is the inability to get vital signs. Very, very difficult to do. Patients can estimate height and weight, but they're estimates.

Many of the things you do remotely, like your capability of e-prescribing or prescribing controlled substances, often has limitations, usually height and weight, in which you have to ask the patient to guess. They might have a scale. They might not have a scale.

You can get a fair representation of that, but obviously you're not going to get blood pressure. You're not going to be able to do finger stick glucose levels. Many people, because of COVID, didn't go out and wouldn't go out to get lab work done, which was another consideration.

People also, in telemedicine, they often think they cannot develop close working relationships with patients. Some doctors will try to develop those close working relationships. Other doctors may feel that it's not possible or unethical to assume that you can have a close interpersonal working relationship with a patient via telemedicine.

Those are the main ethical considerations. The only other one that jumps out that people have trouble with is sometimes doctors and patients now equate digital communication, texting, and other things with intimate relationships.

Even though you might think that the boundaries would be better by using this, in some cases the boundaries are more easily broken and can turn sexual or too personal when using this kind of communication.

Q: Have we seen a lot of changes in technology that's used in telehealth during the pandemic?

A: Unfortunately, we did not. There were platforms that had been trying to get going prior to COVID. Those platforms had a very difficult time keeping up. Whether it was their servers keeping up or their technical support department keeping up, there were a lot of challenges.

I'm not saying that all of our good folks who create telemedicine software weren't working hard to correct those problems during the pandemic. They were, but that was a problem.

Simply getting doctors used to, and teaching, and getting the word out about how to use the technology, about which vendors were available. The APA did a good job.

Local branches, like the Houston psychiatric branch, [Texas Society of Psychiatric Physicians] here in Texas, and the Texas Medical Association made a lot of room on their websites about how to get going fast and instructional material. But nobody was prepared. Everybody did the best they could to get going with this technology.

Q: What are some of the biggest improvements you feel are still needed?

A: If you're in a teaching hospital, for example, money seems to be, often, readily available. They are able to use Epic or other EMRs that have very sophisticated built-in portals on the phones to be able to do telemedicine meetings that have waiting rooms and other functions built in digitally that help things.

It's another thing to just have a patient know there's an appointment and try to call them. Often they have not had teaching on how to use the product on their phone or they don't have a phone or computer, and things have to be done telephonically.

Back in the ethics part I probably should have mentioned, that even though the Centers for Medicare & Medicaid Services is paying for telephone calls to do your office visits, a lot of people have a problem with the fact that it's by telephone. Removing the video part means that you can't do the typical psychiatrist things, which is measuring reactions, or being able, now, in this case, to look at their home surroundings, or whether the patient is disheveled, whether the patient is making eye contact or related. A lot of things disappear when you do it telephonically.

Figuring out how to do consistent audio/video across all populations and all accesses is probably the biggest improvement that we need to make.

Q: What are some of the lessons or takeaways you're hoping clinicians will take back to their practice with them?

A: What I'd really like to do is to show people the massive explosion in e-health. Outside of our offices there are movements going on online of all different types that many of us are not participating in.

For example, Togetherall is probably the world's largest online community for mental health issues. At this point it's not general practice to refer our patients to participate in this online activity that they can do in between sessions with us.

There's also computerized cognitive behavioral therapy, which is available to patients in between sessions that could be used and is not directed for our patients to use in many cases.

Probably the biggest change that we're not yet participating in is prescribed digital technology. These prescribed digital therapeutics are approved by the Food and Drug Administration. They're nothing but software. They're apps you download, but they actually require a prescription and they actually require monitoring by the physician.

We have, within our field, prescriptive digital therapeutics for insomnia, for opioid and substance abuse use, for kids with ADHD, adults with panic disorder. We have these technologies which many psychiatrists, if you mention prescribed digital therapeutics, they don't even know what the term means.

Psychiatry's greater involvement in using these prescribed digital therapeutics, these softwares that are approved by the FDA, or devices, is one of the biggest things I want to get across to psychiatrists, to use them in their practice.

Dr. Avrim Fishkind is Lead Psychiatrist for Telehealth at The Harris Center in Houston, Texas. He also is Chief Executive Officer of Empathic Soul Health and a past president of the American Association for Emergency Psychiatry. He is well known for his creation of an array of psychiatric emergency programs throughout the United States and Canada. In 2005, he led a clinical workgroup that redesigned psychiatric emergency services for the state of Texas, designed around telehealth. In 2007, he formed JSA Health Telepsychiatry to serve the needs of Texas residents in crisis, 24 hours a day, 7 days a week. JSA’s services soon expanded to multiple sites across the country. Dr. Fishkind returned to The Harris Center in 2019 to design telepsychiatry services for the center and is active in textbook writing and consulting.