Telehealth Secrets Conference 2018 by VSee Speaker: Anisha Patel-Dunn (Pacific Coast Psychiatric Associate) More info here: vsee.com/conference

1. Let’s Vsee!
How to implement Telemedicine
into your practice
Anisha Patel-Dunn, DO
Pacific Coast Psychiatric Associates

2.  Evolution of Telehealth at PCPA
 How to implement & utilize Telehealth
 Resolving patient trust, family involvement, emergencies
via a telehealth platform
 Methods to engage participation while improving patient
life and work outcomes
OBJECTIVE

3. ▪ PCPA started in 2006
▪ SF, Walnut Creek & LA
▪ About 100 providers, Psychiatrists and Therapists (General Adult,
C&A, Psychosomatic, Addiction & Geriatrics)
▪ Started as a psychiatric group - Collaborative Care
▪ We have staff of about 15, reception, office management, billing
and recruiting
▪ Population – C&A, Adults &Geriatric Population. Working class,
95% Insurance
▪ SF - Younger adults, a lot of patients in the IT industry
▪ Walnut Creek and LA - Higher number of C&A patients as well as older
adults
▪ Psychiatric Evaluations, Medication Management, Therapy -
Individual, Couples, Family and Groups
PACIFIC COAST PSYCHIATRIC
ASSOCIATES

4.  Developed organically - Travel, college, medical
illnesses, doctor moving, Doctor on Medical Leave
 Offered to all patients, about 10 psychiatrists and 5
therapists - Telehealth exclusively. Most other providers
some % of Telehealth. 35% of all visits are Video.
 Started a trial with UBH then approached other
insurance companies
 Completely electronic and paperless office - Transition
was easy
▪ Registration, Forms, Messaging, Billing
 “Security” of physical offices
PCPA’S TELEHEALTH PROGRAM

5. PCPA WEBSITE

6. PCPA WEBSITE

7. PCPA WEBSITE

8. PCPA WEBSITE

9. PCPA WEBSITE

10. PCPA WEBSITE

11. PCPA WEBSITE

12. PCPA WEBSITE

13. PCPA WEBSITE

14. PCPA WEBSITE

15. PCPA WEBSITE

16. VSEE VIRTUAL WAITING ROOM

17. VSEE VIRTUAL WAITING ROOM

18. VSEE VIRTUAL WAITING ROOM

19. VSEE VIRTUAL WAITING ROOM

20. VSEE VIRTUAL WAITING ROOM

21. VSEE VIRTUAL WAITING ROOM

22. VSEE VIRTUAL WAITING ROOM

23. VSEE VIRTUAL WAITING ROOM

24. PCPA WEBSITE

25. VSEE VIA ABAKA APP

26. VSEE VIA ABAKA APP

27. VSEE VIA ABAKA APP

28.  Overcoming both patient and provider concerns and
biases
 Safety concerns
 Electronic prescribing
 Data
▪ Patient Feedback, Continuity of Care, Provider satisfaction and
well being
 Access to psychiatrists in with varied specialties and
experience
 Recruiting
ORGANIZATIONAL “BUY-IN”

29. PATIENT
SURVEY

30. ANALYSIS

31. “It's great to be able to talk to my psychiatrist within the comfort of my own home”
“I like the experience. I wish all doctors could use it! It's not the easiest to set up but worth
it to figure it out!”
“It had all the benefits of being in person , with the added convenience of having the
appointment from home.”
“It was a convenient way to meet with my doc, especially since I live outside of San
Francisco. I was able to meet midday, during my lunch hour at work. Thank you! ”
“Very convenient and useful in terms of easing stress , which considering stress is a
problem for me I greatly appreciate!!”
“Transitioning to tele psychiatry has been a seamless experience . The technology works
great and was easy to set up. Being able to quickly hop on a video call with my doctor without
going to the office and having to take more time away from work is great and has made it
much easier to keep my appointments.”
”Easy to log in, and very clear audio & video make it an ideal way to communicate. The
session was just as effective as any in -person session I've had.”
PATIENT FEEDBACK

32. “It's so much easier and cost effective for me. I no longer need to cross the GG Bridge and
pay the $6 toll or pay for parking in downtown SF.”
“Because of my new schedule, I found it very hard to find an appointment time that
worked with Dr. Zaken's schedule, and so I'm really grateful that we were able to schedule an
appointment through Telepsych. I've done two telepsych appointments so far, and I find
they have been just as effective and convenient as in -person appointments."
“…The chat program used is reliable and I am able to have chats on both my laptop and
cell phone so it is nearly impossible to miss my appointments.”
“I love Tele-Psychiatry! As someone with anxiety issues, even trying to get to my
appointments on time can be anxiety producing . Now all I have to do is find a quiet place
with an internet connection and I'm set. No more rushing and worrying that I am going to be
late. It is a wonderful convenience that I so appreciate having access to. Thank you!”
“My schedule has recently become very inflexible and using this program allowed me to
prevent a delay in communicating with my Dr. It also minimized the overall time I had to
commit to my appointment due to the fact that I did not have to factor in additional travel
time.”
PATIENT FEEDBACK

33. “I like the convenience and privacy of seeing my doctor in the comfort of my own house. I feel
like we continue to have a good connection and great conversations over video conference
software. I'm not sure if this would be as good if we didn't already have a good
established rapport, but I am more than satisfied with the arrangement.”
“I think the initial appointments/evaluation are best done in person, but once you have a
rapport, follow-up appointments on VSee are great - it's much more convenient to not have to
travel to the office!”
“I am impressed with the quality of the audio and visual of the tele -psychiatry program. There
are aspects of in-person psychiatry that cannot be replaced/replicated , but the
convenience of the program is great. With my work schedule, the lack of flexibility in work
hours, and where i live relative to the PCPA tele -psychiatry has been really helpful for me to
continue to get the treatment that I've grown comfortable with and need. It may not be the
same as in-person treatment, but it's a reasonable enough facsimile to give me the
treatment I want in a format that fits my life.”
“I was a little confused about how it was going to work and it took a minute for things to go
smoothly - there was an echo on his side, and I had both my phone and computer ringing
- but it turned out great and it is MUCH more convenient.”
PATIENT FEEDBACK

34.  Setting Limits - Privacy and Safety
 Technical Limits
 Provider Isolation
 Patient Education - Video
WRINKLES TO IRON OUT

35.  Acute Mania or Suicidality with Difficulty Est. Rapport
 Severe Psychosis (Paranoia, Blunted/Sign Reduced Affect)
 Severe Eating Disorder (requiring weight & body
composition)
 Actively Cutting or Engaging in Self-Harm Behaviors
 Active Substance Use
 Too Many Tech Issues for Patient
 Patient Preference/Comfort
 Avoidance of Treatment
 Work Arounds: Collaborating with PCP/Therapist/Family
?APPROPRIATENESS

36. In my three years at PCPA, I have only had one patient that I "banned" from video
appointments. There were definitely safety concerns and benzo dependence so I only refilled
her Ativan at our weekly appointments. I never would have agreed to see her on Vsee in the
first place but one day she called stating she was unable to come to the office and reception
offered her Vsee w/o checking with me first. The patient then fell in a pattern of calling right
before or during every appointment, asking to switch to Vsee. Essentially she was avoiding
engaging in treatment but just wanted her benzo’s.
I had another psychotic patient that I put an alert on his chart to not offer Vsee, but otherwise
I have been able to manage all of my patients without broad telepsych restrictions.
For the few patients I have on disability for a mental health condition, I also require they come
in periodically - it's hard for me to clinically determine how severely impaired they are simply
over Vsee. However we usually do a mix of video and in person appointments, and I also
require that they are engaged in other forms of treatment - ideally IOP or at a minimum weekly
therapy. Knowing they are seeing other providers in person, and collaborating with these
providers allows me to have some leeway with doing video appointments for med management.
Other times have been if patient is complaining of a side effect ie tremor that I cannot properly
evaluate over Vsee. I request they come in the office, or have another medical provider
evaluate them in person (if the patient lives outside the Bay Area).
PROVIDER FEEDBACK

37. For me it has been more about the quality of the connection and how that might lead me to
miss something clinically important. For example I do think that paranoia and other psychotic
symptoms are extremely difficult to treat by video because they can present very subtly and
become hard to discern on video, also the relationship and trust becomes so much more
important with these patients and that is easier to establish face to face. I have a recent
patient who has schizoaffective disorder, depressive type and in and out of residential
treatment, I have been seeing her in a supportive context by video but from the beginning
session I did let her know that when she left residential treatment I would need to see her in
person weekly at a minimum in order to prescribe. She isn't able to make the trip to SF (from
San Jose) so I am helping her find a psychiatrist who can see her in person closer to where
she lives and more frequently.
Another example is if I am concerned about physical symptoms such as alcohol or benzo
withdrawal, or serotonin syndrome, I feel these would be much harder to pick up on a video
appointment.
All of that being said, I still think even for the most ill patients that video appointments can
play a supportive role even in the interim while they find a more appropriate level of care. I
guess being open with the patient about the limitations of Video appointments (saying that "I'm
not able to prescribe without having a clear and complete picture and/or seeing you in person")
is the most important as some of these patients that are too severe for video appointments
actually need to go to the ER or a PHP.
PROVIDER FEEDBACK

38. I personally don't feel comfortable treating anyone with a complicated Bipolar, psychotic
disorder or acute eating disorder via tele psych since I feel I may miss some important cues
and may not be able to provide appropriate care.
In my experience, treating eating disordered women is really tricky especially if they come in
wearing heavy clothing or try to manipulate the angle of the camera so that it is really difficult
for me to know what's really going on. Similarly if someone is actively cutting or engaging in
self harm behaviors including active substance abuse, I'm unable to pick that up via camera.
This is to give you a general idea of some situations where patients may need to be
transferred. At the end of the day, it really depends on the clinicians judgement and clinical
acumen. The criteria I try to set for myself is that I wouldn't want to transfer a case to a clinic
provider that I wouldn't want to see myself if I were the in -person provider and there has to be
some reasonable justification for the in person visit.
PROVIDER FEEDBACK

39. PATIENT EDUCATION
www.pcpasf.com

40.  Groups
 Testing
 Access to Other States
FUTURE PROJECTS

41. Anisha Patel-Dunn, DO
Pacific Coast Psychiatric Associates
www.pcpasf.com