Telepsychiatry in a private practice setting

1. OPOP conference, September 03 09, Ottawa Telepsychiatry in a private practice setting

2. I, Hugues Richard, perceive no conflict of interest with this presentation but present companies with which I have worked and consulted for: • Lundbeck Canada • Ontario Telemedicine Network (OTN) Disclosure….

3. 1. Discover the benefits and limitations of working with OTN. 2. Find out which patients do best, and if there are any contraindications. 3. Discuss the future of telepsychiatry and ways it can be improved. learning Objectives

4. My practice: general psychiatry, adult, psychotherapy, trauma work, consultation liaison, community psychiatry Private office: Stittsville. Meet my two assistants… introduction

5. Isabelle and nina

6. background

7. After closing my 18 year practice at Centre Alliance in Sturgeon Falls, in 2003… off site at ROH. • Use of a studio at a local hospital, walking distance from my office then in Arnprior. • Since November 08, videoconference equipment installed in my office. • 8 “visits” done since, for the 2 centers I serve up North (Kirkland Lake & Chapleau) Relevant clinical Exposure

8. Direct clinical work including consultation, follow up, psychotherapy even meditation! • Indirect clinical service: case discussion, treatment plan, team meetings • Supervision/teaching • CME Use of Videoconference for….

9. Government’s third phase • Easy process from administrative to technical • One person assigned → very helpful! • ++ Non intrusive “behind the scene action” Installation and implementation

10. to lose control on appointments, To lack efficacy or accountability, To become impersonal, To be left to my own self. apprehensions

11. How is it going to work for new patients? Will I survive working 5 days in a row? How are the patients and staff going to react to this? Apprehensions

12. Smooth process: booking, liaison; Professionalism and reliability; Excellent technical support on line (bridge), and in vivo; My experience

13. Consultations → no problem! Nurse or case worker always present! • Actually enjoying working from my office, feeling ‘at home’… • Integration of activities and technology from my own practice (EMR, fax, phone, instant messaging, cell, computer server, Skype) • Less tired at the end of day/week My experience

14. Sound: raise it or decrease it, or mute yourself off when you need to speak to your assistant • Image: ZOOM in or out, see yourself in interaction • Distance→ different perspective My experience – the technology

15. NORTH: 1 patient declined, preferring to wait to see me in vivo Negative perception from one agency clinical director who thought I was less available My experience

16. Convenience Time saving Comfort Safety ( pandemic, road accidents…) Benefits - physician

17. Environment (↡carbon footprint) No disruption in family life Available to my in vivo practice Benefits-physician

18. Availability of service • Convenience: less driving, specially in winter, ↑ autonomy • Cost • In the North, videoconference used for teaching, health, already part of culture Benefits - PATIENTS

19. SOME PATIENTS WILL SPECIFICALLY PREFER TELEPSYCHIATRY 1.Distance is perceived as protective 2. Control is maintained, can walk out easily 3. Neutral place 4. Those who enjoy technology or like novelty Benefits - patients

20. 65 to 75% of patients who could have benefited from telemedicine chose one-to-one visits. Different with patients from the North: all but one have used OTN. My experience

21. Patients’ satisfaction close to one on one visits. More qualitative studies needed to support this. What do studies tell?

22. Very accurate compare to in vivo The non verbal communication lacks compare to the verbal Most studies show that the “main obstacles to telepsychiatry have to do with physicians and patients adjusting…” What do Studies tell ?

23. Delay to get a studio available; turn around between one and two weeks, at least 48 hrs Registration at an agency makes it more public Having other people involved makes it very hard for some patients to trust (bridge, hackers, OTN = government) Limitations

24. No hand shake! • Non verbal communication somewhat lacking (visual acuity and precision) • Smell is absent: ethylic intoxication for instance • Patients who needs a very strong presence, such as Veterans suffering from traumas, many will not engage with a “TV” or a “COMPUTER” Limitations

25. I had not anticipated this one! • Old chart not easily accessible • progress notes better be at both sites! • KL: Citrix EMR unpractical • →impossible to write in the chart • →very long process to enter and retrieve info from the chart • KL transcriptionists = long distance Limitations – charting!!!

26. Progress notes written on same lap top I use on site; Consultations dictated to and transcribed by my assistant →notes sent rapidly to everyone involved Charting –my solution

27. In her 50s • Referred for consultation • Long past history of sexual molestation as a child • “Interpersonal traumas” later on as an adult. • Symptoms of dissociation with possible PTSD • Resistant to treatment (psychotherapy and many different ads) Clinical vignette 1: Mrs. C.

28. Lives >160 k from my office, but a studio is available 4 k from her Would you have offered her videoconference? She chose…. MRs. C.

29. Patients who refuse this modality (informed consent needed) Violent / unstable / impulsive patients Patients requiring special monitoring when not available Contraindications

30. Patients with specific symptomatology that could be exacerbated by the use of communication technology (Z with hallucinations for instance) Contraindications

31. Patients with whom news must be shared in person, because it could cause significant emotional reactions (HIV test results) Patients who have hearing, visual, cognitive deficits that limit their ability to communicate via this technology Contraindications

32. In her30s Recently separated Referred to me by FP and SW for symptoms of depression and anger SW attends the session I have completed the assessment, at least that’s what I thought… But apparently not her! Clinical vignette 2 –Ms. D.

33. Starts throwing chairs around, Screams that she’s had it; nobody listens to her, and she is to kill herself SW is hysterical Me too !!! Clinical vignette 2 –Ms. D.

34. Have phone and fax very close by if not in the studio Have certification forms at hand Have a coordinator of care on site Have triage done beforehand Patient = realistic expectations Good rapport with ER staff What have I learned ?

35. A good story at last! • 46 year old native, married; • Works as bus driver at local Casino; • Known to me since early 90s, in Sturgeon Falls; • Bipolar II Disorder, mostly hypomanic, on Lithium • Panic Disorder without agoraphobia, • Alcohol Dependence in remission. • Obese • Diabetes dx while on Olanzapine 12.5mg. Clinical vignette 3 –Mr. F.:

36. 2003-2006, treated by FP and SW • Comes back in 2006 in need of psychiatric report re: driver’s licence • Booster sessions 3 to 4 times a year, travelling from Orillia to Stittsville • Spring 08: father dies, depression triggered • Dec 08: sick leave, Paroxetine started by FP Clinical vignette – mr. F.

37. Telemedicine equipment recently installed in my office allows for weekly intensive sessions. Also use of Skype (once) and numerous emails. I talk with his SunLife case manager on phone Clinical vignette

38. Trial of different drugs • Lots of support to his wife, psychoeducation to both of them • Grief work related to his dad and his inability to work and to function. • Work on regression, and nutrition. Clinical vignette –Mr. F.

39. Patient on his own decided to see a Native Healer, and took Rescue remedy (BACH flowers) • Good response to Seroquel XR 600 mg, Lithium 1200mg, Modafinil 100mg bid. • I also reluctantly raised his Clonazepam from .75mg AM + 1mg PM to 2.5mg AM + 2mg PM. Clinical vignette –Mr. F.

40. Presently back to work full time No need for hospitalization His wife is still with him Clinical vignette –Mr. F.

41. Excerpt from an email received July 16 09 “ In the Objibway language “Meegwetch” means thanks from the heart... • I wish to live to the fullest and that is my choice • You have helped me through a hardship so I say • MEEGWETCH Dr Richard” Clinical vignette –Mr. F.

42. Telepsychiatry is very valuable in many different ways It has shown that it is an accurate way to assess and treat patients; It offers psychiatric services to people who have no direct access to such services REcapitulation

43. For some patients, it’s their preferred way of treatment It is not for psychiatric emergencies It is not to replace one on one sessions It might be a cost saving treatment Obstacles are mostly from professionals recapitulation

44. To me, it is an exciting way to practice; Without telemedicine, I would not have been able to serve the northern communities last winter. Recapitulation

45. Need to know more about who are the best candidates Contraindications to be more precisely defined Future

46. Need to improve the image quality to get more of the non verbal communication. • Professionals need to learn more about the potential benefits from this medium. Future

47. A must: “Telehealth-clinical guideline and technical standards for telepsychiatry”, Gilles Pineau, Khalil Mogadem, Carole St-Hilaire, Eric Levac, Bruno Hamel et al. (AETMIS 06-01) Montreal AETMIS 2006 xxii-72p. Bibliography