Remote psychiatric consultations – top tips for clinical practitioners

The COVID-19 pandemic presents psychiatrists with new challenges in delivering safe and effective care, with reduced face-to-face contact with patients. To try to address this the Royal College of Psychiatrists has encouraged clinicians to review patients remotely to reinforce the protection of patients and staff. This article aims to provide a structured approach for clinicians to conduct remote psychiatric assessments and considers future developments in telepsychiatry globally.

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Social distancing, quarantine and isolation during the COVID-19 outbreak are presenting unique challenges to how we deliver patient care effectively and safely. There is limited research on using technology to remotely assess patients within the pandemic setting. There is some emerging literature on the practicalities of remote assessment within general practice specifically and medical practice widely.1–4,17     

Psychiatric interviews conducted via video conferencing technology have been shown to be as reliable for diagnostic assessment and treatment recommendations5 as face-to-face assessments. While telepsychiatry has been used for decades in certain settings, eg emergency medicine, forensic psychiatry and rural settings, practical guidelines for its use in wider psychiatric practice are limited.5,6 Literature on telepsychiatry from countries like Australia and India are available, however, a robust systematic review is still warranted to determine the value as part of clinical practice in psychiatry following the COVID-19 outbreak. This is now a priority in the UK.14     

This article provides tips for the use of telephone and video consultations in routine clinical practice. The tips have been compiled from reviewing a range of guidance and literature coupled with collective knowledge and expertise of the author group.

Tip 1: Regulation

Before embarking on teleconsultations of any kind, clinicians should familiarise themselves with regulations/guidance relevant to their region of practice. Examples include UK, Australia, New Zealand and India.3,5,7  Remote consultations may not be appropriate if there is no access to medical records; if capacitous consent or an alternative legal mechanism for authorising remote consultation is not available, or where maintaining confidentiality during the consultation is not possible.     

Clinicians must ensure that they have adequate and appropriate indemnity in place to cover remote consultations – for example UK-based indemnity cover does not usually cover remote consultations with patients located outside the UK. For clinicians, it is vital that they also pay heed to their organisational policy on remote consultations, especially working within information governance and GDPR regulations. Professionally, it is important to ensure that the standard of care delivered via remote consultation is equivalent to in-person care.

Tip 2: Appropriateness of remote consultation

Preventing the risk of the spread of infection in response to the COVID-19 pandemic has proved to be a significant driver to accelerate the use of remote consultations. While there is no absolute contraindication to remote consultations, some simple rules are probably universally relevant.     

Remote consultations may not suffice for patients with cognitive or perceptual impairment. Other scenarios include high-risk patients presenting with acute medical or mental illness, patients unable or unwilling to use remote technology and for those situations where a clinician judges that the clinical situation requires a physical examination and assessment. A detailed review of medical records prior to the review is therefore quite critical.     

An important consideration should be the location and availability of emergency medical facilities if needed. Cultural factors need to be taken into account when interacting with patients and carers remotely. Session management details need to be discussed at the outset so that there is an explicit understanding between clinicians and patients about what content is appropriate to share remotely or digitally and the circumstances in which the session might be terminated.

Tip 3: Use appropriate technology

The choice of video conferencing platform depends on a range of factors, including cost, ease of use and the robustness of confidentiality and security parameters. During the COVID-19 outbreak, platforms such as Skype for Business, Attend Anywhere, etc, have been widely used by clinicians. A detailed review of these applications is beyond the scope of this article but readers should follow the recommendations of their organisation, or, if that is not available, use widely available technical reviews to select the platform best suited to their needs.     

Before connecting with patients, clinicians should familiarise themselves with the technology ensuring that they have adequate internet connectivity, working camera/microphone and correct details for the consultation (meeting dial-in details/patient’s telephone number). If a mobile phone/handheld device is being used, consider positioning it on a solid space to maintain a hands-free professional appearance.     

Back-up plans for contact, for example a telephone, if the technology fails must be agreed in advance. Contact details for IT (information technology) support and for the clinical supervisor (if relevant) should be at hand if needed.


(Click table to access full size image, or the PDF version of their article)
Table 1. Comparison of face-to-face versus remote assessments

Tip 4: Ensure appropriate physical environment

Both the clinician’s and the patient’s physical environment should be considered as a clinical examination room and should be comfortable, well-lit and private. On a video conference, the camera should be at the same elevation as the eyes to ensure that the face is clearly visible. Clinicians must ensure that the background is blurred (if technology allows) or any confidential/personal objects are not visible to the camera. Similarly, if using speakers, it must be ensured that no sounds can be overheard. Alternately, a set of headphones should be used. When doing remote assessments on wards/nursing homes a side room should be requested.

Tip 5: Set expectations on initial contact

The clinician should introduce themselves with their full professional designation and confirm the patient’s identity, their location and affirm confidentiality. Check if anyone else is listening in at the patient’s end and if so, whether the patient consents to this. As in face-to-face consultations, the other person may be requested to leave the room or the call temporarily, to confirm this. If the consultation does involve a carer/representative or a ‘facilitator’ who is helping with the session, eg in medical wards/care home or in school-based assessments, it is important to ascertain their identity and consider confidentiality issues particularly if the facilitator is a friend/family member. An interpreter, if needed may require appropriate adjustment to the setting and valid consent.8     

Appropriate consent must also be obtained to record the session, with an explicit statement of the reason for recording, for example medical record, quality monitoring, training, etc.     

The reason for the remote consultation and parameters for the session, including the key purpose, likely duration and possible outcomes of the consultation, should be discussed at the outset. This should include an explicit clarification of the steps that might be taken if there is perceived to be a significant risk of self-harm or harm to others. Clinicians should have clear strategies in place to manage such risks, eg referring to the crisis team or involving the emergency services.     

At the start of session, it may be helpful to allow a patient or carer to talk almost uninterrupted as it may save time later. It can help to determine if the consultation can continue remotely or whether a face-to-face appointment is required.

Tip 6: Keep it real during the consultation

Look directly into the camera when talking to the patient. Watch out for non-verbal clues. Keep note-taking to a minimum with the notepad to the side out of the camera field. Be aware that anxiety may be exacerbated in virtual conversations and the clinician’s non-verbal cues may not have the usual mollifying impact. Using verbal prompts such as ‘Can you tell me what is on your mind’ rather than silent pauses may be more appropriate. Checking the patient’s experience of communicating remotely should also help alleviate some of this anxiety.     

There is a risk in moving to closed questioning sooner during remote consultations and awareness to vary the style with use of open questions is beneficial. Using established consultation skills with interruptions at natural pauses, clarification or summarising are essential.     

As in face-to-face consultations, inform the patient that if you think there might be a serious risk of harm to the patient or others, you may have to share information with other professionals and they will be fully informed of this. History taking in remote assessments may need to be supplemented with collateral history from carers/medical or nursing team. Consent should be obtained for this.     

Mental state examination solely on the telephone poses some challenges with the absence of visual cues. Box 1 offers some tips.     

Physical examination may not be possible in remote consultations, but clinicians should ask screening questions relevant to their patient and context, eg screening for COVID-19.2 It is also possible to note and use any physical observations like blood pressure readings and weight measurements carried out by the patient themselves at home.

Tip 7: Collaborate to create a formulation

A person-centred approach is key to psychiatric practice.9 All consultations should aim at generating a shared narrative of the presenting problem and an account of the predisposing, precipitating and perpetuating factors.10 This is especially important in remote consultations where the full range of information that normally informs a formulation may be missing. Explaining uncertainties, offering options and having a shared discussion of the research evidence and patients’/carers’ views inform the clinical decision. The shared formulation also helps the safety plan to manage risks of self-harm, neglect, aggression, etc, where relevant.     

Safety netting through a jointly agreed crisis plan remains important in remote consultations. A range of options are usually available from support of family/friend to contacting GP or crisis line numbers such as 111 or the Samaritans’ helpline in the UK.     

It would be good practice where possible to discuss the formulation/tentative care plan with the multidisciplinary team, but this is particularly important where there are complex needs, multiple comorbidities and/or safety concerns. It should be possible to involve not just the usual team members but rather a multidisciplinary and multi-agency response. This could include nurses, occupational therapists, pharmacists, social workers, GPs, police officers, ambulance staff, etc, where relevant and can be done virtually using tele or video conferencing.

Tip 8: Prescribe safely

The shared care plan developed may include the prescription of medications. Clinicians must ensure that they have a clear rationale for the choice of medication and that they have access to all the ancillary information needed for safe prescription, including access to physical healthcare findings, blood and other test results where relevant and a list of the patient’s current medications (ideally also a history of response to/side-effects with other treatments).     

If checking the patient’s results online during the consultation, inform the patient that they are being kept on hold or arrange for a call back.     

As is the norm, all medication prescriptions should involve a discussion of the expected effects, side-effects, mechanism of action, details of dosing regimen, duration before an effect is seen, monitoring, compliance, licensing, likely duration of treatment and possible options if the desired treatment response is not seen. Certain platforms allow the sharing of documents and this may be an opportunity to signpost patients to online resources offering more details about the medication in question or the resources may be posted if preferred.     

Prescribing based on remote assessment will always strain the comfort zone of a prescriber, as it should, and it is vital that clinicians adhere to their zone of competence, to their local or national guidance and seek advice when required.4 If further assessments are needed for safe prescription, explain this to patients and make the necessary arrangements for it to happen either remotely or face-to-face, as the case may be. Any decision to prescribe should include clear instructions on where to collect a prescription or medication, for example a community pharmacy.     

The remote consultation should end with the summarising of key points and checking whether any further clarification is needed. The end of a consultation should be clearly signalled with ‘I am going to log off now’ or similar.

Tip 9: Document diligently

Remote consultations should be documented in detail like any other consultation, but special attention must be paid to documenting the reasons for the remote assessment, a brief statement about the possible reasons why face-to-face assessments might have been preferable and why that option was rejected. The detailed assessment with a summary of the diagnosis, formulation, key risk factors – both current and historic – management plan, including both medical as well as non-medical treatment strategies, highlighting any changes to the current medication, should be recorded in the notes (electronic or otherwise). A copy of this should be sent to the patient and to their general practitioner, or a letter written to the patient as
recommended by the Academy of Medical Royal Colleges.11

Tip 10: Be aware of special settings

Old age

Hearing/visual impairment and cognitive impairment can pose special challenges for remote consultations in this population. Adequate adjustments need to be made, including using the assistance of carers to help with technology or to use assisted technology aids to compensate for hearing/visual impairment. Physical health information and knowledge of medications prescribed is all the more important given the risk of physical comorbidities and impact on pharmacokinetics.     

It is important to ensure that virtual cognitive assessments are carried out using tools validated for remote assessments: Modified Telephone Interview for Cognitive Status (TICS-m),12 Telephone-Montreal Cognitive Assessment (t-MoCA) and Cognitive Telephone Screening Instrument13 (COGTEL) have reasonable validity in community-based studies.

Children and adolescents

Assessment for competent young persons should follow the same principles as for adults. Younger children’s face-to-face assessments typically involve parents, family members or adult carers and remote assessments should do the same with the availability at the patient’s end of age-appropriate toys and activities to facilitate the interview.

Care settings

These include residential, nursing and acute care settings. Attempts should be made to formalise the sessions through the use of a dedicated room, equipment and structured involvement of staff members to promote better coordination of care, if tele-assessments are being carried out on a regular basis.

Forensic and legal settings

Given the higher risks and stakes involved, the protocol for such assessments should have institutional approval and should also have built-in safeguards to ensure adherence to those protocols.

Conclusion

With COVID-19 around we are facing new challenges. This is an opportunity to review how we practice medicine in general and psychiatry in particular. Providing care and support for illness and suffering in such times needs novel approaches.14 We must assess and review clinical risks and come to a reasonable diagnosis, and, if required, even prescribe treatments remotely using available technologies.     

Key principles of remote consultations are confidentiality, appropriate physical environment, appropriate technology, good documentation and a collaborative formulation and care plan involving all relevant stakeholders. As a follow up to a remote assessment, patients should be sent a copy of the assessment and management plan with details of any crisis support they can access. The use of telemedicine in mental health has been part of the strategic development of psychiatric care even prior to the pandemic.15 The potential of remote technology for providing care to people who live in geographically remote areas has been well demonstrated. The current global viral outbreak has forced and accelerated the use of this technology in more routine settings. Regular standardisation by reviewing the process, structure, user experiences and outcome, cost and clinical effectiveness of remote consultations should help tailor these consultations to particular populations.     

Another area needing research focus is that of service user experience and perspectives about remote consultations in psychiatry. Research in this area, albeit minimal, is largely positive in terms of patient outcomes and cost.16–18     

Our current experience has highlighted some circumstances in which remote consultation may be preferable to face-to-face; these include patients with social anxiety who may find it difficult to leave the house; patients with mobility issues, including those with chronic pain or chronic physical health problems, and patients who live in remote areas of the country. Incorporating the use of remote consultations beyond the pandemic in clinical practice alongside other technological advances of e-prescribing and electronic patient records will further advance patient care providing greater access to a wider geographical area in a timely fashion. Remote consultations may facilitate a multidisciplinary team review of the patient more easily than a face-to-face appointment; this could be in the context of mental health liaison, old age psychiatry, forensic settings, working-age population, care homes and child and adolescent service settings. With patient consent, video consultations might also offer insights into a patient’s level of functioning in their own home, which might not normally be gained from an outpatient appointment. Lastly it offers greater choice and flexibility to patients who, due to vocational, personal or educational commitments or stigma, might struggle to access mental health services.     

Embedding remote consultations in routine practice will need a cultural change in practice but will also necessitate changes in training curricula for mental health professionals. The practice of medicine has changed, adapted and evolved through centuries depending on what the situation of the period demanded. But the central theme of person-centred care remains sustained, despite the pursuit of constant innovations.     

The famous American writer Alvin Toffler has said: ‘Change is not merely necessary to life – it is life’. We, as clinicians, have to embrace changes that sustain our practice.

Conflict of interest

No conflicts of interest for all the authors.

Dr Ramkisson is Consultant Psychiatrist, Training Programme Director Core Psychiatry, Associate Director of Medical Education, NICE Fellow, at Pennine Care NHS Foundation Trust; Dr Dave is Associate Dean and Consultant Psychiatrist at the Royal Derby Hospital; Dr Abraham is Consultant Psychiatrist at Pennine Care NHS Foundation Trust; Dr Moir is CT1 Psychiatry Trainee at Royal Oldham Hospital; Dr Pillai is Consultant Old Age Psychiatrist and Training Programme Director, Old Age Psychiatry HEE (Yorkshire and Humber) at Bradford District Care Foundation Trust; Dr Matheiken is ST4 Old Age Psychiatry, East London NHS Foundation Trust, and Prof JS Bamrah is Consultant Psychiatrist at North Manchester General Hospital.

References

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