Apr 8, 2020
Jay H. Shore, MD, MPH, returns to the Psychcast, this time to
conduct a Masterclass lecture on using telepsychiatry in a
regulatory environment that is quickly changing because of the
physical distancing forced by the COVID-19 pandemic.
Dr. Shore is director of telemedicine at the Helen and Arthur
E. Johnson Depression Center at the University of Colorado at
Denver, Aurora. He also directs telemedicine programming at the
medical center’s department of psychiatry.
He disclosed serving as chief medical officer of AccessCare
Services and receiving royalties from American Psychiatric
Association Publishing and Springer.
Practicing telepsychiatry has administrative, technological, and
- Administrative concerns include licensure, prescribing,
billing, and establishing a procedure and protocol, especially
- Technological considerations include choosing software,
understanding HIPAA compliance during the current COVID-19 crisis
(and afterward), and incorporating a virtual clinic workflow, such
as scheduling and billing.
- Clinical considerations include understanding how to manage a
hybrid relationship with patients and tailoring your clinical style
to teleconferencing, such as reading body language through video
and directing the environment as the clinician.
- Basic dos and don’ts: The clinical space for teleconferencing
of both clinician and patient must be private and secure. Every
person in each room must be introduced. The webcam should be placed
on top of the computer screen that so eye contact is maintained,
and the clinician’s head should take up two-thirds of the
- To practice telepsychiatry, typically psychiatrists must be
licensed in the state in which the patient is located, with some
exemptions within federal systems. During the COVID-19 pandemic,
however, many states have waived this requirement. Inform your
malpractice company that you are now participating in
telepsychiatry to ensure that you are covered. During the COVID-19
crisis, the federal government has waived the Ryan
Haight Act to allow the prescription of controlled substances
without an initial in-person visit.
- Tips for dealing with an emergency: The psychiatrist should
establish the physical location of the patient at the start of
every appointment and document how to get a hold of them if the
connection is lost. It’s helpful to know how and when to contact
local emergency services; 911 is often a local call based on the
GPS of the cell phone. American Telemedicine Association and
American Psychiatric Association guidelines suggest using a patient
support person. That person would either be a family member or
close friend who is onsite during the event with whom you have
preconsent to contact the clinicians if an emergency occurs.
- Telepsychiatry services should have a procedures and protocol
document to outline scheduling, billing, documentation, and how to
address psychiatric emergencies. For telemedicine, the
videoconferencing software must be HIPAA compliant. During the
COVID-19 emergency declaration, the Department of Health &
Human Services’ Office for Civil Rights will exercise “enforcement
discretion” and, in most cases, waive penalties of HIPAA
enforcement for clinicians who are serving their patients in good
- Use only technologies such as FaceTime or Skype if you are
unable to make adequate connection with HIPAA-compliant
- Take your in-person operational workflow and try to replicate
it virtually. Make sure that people’s responsibilities are clearly
- “Hybrid relationships” are increasingly more common with
in-person and virtual interactions from videoconferencing, patient
portals, email, etc. In hybrid relationships, there are both
physical and virtual spaces. The physical space provides immediacy,
often more trust, and clear boundaries. The virtual space often is
convenient and provides a sense of physical and emotional space
between clinician and patient, with advantages and disadvantages.
The virtual space means rendering care to the patient in their home
and gives insight into their environment. The virtual space can
also decrease stigma because the patient does not have to seek care
in a physical clinic. Sometimes, more small talk than usual about
the environment is helpful to bridge that virtual gap. Use more
active inquiry into emotions or body language if these are not
clearly communicated over videoconference.
- Dos and don’ts: Make sure that the lighting is good. Use the
picture setting, so you can monitor your body language during the
- Make sure you are not too passive
during the session. Be proactive. Animate yourself a little more
than you would in person.
- Ask patients questions about their
- Have a lower threshold for asking how
patients are doing. More active inquiry can prove helpful.
American Psychiatric Association Telepsychiatry Toolkit:
American Telemedicine Association: https://www.americantelemed.org/
Joint guideline on telepsychiatry from APA and ATA:
State licensure exemptions:
HHS HIPAA information:
Ryan Haight Act information:
Yellowlees P and Shore JH.
Telepsychiatry and Health Technologies: A Guide for Mental Health
Professionals. Arlington, Va.: American Psychiatric Association
Show notes by Jacqueline Posada, MD, associate producer of the
Psychcast and consultation-liaison psychiatry fellow with the Inova
Fairfax Hospital/George Washington University program in Falls
Church, Va. She has no disclosures.
For more MDedge Podcasts, go to
Email the show: email@example.com