Telemedicine as a permanent change to psychiatric practice and the 'return of the home visit' with Dr. Peter Yellowlees

Psychcast host Lorenzo Norris, MD, talks with Peter Yellowlees, MBBS, MD, about the changes to clinical practice forced by the COVID-19 pandemic and the likelihood that many of these changes are here to stay.

Dr. Yellowlees is a professor of psychiatry and chief wellness officer at the University of California, Davis. He has no disclosures. Dr. Norris is director of consult liaison psychiatry at George Washington University, Washington. He has no disclosures.

Take-home points

• Prior to the COVID-19 pandemic, 1%-2% of psychiatric consultations occurred on telepsychiatry modalities. During the pandemic, however, telepsychiatry has become the norm for psychiatric patient encounters.
• With the pandemic, the federal government relaxed many regulations that limited the use of telehealth.
• For many, telepsychiatry is now a preferred modality, because it confers high patient satisfaction, and many view it as more egalitarian, convenient, and less intimidating. Some even consider it more private, because the patient does not have to come to the office, and they can remain in a safe personal space.
• Telepsychiatry can be used within a hybrid model, where a patient can see the psychiatrist in person, using video, and the modality changes based on the needs of the patient and the clinician.
• Telehealth has expanded access to care to many populations, so the American Psychiatric Association and other professional associations are lobbying the federal government to keep certain telehealth regulations relaxed beyond the pandemic.

Summary

• Dr. Yellowlees sees telepsychiatry as the return of the home visit because the tool allows the clinician to see how the patient lives. He believes telepsychiatry fosters even more intimacy in the clinical relationship because of the extra distances created through the virtual space. In hybrid relationships, there are the physical and virtual spaces. The physical space provides immediacy, often more trust, and clear boundaries. But the virtual space is convenient and provides a sense of physical and emotional space between the clinician and patient – which can make it easier to share intense emotions.
• The textbook that Dr. Yellowlees wrote with Jay H. Shore, MD, MPH, "Telepsychiatry and Health Technologies: A guide for mental health professionals," includes a chapter on clinical skills for seeing patients over video. Dr. Yellowlees points out that trainees need instruction about the work flow and clinical process, but most are savvy about how they should present themselves on screen.
  • Dos and don'ts: The clinical space for teleconferencing for both the clinician and the patient must be private and secure. Ensure that everyone in either room is introduced. The webcam should be placed on top of the computer screen so that eye contact is maintained.
  • The clinician's head should take up two-thirds of the screen. Use picture in picture setting, so you can monitor your body language during the session.

• The APA and other professional associations are lobbying the federal government to keep certain telehealth regulations relaxed beyond the pandemic. The changes would include removing the geographic restrictions on licensing, maintaining parity of reimbursement between telehealth and in-person visits, removing frequency limitations on telehealth services in nursing homes and inpatient settings, finalizing regulatory changes to the Ryan Haight Act, and allowing prescribers to continue to prescribe controlled substances without an initial in-person visit.

References

Yellowlees P, Shore JH. Telepsychiatry and Health Technologies: A guide for mental health professionals (Washington: American Psychiatric Association Publishing, 2018).

Yellowlees P. Physician Well-Being: Cases and Solutions (Washington: American Psychiatric Association Publishing, 2020).

Support for Permanent Expansion of Telehealth Regulations After COVID-19. American Psychiatric Association. 2020.

Telepsychiatry Toolkit. American Psychiatric Association

American Telemedicine Association

Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest.

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