Telepsychiatry Early in the COVID-19 Pandemic
Key findings
- During the week of March 16, 2020, leaders of the Massachusetts General Hospital Department of Psychiatry decided to convert outpatient visits to telephone or video, permitting in-person visits only in carefully selected cases
- The existing telehealth platform was part of the electronic medical records system, and drastically increased demand required a rapid pivot to commercial options
- Common problems were technological glitches, difficulty reading patients' nonverbal communication and increased effort required to establish rapport
- Among the advantages of telepsychiatry were a reduction in no-show rates by 20% and the opportunity for more frequent, briefer meetings for managing patients in crisis or undergoing medication titration
- Whether telehealth will remain "the new normal" after COVID-19 subsides depends on regulators and insurers
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The COVID-19 crisis has resulted in widespread and rapid adoption of telepsychiatry, made possible by payment parity and reduced governmental regulations. In General Hospital Psychiatry, Justin A. Chen, MD, MPH, medical director of Adult Outpatient Psychiatry Services at Massachusetts General Hospital, Wei-Jean Chung, PhD, co-director of Primary Care Psychiatry, Janet Wozniak, MD, associate chief of Quality and Safety in the Department of Psychiatry, and director of the Child and Adolescent Outpatient Service, and Jeff C. Huffman, MD, associate chief of clinical services in the Department of Psychiatry, and colleagues discuss the experience of their outpatient clinic during the early days of the pandemic.
The Decision Point
During the week of March 16, 2020, department leaders decided to convert outpatient visits to telephone or video. In-person visits were permitted only when patients could not access telepsychiatry or there was a clinical necessity, such as for the administration of long-acting injectable medications. For those visits, a newly created psychiatric urgent care clinic was outfitted with personal protective equipment.
Limitations of the Existing Platform
The department had been an early adopter of telehealth. In March 2019, 457 virtual psychiatric visits were made via a platform integrated into the electronic medical records system. However, drastically increased demand in March 2020 led to failed and dropped connections, inconsistent video quality and an unpredictable audio system. Clinicians had to shift to telephone calls or commercial platforms such as doxy.me or Zoom.
These efforts almost completely reversed the rates of in-person and virtual care. The outpatient psychiatry division switched from under 5% virtual visits in March 2019 to over 97% in March 2020, including group-based mental health treatment.
There was a 22% increase in productivity, not surprising considering new-onset psychological distress related to increased social isolation, financial and employment instability, stressors for health care workers, and widespread anxiety, uncertainty and grief.
Addressing Logistical Issues
Besides coping with the platforms themselves, clinicians and administrative staff had to:
- Document verbal consent for releases of information
- Collaborate with in-hospital colleagues to fax orders for involuntary psychiatric evaluation
- Avoid calling patients from personal phone numbers (online platforms such as Doximity and Jabber provide secure dialing/fax)
These changes, amid personal stressors and uncertainties, placed substantial demands on clinical and administrative staff. Clinical leaders provided instrumental and emotional support by sending daily email updates about evolving guidelines, holding frequent virtual meetings and electronically distributing tip sheets and technical support.
Advantages
No-show rates decreased by 20% between January/February 2020 and April/May 2020, probably due to decreased logistical barriers to access. Telepsychiatry may be particularly beneficial for patients whose psychiatric pathologies interfere with their ability to leave home (e.g., immobilizing depression, anxiety, agoraphobia and/or time-consuming obsessive-compulsive rituals).
Some clinicians caring for patients prone to violence and behavioral dysregulation reported a greater sense of personal safety with virtual care. Telepsychiatry also facilitated more frequent, briefer meetings for managing patients in crisis or undergoing medication titration. In some cases, clinicians were able to gain insight into patients' family and home dynamics.
Tips for optimizing telepsychiatry, include (but were not limited to):
- Use headphones to increase privacy
- Set up the screen to look at the camera more naturally and to appear that you are looking at the patient
- Communicate and establish a back-up plan if the video connection is lost (e.g., phone contact)
- Seek regular peer supervision to share best practices
- Schedule your day intentionally, understanding that patients may show up for appointments more consistently, and plan accordingly
Disadvantages
Clinicians reported frequent disruptions (e.g., technological glitches), difficulty reading patients' nonverbal communication and increased effort required to establish rapport. Telepsychiatry precludes the physical examinations necessary for monitoring certain conditions and medications.
Video communication is difficult for patients with psychotic symptoms, auditory and/or visual impairments, and migraine headaches, among others. It is unavailable to people without an internet connection—often poor, elderly or living in a rural area—which exacerbates existing health disparities. At Mass General between March 30 and April 24, 2020, 30% of virtual outpatient psychiatry visits were conducted via phone.
Is Telepsychiatry Sustainable?
Whether telehealth will remain "the new normal" after COVID-19 subsides depends on regulators and insurers. Assuming outpatient psychiatry continues to be reimbursed comparably to in-person care, the question of whether a visit should be conducted virtually will probably become a routine component of treatment planning.
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