OPOP conference, September 03 09, Ottawa

I, Hugues Richard, perceive no conflict of interest with this presentation but present companies with which I have worked and consulted for:

Lundbeck Canada Ontario Telemedicine Network (OTN)

1. Discover the benefits and limitations of working with OTN.

2. Find out which patients do best, and if there are any contraindications.

3. Discuss the future of telepsychiatry and ways it can be improved.

My practice: general psychiatry, adult, psychotherapy, trauma work, consultation liaison, community psychiatry

Private office: Stittsville.

Meet my two assistants…

After closing my 18 year practice at Centre Alliance in Sturgeon Falls, in 2003… off site at ROH.

Use of a studio at a local hospital, walking distance from my office then in Arnprior.

Since November 08, videoconference equipment installed in my office.

8 “visits” done since, for the 2 centers I serve up North (Kirkland Lake & Chapleau)

Direct clinical work including consultation, follow up, psychotherapy even meditation!

Indirect clinical service: case discussion, treatment plan, team meetings

Supervision/teaching

CME

Government’s third phase

Easy process from administrative to technical

One person assigned → very helpful!

++ Non intrusive “behind the scene action”

to lose control on appointments,

To lack efficacy or accountability,

To become impersonal,

To be left to my own self.

How is it going to work for new patients?

Will I survive working 5 days in a row?

How are the patients and staff going to react to this?

Smooth process: booking, liaison;

Professionalism and reliability;

Excellent technical support on line (bridge), and in vivo;

Consultations → no problem! Nurse or case worker always present!

Actually enjoying working from my office, feeling ‘at home’…

Integration of activities and technology from my own practice (EMR, fax, phone, instant messaging, cell, computer server, Skype)

Less tired at the end of day/week

Sound: raise it or decrease it, or mute yourself off when you need to speak to your assistant

Image: ZOOM in or out, see yourself in interaction

Distance→ different perspective

NORTH: 1 patient declined, preferring to wait to

see me in vivo

Negative perception from one agency clinical director who thought I was less available

Convenience Time saving Comfort Safety ( pandemic, road accidents…)

Environment (↡carbon footprint)

No disruption in family life

Available to my in vivo practice

Availability of service

Convenience: less driving, specially in winter, ↑ autonomy

Cost

In the North, videoconference used for teaching, health, already part of culture

SOME PATIENTS WILL SPECIFICALLY PREFER TELEPSYCHIATRY

1.Distance is perceived as protective

2. Control is maintained, can walk out easily

3. Neutral place

4. Those who enjoy technology or like novelty

65 to 75% of patients who could have benefited from telemedicine chose one-to-one visits.

Different with patients from the North: all but one have used OTN.

Patients’ satisfaction close to one on one visits.

More qualitative studies needed to support this.

Very accurate compare to in vivo

The non verbal communication lacks compare to the verbal

Most studies show that the “main obstacles to telepsychiatry have to do with physicians and patients adjusting…”

Delay to get a studio available; turn around between one and two weeks, at least 48 hrs

Registration at an agency makes it more public

Having other people involved makes it very hard for some patients to trust (bridge, hackers, OTN = government)

No hand shake! Non verbal communication somewhat

lacking (visual acuity and precision) Smell is absent: ethylic intoxication for

instance Patients who needs a very strong

presence, such as Veterans suffering from traumas, many will not engage with a “TV” or a “COMPUTER”

I had not anticipated this one! Old chart not easily accessible progress notes better be at both sites! KL: Citrix EMR unpractical

→impossible to write in the chart →very long process to enter and retrieve info

from the chart KL transcriptionists = long distance

Progress notes written on same lap top I use on site;

Consultations dictated to and transcribed by my assistant →notes sent rapidly to everyone involved

In her 50s Referred for consultation Long past history of sexual molestation as

a child “Interpersonal traumas” later on as an

adult. Symptoms of dissociation with possible

PTSD Resistant to treatment (psychotherapy

and many different ads)

Lives >160 k from my office, but a studio is available 4 k from her

Would you have offered her videoconference?

She chose….

Patients who refuse this modality (informed consent needed)

Violent / unstable / impulsive patients

Patients requiring special monitoring when not available

Patients with specific symptomatology that could be exacerbated by the use of communication technology (Z with hallucinations for instance)

Patients with whom news must be shared in person, because it could cause significant emotional reactions (HIV test results)

Patients who have hearing, visual, cognitive deficits that limit their ability to communicate via this technology

In her30s Recently separated Referred to me by FP and SW for

symptoms of depression and anger SW attends the session I have completed the assessment, at

least that’s what I thought… But apparently not her!

Starts throwing chairs around, Screams that she’s had it; nobody

listens to her, and she is to kill herself SW is hysterical Me too !!!

Have phone and fax very close by if not in the studio

Have certification forms at hand Have a coordinator of care on site Have triage done beforehand Patient = realistic expectations Good rapport with ER staff

A good story at last!

46 year old native, married; Works as bus driver at local Casino; Known to me since early 90s, in Sturgeon Falls; Bipolar II Disorder, mostly hypomanic, on

Lithium Panic Disorder without agoraphobia, Alcohol Dependence in remission. Obese Diabetes dx while on Olanzapine 12.5mg.

2003-2006, treated by FP and SW Comes back in 2006 in need of

psychiatric report re: driver’s licence Booster sessions 3 to 4 times a year,

travelling from Orillia to Stittsville Spring 08: father dies, depression

triggered Dec 08: sick leave, Paroxetine started

by FP

Telemedicine equipment recently installed in my office allows for weekly intensive sessions.

Also use of Skype (once) and numerous emails.

I talk with his SunLife case manager on phone

Trial of different drugs

Lots of support to his wife, psychoeducation to both of them

Grief work related to his dad and his inability to work and to function.

Work on regression, and nutrition.

Patient on his own decided to see a Native Healer, and took Rescue remedy (BACH flowers)

Good response to Seroquel XR 600 mg, Lithium 1200mg, Modafinil 100mg bid.

I also reluctantly raised his Clonazepam from .75mg AM + 1mg PM to 2.5mg AM + 2mg PM.

Presently back to work full time

No need for hospitalization

His wife is still with him

Excerpt from an email received July 16 09 “ In the Objibway language

“Meegwetch” means thanks from the heart...

I wish to live to the fullest and that is my choice

You have helped me through a hardship so I say

MEEGWETCH Dr Richard”

Telepsychiatry is very valuable in many different ways

It has shown that it is an accurate way to assess and treat patients;

It offers psychiatric services to people who have no direct access to such services

For some patients, it’s their preferred way of treatment

It is not for psychiatric emergencies It is not to replace one on one sessions It might be a cost saving treatment Obstacles are mostly from

professionals

To me, it is an exciting way to practice;

Without telemedicine, I would not have been able to serve the northern communities last winter.

Need to know more about who are the best candidates

Contraindications to be more precisely defined

Need to improve the image quality to get more of the non verbal communication.

Professionals need to learn more about the potential benefits from this medium.

A must: “Telehealth-clinical guideline and

technical standards for telepsychiatry”, Gilles Pineau, Khalil Mogadem, Carole

St-Hilaire, Eric Levac, Bruno Hamel et al. (AETMIS 06-01) Montreal AETMIS 2006 xxii-72p.