Telepsychiatry Tips: Etiquette and Ethics

Nancy A. Melville

November 17, 2022

From providing virtual therapy sessions to patients in the front seats of their cars, to sessions with patients who turn out to be in another state, the new paradigm of telepsychiatry is presenting clinicians with a host of situations with unwritten or constantly changing rules.

Dr Sanjay Gupta

But key practice tips are emerging for the optimization of virtual sessions, said Sanjay Gupta, MD, chief medical officer of the BryLin Behavioral Health System in Buffalo, N.Y., during a presentation on the subject at the 21st Annual Psychopharmacology Update presented by Current Psychiatry and the American Academy of Clinical Psychiatrists in Cincinnati, Ohio.

Gupta noted that while "many pitfalls [may] occur," an overriding rule that should be emphasized with telepsychiatry is that "[virtual visits] are held to the same standard of care as an in-person visit." This "rule" needs to be followed diligently, he said, as the key difference in virtual visits is a reduced sense of the formality of a psychotherapy session.

With virtual sessions, the therapeutic experience "can feel kind of trivialized," said Gupta, who is also a clinical professor in the department of psychiatry, State University of New York at Buffalo. He noted that it is crucial that "the sacredness of a private setting should not be diluted."

Challenges in finding that privacy for some, however, lead to the issue of the "patients in cars" scenario, Gupta said. Still, he added, while psychiatric sessions should never be conducted when a patient is driving, the front seat of a parked car may, for some, be the most private setting available.

"For many patients, their car may be the only private place from which they can take a video call," Gupta noted. "Perhaps they are at work and the only way they could fit in the appointment is by going out to their car on their break. Or patients may even be at home, but they're not alone and need to go out to their car for privacy."

If the car isn't being driven, sitting inside it should be fine for virtual therapy, but even there, clinicians should retain a focus on the consistency of care regardless of the setting.

Meanwhile, psychiatrists can take key measures to keep things professional, at least on their end of the session.

Before starting, for instance, keep in mind the patient's viewing experience, Gupta suggested. Tips he offered include:

  • Keep the background of your video image subtle, with no distractions, such as windows looking out to an ocean or other distracting background elements.

  • The camera should be above eye level to suggest a face-to-face conversation more effectively.

  • Try not to have other browser windows open and look directly into the camera lens so that the patient knows they have your full attention.

  • Try not to take notes or document in the electronic health record during the session, which also can give the impression of being distracted and not listening to the patient.

Psychiatrists should remember that older patients — who may be uncomfortable with email, much less video conferencing — may still struggle with video-calling technology. In such cases, consider:

  • Sending the patient instructions in advance of the appointment.

  • Have your office hold a "tech check" prior to the appointment to ensure the patient is ready.

  • Be prepared to provide troubleshooting.

Whether the patient is tech savvy or not, make sure communication is clear:

  • Speak in short sentences on teleconferencing sessions.

  • Speak slowly and use a lower frequency.

  • Recognize that non-native English speakers may struggle with comprehension, and explore interpreter options.

Gupta noted that the first minute of the virtual therapy session is crucial in setting the tone.

"The patient wants to hear a professional, confident tone on the other end at the beginning of the session," he said. "Be warm and respectful throughout the visit, and make sure to explain to the patient how the session will be reconnected if the call is interrupted."

Clinicians should also make sure to identify the patient's physical location during the session in case of an emergency, such as the patient becoming suicidal.

Impending "Telehealth Cliff'

Many laws and licensing requirements for telehealth are still relatively loose, falling under the COVID-19 public health emergency (PHE) policies. These policies allow practitioners who are eligible to bill Medicare for telehealth services regardless of where the patient or provider is located, and providers can also deliver telehealth services across state lines, depending on state and federal rules.

However, Gupta warns that practitioners should be prepared for the potential "telehealth cliff" that is anticipated when those PHE policies are lifted, as barriers in licensing, billing, and other factors, such as HIPAA, are reinstated.

"HIPAA is [flexible] now as long as the public emergency policies exist," Gupta said. "However, in noncrisis times, technology will be required to be HIPAA compliant. If you are a solo provider, for instance, you really need to choose a telepsychiatry platform that is HIPAA compliant before that happens."

While the timing of the "telehealth cliff" is still uncertain, providers have been promised a 60-day advance notice of the PHE end, and at that time, there will be an additional 151-day grace period before the waivers lift.

A key federal measure that could protect more favorable telemedicine policies across state lines, the Temporary Reciprocity to Ensure Access to Treatment Act, currently remains stalled in Congress.

Regardless of those developments, Gupta underscored that "telepsychiatry is here to stay because the patients and their families like it, and they will be the driving factors."

He noted that "the future is likely going to be a hybrid model of in-person and virtual visits," to accommodate the various scenarios in which in-person visits may be preferred or necessary, but many will still likely choose the convenience and greater flexibility of virtual sessions.

Gupta serves or has served as a speaker or member of a speaker's bureau for AbbVie, Acadia, Alkermes, Intra-Cellular Therapies, Janssen, Neurocrine, and Otsuka, and serves as a consultant/on an advisory board for Intra-Cellular Therapies.

The Psychopharmacology Update was sponsored by Medscape Live. Medscape Live and this news organization are owned by the same parent company.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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