TCPR: Do patients like telepsych?
Dr. Yellowlees: Yes. The studies show very high levels of patient satisfaction, higher even than what we see with in-person care. Most of those studies were done before 2010, when the technology was not as good and patients often traveled to their primary care doctor’s office to connect by telemed. I suspect the satisfaction is higher today when they can connect from the convenience of their home (Chan S et al, Curr Psychiatry Rep 2018;20(10):85).
TCPR: Does this high satisfaction extend to psychotherapy or just medication management?
Dr. Yellowlees: Both. There are several studies with cognitive behavioral therapy, and there’s a long tradition of telephone therapy in psychoanalysis. Analysts often treat patients by phone when they move or go on holiday, and they argue that telepsychiatry in general makes sense because they don’t want the patient to look at their face during the session.
TCPR: Most of us have been forced to switch to telepsychiatry due to the coronavirus crisis, and a lot of psychiatrists aren’t exactly glowing about it.
Dr. Yellowlees: That’s been the case since day one. Most physicians believe in the magic of the in-person interaction, so they perceive telepsychiatry as a second-class approach. My view is very different. I think it’s suboptimal to rely solely on in-person visits, much as it would be if a physician refused to use the telephone. The best way is to use a hybrid model where you see patients in person, also see them on video, and communicate through email or messaging. You have a broader relationship that way, and care is more accessible. Over time, that creates a better relationship.
TCPR: What advantages stand out for telepsychiatry?
Dr. Yellowlees: There are certain groups of patients who prefer video, like children and younger patients. When you see a child by video, you get a better sense of the child’s home environment and family interactions. For example, when children act out in the office, the parents will often leave behavior management up to you. But in a televisit, that’s not possible, so you get a better view of what their parenting skills are like and can coach them in real time.
TCPR: What other groups do better with telepsychiatry?
Dr. Yellowlees: Patients who have a hard time engaging in treatment, like those with PTSD or agoraphobia, can do better with telepsych. There is some evidence that seeing them on video for the first few sessions makes it easier to engage them in the long run. Also, those who can’t make it to the office because of physical limitations or privacy needs, like celebrities, are a good fit.
TCPR: Is there a risk that televisits will enable avoidance in agoraphobia?
Dr. Yellowlees: Yes, but if they won’t come to see you in the first place, then you can’t even get to first base, so why not start in their home and teach them some techniques that might get them out of the house? When I see patients with agoraphobia, I’ll have them go to places they haven’t been to and take a selfie there. Then they can show me their progress. Likewise with patients who hoard: I can watch them at home cleaning up or see the results on video.
TCPR: I’ve heard psychiatrists complain that conversations are more superficial in telepsych.
Dr. Yellowlees: Actually, I find the opposite. People are more comfortable having intimate conversations on video than in person. It’s less threatening. There’s a large body of research showing that if you want to get an honest answer on a questionnaire, you should give it through a computer rather than in person. We found the same thing in telepsychiatry research. I’ve frequently had patients tell me intimate stories on video that they’ve never told before. They do that for three reasons. One is that the video makes me seem more distant, so they feel like they’re less likely to run into me at the grocery store, and that creates more safety. The second is that I’m less intimidating on video. Let’s say I’m seeing a woman who has been raped. In an office visit, she’ll be less likely to tell me about the rape because of the gender dynamics, but it’s safer from a distance. The third is that video is more egalitarian. Patients don’t have to come to my office on my terms and wait for me. So it brings us closer to the same level (Kocsis BJ and Yellowlees P, Telemed J E Health 2018;24(5):329–334).
TCPR: How can we connect better with patients during digital visits?
Dr. Yellowlees: Start off on a good note. You shouldn’t just jump in with clinical questions. I’ll start by noticing something in their room and saying, “That’s an interesting picture, can you aim your camera there and show me that?” I encourage my patients to use their phones, tablets, or laptops because I want them to walk me around their garden and introduce me to anyone they are comfortable with in their home. I want to see their pets. I may want to look in their fridge if we’re working on eating habits or if I’m concerned about self-care. You see all sorts of things in patients’ homes, and these are opportunities for connection. You might learn you both like the same sports team. Think of these as home visits, not just televisits.
TCPR: What if patients can’t be at home or their home isn’t private?
Dr. Yellowlees: That happens particularly when I treat physicians, and I’ll encourage them to see me from their car using a smartphone. The car is actually a very private place.
TCPR: When is telepsychiatry less ideal?
Dr. Yellowlees: There are patients who are phobic or paranoid about technology, but that’s getting less and less common. The only relative contraindication is when dangerousness is an active concern because it’s more difficult to hospitalize someone long distance—not that it’s particularly easy from the office either. In both situations you’d need to contact the police, but there’s one difference with telepsych: You need to call the police station where the patient is located, which may not mean calling 911 because 911 routes to your local police. Another facet of telepsychiatry is that you should document the address where the patient is located, because legally that is where the consultation takes place. I also like to get a cell phone number in case the video breaks up, and the phone number for an emergency contact whom the patient trusts.
TCPR: If the consultation officially takes place where patients are located, does that mean you have to be licensed in the state where they connect from?
Dr. Yellowlees: Yes, though that regulation has been dissolved temporarily during the coronavirus crisis. In normal circumstances this can cause difficulties. If your patient travels to another state, say for a holiday or college, then legally you should not see the patient on video in that state, even for one session. I would advise one or two pro-bono phone or email contacts just as for patients we see in person who travel, then ask a colleague to take over if the patient is going to be out of state continually. About half of the states participate in a telemedicine compact that simplifies the process of getting multiple licenses, but there is still a cost hindrance.
TCPR: Are there any other documentation requirements that are unique to telepsychiatry?
Dr. Yellowlees: That varies by state, so you’ll want to check in on that. Two resources to start with are the APA’s Telepsychiatry Toolkit (www.psychiatry.org/psychiatrists/practice/telepsychiatry) and the American Telemedicine Association (www.americantelemed.org).
TCPR: What about controlled substances?
Dr. Yellowlees: With the coronavirus crisis, the government has removed the long-standing obstacles to prescribing controlled substances over video, so even maintenance medications for addictions can be prescribed through telepsychiatry. But generally the rule is that you have to see the patient in person at least once a year to maintain controlled substances through telepsychiatry visits (as required by the Ryan Haight Act). That may change in the future.
TCPR: Is it necessary to use a HIPAA-compliant platform, or can you just have the patient sign a consent to communicate insecurely through Skype or FaceTime?
Dr. Yellowlees: Right now during the coronavirus outbreak they’re allowing any system, but that’s not going to last and I would encourage psychiatrists to get a HIPAA-compliant system. You have that option, so it’s hard to justify not using it. And I don’t think a consent like that would hold up in court.
TCPR: How do you know if your system complies with HIPAA?
Dr. Yellowlees: The company you purchase it from should give you a business associate agreement that essentially says the company is unable to look at your transmissions.
TCPR: What’s the ideal telepsychiatry setup for a provider on a low budget?
Dr. Yellowlees: You don’t need a fancy system, and there are lots of good ones that will cost you about $50–$100 per month. I usually mention Zoom, Vsee, and Vidyo, two of which I use personally. The easiest thing to do is to run video on your smartphone or iPad. I stand the device up beside my laptop so that I can see the patient while I’m writing my notes.
TCPR: Are there advantages to a more expensive setup?
Dr. Yellowlees: Not really. With today’s cell phones you can get a high-definition picture, much better than what we got in the old days when some of those patient satisfaction studies were done. Quality audio is actually much more important than quality video. If you’re going to do a lot of telepsychiatry, I’d suggest an echo-cancelling microphone so there’s no feedback from the speakers. A good one is ClearOne’s Chat 50 speakerphone.
TCPR: How do you make eye contact in a telepsych visit?
Dr. Yellowlees: If you look at the camera, it will seem that you’re making eye contact with the patient. So you want the patient’s image to be as close to your camera as possible. I use a split screen where my image is on the bottom and the patient’s image is on top—closer to the camera—so there is little difference between our eye-to-eye angle and the camera angle.
TCPR: What about lighting?
Dr. Yellowlees: You want to avoid backlighting, which casts a shadow over your face. Dim the lights that face the camera from behind you, and place a bright light—like a flexible reading lamp—above the computer and aimed at your head. You should be about 2 feet from the camera.
TCPR: How is billing different for telepsychiatry?
Dr. Yellowlees: It varies by state. I usually bill an evaluation and management (E&M) code and psychotherapy code for a 30-minute appointment, with the same codes I use for in-person visits. You are required to modify the code with “GT” or “95” to indicate that it was done by telemedicine, and some insurers require you to change the place of service to “02” for tele instead of “11” for office.
TCPR: How is the reimbursement?
Dr. Yellowlees: Medicare has historically been the biggest barrier to reimbursement. They’ve insisted that patients who are seen by telemed live in a tightly defined rural geographic region (Editor’s note: For a list of underserved ZIP codes, see “Downloads” at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HPSAPSAPhysicianBonuses). That has been changed for the length of the current crisis, and Medicare is now paying for doctors to use video with their patients in any state, as long as the physician is fully licensed in at least one US state. That will undoubtedly change after this crisis, but I hope not by much. Medicare pays the same rates as for in-person consults, as does Medicare/Medicaid in most states. In California we have a law that forces insurers to pay the same for telepsych as they do for in-person visits, and many states are moving in that direction.
TCPR: Does anyone pay more for telepsychiatry?
Dr. Yellowlees: No, but if you are seeing a patient in a clinic, the clinic can bill a facility fee (code Q3014), which usually pays about $25. And you can charge for two physicians at the same time if you’re doing collaborative care with a primary care physician (PCP) through telepsychiatry. In those cases I’ll generally see new referrals for 35–40 minutes, and then for the last 10 minutes I’ll consult with both the patient and the PCP. The PCP would then prescribe the medications and put in any orders, and both of us can bill for that time.
TCPR: Physician morale is at an all-time low. How can telepsychiatry help?
Dr. Yellowlees: Telepsychiatry saves you time. You can complete your notes during the visit. Just place your cell phone’s camera near your laptop and touch-type as you talk. Let the patient know what you’re doing. It helps to have a quiet keyboard—search for “silent keyboard” on Amazon. There’s also less in-and-out time with patients entering and leaving the room, which saves you time, and fewer no-shows. If a patient no-shows for an office visit it’s hard to get them in, but with telepsych you could phone the patient and start the visit. Patients can see you even when they are feeling physically under the weather. The biggest plus is geographic flexibility. You’re no longer bound to your office. I routinely see patients from my home, but you could also practice telepsych while traveling.
TCPR: What does the future look like after this crisis settles?
Dr. Yellowlees: Right now, many of us are seeing patients 100% on telepsychiatry. I hope that in the future, patients will have more choice and most of us will be practicing in a hybrid manner. Sometimes we’ll still want patients to come in, but there are advantages to both types of visits, and our patients will be best served by having more choice and a more flexible relationship with us.
TCPR: Thank you for your time, Dr. Yellowlees.Editor’s note: Dr. Yellowlees’ textbook, Telepsychiatry & Health Technologies, is available through the APA Press, 2018.
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