Adventures in telepsychiatry

During the recent blizzard, I did more telepsychiatry in one day than I’ve done before, so I thought I would share some comments about doing a lot of it in one day, rather than a few scattered visits per day.

I really didn’t notice much difference between staying at home and doing several hours worth of telepsychiatry versus doing face to face visits in my office. However, I was acutely aware of how important it is for me to get myself organized at home and how useful a dual monitor would be when I get around to buying one.

In my practice office, I’ve got the supplies I need at my fingertips, and have routines for the usual things like writing and printing prescriptions, making return appointments and taking payment.

I didn’t have any of these things really set up at home, and I really noticed what a difference it makes for me to have things better organized. This wasn’t really much of a surprise, but I did notice one thing that was much better at home: my efficiency at using my computer and doing telepsychiatry at the same time.

At work, I typically use a desktop computer to do Skype, and type on a laptop to take notes. This is a little silly, I know, but I’m usually using the laptop with my face to face patients, and so sticking with the laptop at work means doing what I’m already doing anyway.

A couple of years ago I bought a 30 inch computer monitor. With this much screen space, I can easily use Skype on one side of the screen and do notes on the other side. (The laptop I use at my practice was locked in the file cabinet at my practice when the blizzard came, and I didn’t have access to it the day I was doing so many Skype visits.)

Telepsychiatry intrinsically requires some multi-tasking if you are taking notes while you see the patient: you have to look at the patient most of the time, but you also have to look at where you are typing part of the time so you can correct your typing.

Having a big screen or two monitors really makes a difference when I need to do more than one thing on the computer at one time and be efficient about it. When I’m talking and typing, I really don’t have time to be moving the mouse all over the place and clicking icons to switch from one window to another.

I’ve been told that one of the best means that many people can use to increase their productivity on a computer is to go to dual monitors or a big screen.

I’m very certain that this is true, and I would suggest that people doing telepsychiatry really go for a dual monitor system.

One of the key enabling technologies to make something like telepsychiatry work is E-Prescribing. If people have to come in to pick up prescriptions or wait for the postal service, that’s a problem.

I use National eRx for most of my prescribing, and although I like it, the user interface is really clumsy to use and could be vastly improved to speed things up. It’s free, and that counts for something.

I’ll write a review of National eRx some other time, but I just want to rant a bit about how unbelievably clumsy the current system for e-prescribing here in Maryland tends to be.

As far as I can tell, almost no pharmacies actually accept prescriptions from National eRx directly. Instead, every pharmacist I’ve spoken to about it describes a long and clumsy process of either receiving faxed prescriptions with some unknown delay from minutes to days or only getting the prescriptions halfway into whatever proprietary system the pharmacy uses but not having any real integration–there’s still a lot of manual data entry, and someone has to remember to check the queue in many cases.

End result: wasted time for patients, pharmacists and me.

I can’t understand what would be wrong with having one national database for the whole country which doctors and pharmacists could log onto and leave and fill orders for prescriptions.

I think many banks routinely handle many more transactions per minute that would be necessary to do all prescriptions electronically, so it really isn’t a technological issue at all, as far as I can see.

There’s a lot of talk these days about initiatives and grants to improve healthcare.

Why not start with putting together a federated database of prescriptions? Every doctor I know, whether psychiatrist or not, would benefit from a simple web-based interface to write prescriptions and pharmacies could just take off all the prescriptions electronically. If the database was federated, it would make sense for pharmacies to integrate that database with their own proprietary systems.

I realise there’s lot of issues here: privacy, security, load-balancing, and the like, but it seems to me that banks are pretty much already there so far as I can see.

Forget all these attempts to do complicated electronic medical records and so forth right now. Get a national drug list that every physician in every ER in the country could have access to. It would save a lot of medication and physician errors, and cut down on illegal diversion of controlled substances besides.

I noticed that moviedoc has a recent post on his blog that mirrors some of my own thoughts on how telepsychiatry might change the economics of renting office space for psychiatrists.

Moviedoc is thinking about two of the same things that I am:

• Could I do more telepsychiatry at home and think about making part time arrangements for office space rather than full time ones?
• If I only have part time office space, how do I handle emergencies where I really feel I should see the patient, not just talk or video Skype him or her?

He does ask one question though, that I think that I know the answer to. He wants to know a good way to manage scheduling office space online. I would suggest webcalendar on some hosting provider. The security is easy to set up, and although it isn’t customized for mobile phones, it really makes it easy to coordinate scheduling among people who have to do this already, as long as you make a couple of ground rules for how to use it.

I think this blog makes it pretty clear that I’m enthusiastic about telepsychiatry. I’ve tried to keep my enthusiasm for it low key with my patients, primarily because I want to accommodate their needs, and not have them feel pressured about whether to use telepsychiatry or not as I work out the best way to do it.

I guess I’ve been drinking my own Kool-Aid, because I’ve now gone from passively offering to do telepsychiatry to pretty much insisting that some of my patients be able to use it.

Snow has been at record levels in Baltimore this season, and that’s been a pain for everyone living here. Recently, we had a record snowfall, and the city was pretty much paralyzed for several days.

Unfortunately for me and four of my patients, this total shutdown of everything came at a really bad time. I have a small practice, but I pride myself on doing everything I can to keep people out of the hospital, so I have a patient or two in my practice who are on the verge of being too sick to care for as an outpatient.

What happened was that the city was shut down and I was taking care of four people who were either on waiting lists for specialty beds or needed hospitalization., The possibilities for admission were murky because of a lack of hospital beds or the patient’s decision to decline to go to a particular hospital because of a bad experience there in the past.

It boiled down to four patients, all of whom probably needed to be in the hospital, and me trying to do what I could until beds opened up in a city where most people couldn’t drive anywhere and the public transportation system was barely working at all.

Two of these patients had Skype, two didn’t. I realize that a sample of four doesn’t prove anything, but the differences between what I could do via Skype and what I could do by telephone were so stark I just couldn’t believe it.

The two patients with Skype were, if anything, more ill than the two patients without.

I felt confident dealing with some pretty aggressive med changes with the patients with Skype. I could see and talk to the patients and the people who were staying with them. Although I couldn’t assess muscle tone over Skype, it wasn’t that hard for me to see that I had given too much neuroleptic to one of them, simply from his facial expression. I was also very confident that I had not made the other patient with Skype delirious, because I could do almost all of a mini-mental state exam without being there, and I could see the patient as well as talk to her.

By contrast, dealing with the two patients without Skype by telephone was much more challenging, and I managed them much more conservatively because I didn’t feel that I was getting the kind of information that I needed to do bold things safely. One of them ending up in an ER, and got admitted and discharged two days later. I think I might have prevented this admission if I could have had a better handle on what was going on.

Basically, for the patients with Skype, I treated them almost as aggressively as I would have in a hospital. For the patients without Skype, I didn’t feel I could do as much and feel that they were safe.

These four cases really made an impression on me. Both of the patients without Skype are in circumstances where getting set up for telepsychiatry involves little more than making the effort to get a Skype account. The expense of a webcam is not likely to represent a significant financial outlay for either of them.

With these latter two patients, I’ve crossed the line from being passive about telepsychiatry to being much more active. I told both of their families that I really thought they should be ready to do things by telepsychiatry next time. I certainly can’t force anyone to use it, but I didn’t have any problem writing that my medical advice was that they should, that their care with me would be worse without it, and that they were making a mistake if they chose to ignore my advice.

Over the past few months, I’ve been doing more and more rating scales with patients. When people first come in, they download and fill out an initial form which asks the usual demographic information like addresses and phone numbers but also includes a patient health questionnaire (PHQ) . The PHQ screens for somatization disorder, panic disorder, anxiety disorder, eating disorder, and alcohol problems. The PHQ is the only self-report rating scale I use; I think the clinician-administered rating scales are better.

When I see someone the first time I usually do:

• the Short Portable Mental State Questionaire (SPMSQ),
• the Hamilton depression scale (HAMD), and
• the Brief Psychiatric Rating Scale (BPRS).

Depending on what else is going on, I sometimes do:

• the Mini-Mental State Exam (MMSE),
• the Hamilton Anxiety scale (HAMA),
• the Young Mania Scale (YMRS),
• the Adult ADHD Self-Report scale (ASRS) , or
• the Yale-Brown Obsessive Compulsive Scale (YBOCS).

For follow up visits, I sometimes do:

• the HAMD
• the HAMA, or
• the YMS,

depending on how the patient is doing.

Really, there aren’t that many things that you can’t do by telepsychiatry, but there are some. For example, it’s impossible to do parts of the AIMS without touching the patient, and the HAMD asks me to look for things like fidgetiness, which might be hard to see on a skype call.

I can see a PhD thesis in here somewhere called “Adapting Psychiatric Rating Scales for Telepsychiatry.”