TELEPSYCHIATRY Guidelines and Procedures for Clinical Activities Reviews and Opinions

1. INTRODUCTION

Canada is a vast country and this makes it a challenge to provide adequate access to psychiatric care. Telepsychiatry can be an effective vehicle to provide this service to rural and remote communities. Telepsychiatry can also offer support for mental health care professionals who live and work in these areas. In recent years, advances in technology have enabled electronic methodologies to play an important role in the delivery of psychiatric services to distant sites (Picot, 1998). While these developments are exciting and they present new opportunities, there is a need to proceed cautiously.


Telepsychiatry Guidelines & Procedures for Clinical Activities was developed to meet the needs of clinicians and administrative staff working with the University of Toronto Psychiatric Outreach Program. This edition represents a work in progress and will be updated in response to internal and external feedback as developments occur in clinical practice, legislation, legal precedents, technology and evaluation. These guidelines are neither exhaustive nor absolute, nor do they speak to policy. Our goal is that these guidelines will contribute to the development of Canadian-specific guidelines and policies. The Canadian Psychiatric Association and others are working on developing

guidelines, analogous to those produced by the American Psychiatric Association and the Royal Australian and New Zealand College of Psychiatrists (see Appendices II and III).

2. DEFINITION

Telemedicine is an enabling technology, originally conceived to enhance access to health care for people who are geographically isolated and underserved. The American Psychiatric Association defines telepsychiatry as "the use of electronic communication and information technologies to provide or support clinical psychiatric care at a distance.

This definition includes many communication modalities such as telephone, fax, e-mail, the Internet, still imaging, and live two-way audio-visual communication" (APA, 1998).

The Australian and New Zealand definition states that: "telepsychiatry is the use of communication technology to provide psychiatric services from a distance"
(RANZCP, 1999, p. 2).

3. APPLICATIONS

The possible applications of videoconferencing technology in clinical psychiatry are many and they are in a state of constant evolution as new technologies are introduced and they become more readily available. Applications of telepsychiatry include

* Assessment and diagnosis
* Treatment Consultation
* Case conferencing and management
* Education — continuing education and supervision
* Support
* Forensic and legal assessments
* Administration and transfer of data
* Research
* Psychological testing.

The American Psychiatric Association resource document on telepsychiatry discusses a limited number of applications, including clinical interviews, either between different health professionals involved in a particular case, or including the patient and others, such as another health care provider or family members; emergency evaluations; case management situations where videoconferencing can bring together dispersed team members; forensic and legal assessments, including involuntary committal; supervision of procedures such as electro-convulsive therapy, hypnosis or amytal interviews, and clinical supervision of remote trainees, or "physician extenders" such as nurses, physician’s assistants, etc. (APA, 1998).

The South Australian group suggests the main applications of telepsychiatry are

* Emergency and urgent consultations. This application benefits patients and clinicians in remote areas by decreasing the waiting period for a consultation. It includes pre-admission consultation.

* Inpatient liaison. When a patient from a rural area receives treatment at an urban hospital, telepsychiatry can be used as a tool to communicate with rural health care workers and family.

* Ongoing support of rural inpatient and outpatient services (Hawker & Kavanagh, 1998).

Currently the University of Toronto Psychiatric Outreach Program uses telepsychiatry for consultation, assessment, diagnosis, treatment support, support of local clinicians, case conferencing and education. We suggest consultation as the primary model for telepsychiatry, including consultee-centred and client-centred models as described by Caplan (1970) rather than the provision of direct patient care or treatment from a distance. Certainly we are aware of clinicians working in the treatment mode, but there are legal and practical implications that must be considered which are beyond the scope

of this document (see section 4 - Medical Legal Considerations). We expect that the ability to provide treatment from a distance will continue to evolve and become more common.

Martin (1994) defined consultation as a "process of intervention between two individuals (usually professionals) and/or agencies where one individual (the consultee) asks for help or input from the other (the consultant) regarding a current work problem." She described it as an indirect, time-limited method of service delivery that is joint, systematic and problem solving, cooperative, collegial, confidential and voluntary, in the sense that the consultee chooses whether or not to participate and whether to accept input from the consultant/expert.

By working in a consultative way, the consultant addresses issues of duty of care (see section 4, Medical Legal Considerations, parts b and c) and does not accept responsibility that would be impossible to carry out. This model supports the consultee who is working at a distance in an underserviced area. It does this by providing expert knowledge that would otherwise not be available, thereby multiplying the influence of the consultant beyond what would be provided through direct patient care. In this model, the agency or clinician requesting the consultation retains primary case responsibility with the patient/client/parent, and control over which suggestions to implement.

In children's mental health, the clinician who is providing direct care to the child is often not a physician. Nevertheless, the consultation is often based on the need for medication. The consultant’s role is to make recommendations. The local physician, clinician and family then decide if they wish to accept them. The consultant working with the family and/or child may have little contact with the local doctor, but with the family's consent, the consultant may communicate with the physician to respond to questions and provide information. This method of patient care also supports the clinician/case manager who sees the child/family frequently. It allows the consultant to provide information that may be useful in monitoring the efficacy of medical intervention to the prescribing physician.

We believe that a responsible clinician should always be present in a consultation. Ensuring that a responsible person is accessible contributes to a safe and supportive environment, especially as a patient may become emotional during a consultation. Involving the responsible clinician in the consultation has other benefits. It reinforces that the consultation is to the local primary caregiver, provides emotional support to the patient and family, and strengthens the therapeutic alliance by recognizing the local person’s expertise on available resources.

4. PROCEDURES

It is advisable to have sufficient clinical documentation available in advance and toreview it before going online. This contributes to a focused and efficient consultation. Technical support should also be available in case the videoconferencing equipment fails.

[a] Working with the Equipment

Videoconferencing is a real-time communication tool that connects participants in

multiple physical locations utilizing both their visual image and spoken word (CAMH, 2001). The existing technology places some limitations on the process of an interview, particularly in terms of non-verbal communication. Following are some suggestions to help compensate for these limitations when conducting an interview by videoconference

:

* In an optimal arrangement, the camera is set up so that the consultant clinician can initially view everyone in the room. Later, the consultant can focus on individual members of the family or care team as clinically indicated.

* In controlling the technical environment, the consultant should be able to adjust the pan, tilt and zoom of the near- and far-site cameras to allow for maximum flexibility of camera control, for viewing the patient and how the patient sees the consultant.

* Before beginning, the consultant should ensure his image is large enough so that his face can be seen clearly. He should sit a few feet away from the camera and zoom in on himself to determine if the size of his image is adequate. It is easier to engage with others when subtleties of facial expression can be seen.

* For the reasons above, the consultant should zoom in on the person/people being interviewed.

* In situations where the consultant is seated close to the videoconferencing equipment, he should look into the camera. Although it is natural to look at the image on the video screen, the consultant will appear to the other person/people as if staring at their feet. This is because the camera is usually located on top of the video monitor. Eye contact in many cultures is important to establishing rapport so eyes should be kept on the camera rather than on the video screen. If space permits, by sitting farther away from the equipment, the consultant can look directly at the image on screen.

* The microphones pick up extra noise easily. The consultant should avoid shuffling apers and other activities that can obscure the conversation. He should also enunciate clearly to help ensure that everything is understood fully. It is important to remember that when the videoconference unit is connecting with the remote site, the picture may not be visible, but the audio channel may have already engaged. Therefore, the microphone should be kept on mute until the start of the consultation.

* The consultant should wait for the other person to finish speaking before speaking, otherwise the sound may cancel out. Hand signals, such as raising one hand, should be used when there is a need to interrupt.

* The image the patient sees is very important in how he or she reacts to the entire experience. If the consultant is wearing a striped, checkered or white shirt or jacket, it may transmit a vibrating or distorted image. A solid colour works best.

* Both the consultant and the client room should be properly lit for clear video

transmission. The room should be enclosed and soundproofed to ensure quiet and confidentiality, and it should be comfortably furnished.

[b] Materials

Materials required during the interview should be readily available, including the

Compendium of Pharmaceuticals and Specialities (CPS), the Diagnostic and Statistical Manual of Mental Disorders 5th edition, text revision (DSM-IV-TR) or other reference material for the consultant; tissues, paper and pencil for the Folstein Mini-Mental Status Exam for adult patients; or toys and drawing material for children. Loud toys should be avoided as they may interfere with sound transmission.

[c] Recommendations and Reporting

Diagnosis and treatment options should be discussed prior to the conclusion of the session. This helps to ensure the recommendations are feasible and culturally sensitive. The family physician may attend or can be contacted by telephone after the session ends. Finally, a report should be sent to all referring and associated clinicians, such as the family physician, provided that appropriate consents have been obtained.

In many jurisdictions, telepsychiatry has been used for direct patient care, including treatment of individual patients, management of a ward from a distant site, prescription of medication and psychotherapy consultation. While these are potentially valuable services, the legal and practical implications are complex and beyond the scope of this document.



5. MEDICAL- LEGAL CONSIDERATIONS

According to the Canadian Medical Protective Association there are no legal precedents regarding telepsychiatry. Future actions will be resolved according to provisions of a

reasonable standard of care, accompanied by good documentation regarding what was said (Broder, 2001a).

The most important principle is always act in the best interests of the patient. There is consensus among many authorities 1 that the issues to be considered include informed consent, clinical/case responsibility, duty of care, delegation of responsibility to a non-medical person, confidentiality, medical records, licensure and liability/malpractice.

[a] Informed Consent

According to the Oxford Dictionary, a consent is a voluntary agreement, compliance; permission (Fowler & Fowler, 1951). Consents have three components: disclosure/the consenting individual being properly informed, capacity, voluntariness.

Patients have the right to full information about any procedure in which they will be involved, including the potential risks, consequences and benefits (Brown & Evans, 1996; Evans, 1997). Consent can be implicit, e.g., attending a consultation, or explicit, e.g., signing a form. However consent is a process of providing information to the patient/family/client and includes more than a signature on a form.

Informed consent should be obtained, preferably in writing, from the patient, next of kin or guardian prior to the consultation. A written description of the activity should be prepared and given to those involved before the consents are signed. As many people may be functionally illiterate, the content of the consent should be discussed fully and a note should be placed on the chart that this occurred.

The patient and family should also be advised that information obtained will be used solely for the consultation or for evaluation of the program where the identity of the individual or family is kept hidden.

The consent must be voluntary and given freely, without pressure. It must be made clear to the patient/family that additional services will not be withheld if there is no agreement on the consultation.

The description of the consultation for which consent is being sought should include the following information:

* Potential risks, consequences, benefits and alternatives.
* A statement advising there is no penalty for disagreeing.
* Who has case responsibility and his or her obligations.
* Who has access to information.
* A description of procedures that will be followed.
* Who has ownership/access to the consultant’s report.
* Who will take responsibility for transmission of information to the family
* How information will be transmitted.
* A statement that the consultation has been discussed and the patient/family/guardian have been fully informed and are in agreement.

The capacity to consent or refuse treatment or consultation is now seen as the ability to understand the information that is relevant to making a decision about the proposed intervention, and to appreciate the reasonably foreseeable consequences of a decision or lack of decision (Brown & Evans, 1996).

The important determinant is not only the person’s age, but the ability to comprehend and appreciate consequences. When a child or youth is the subject of the consultation, the prudent consultant will wish to involve parents or guardians and have their consent.

At the start of a consultation, the consultant should introduce the task, explain his or her expertise, and outline the process and limits of service. It is also the consultant’s responsibility to clarify that the contract ends when the report is sent, and that he or she is not assuming duty of care or shared responsibility.

[b] Duty of Care

The term implies a doctor-patient relationship that occurs if the consultant has

* Met the patient and knows the patient’s name.
* Examined the patient’s chart.
* Examined the patient.
* Accepted a fee for service.

The law in Canada is unclear on the issue of duty of care, but concedes that a

doctor/patient relationship may exist if an appointment is arranged, but the patient has never been seen. In telepsychiatry this is even more complex as the "patient" may develop expectations prior to the consultation. The consent process and a preliminary discussion with the patient/family regarding expectations are helpful. "Interactive video link creates a "shared care" situation such that it is important that all parties have a clear, explicit understanding of their various responsibilities and obligations" (Broder, 2001a).

"Legal obligations flow from this duty of care, not the least of which is the obligations of the expert consultant to provide clear direction concerning the conclusion of the consultation — and provide this in writing to the attending physician or other primary care givers" (Broder, 2001a; CPSO, 1999; Ministry of Health, 1991).

The consulting and referring clinicians should identify who is responsible for

communicating the results of the consultation to the patient or the patient’s family if the family is not present. Similarly, the patient, or the patient’s family, needs to understand who is responsible for care. If the family doctor is not in attendance, it should be decided who is to inform him or her about any recommendations. These responsibilities should be documented.

[c] Clinical Case Responsibility

In consultation, the clinical case responsibility remains primarily with the agency or physician requesting the consultation. The psychiatrist providing the consultation does not accept ongoing responsibility for primary care, nor will he or she prescribe medication or do treatment.

Notwithstanding, duty of care or shared care is implied if the circumstances might lead responsible people to think that was the case (Broder, 2001a; Broder, 2001b). Hence, it is important both at the beginning and at the end of the consultation for the consultant to make clear the extent of his or her involvement and to explicitly state that he or she will not continue to have responsibility and that the duty of care or shared care will be terminated at the end of the consultation.

[d] Delegation* of Responsibility to Non-Medical Personnel

The consultant must be clear that recommendations made are within the competencies of the consultee. There needs to be considerable discussion about any recommendations and whether they are feasible (Broder, 2001a). As the consultant is not assuming clinical case responsibility, it must be made clear that he or she is only making suggestions and it is up to the case manager and family to make decisions. There is no formal delegation of responsibility, as responsibility was never assumed and always resided with the case manager and family physician.

*Delegation is a formal, legal word that implies supervision, control and responsibility. In providing consultation the consultant is not acting in that capacity and not assuming that responsibility.

[e] Medical Records

The agency or family doctor requesting the consultation is responsible for maintaining the medical record and should write a progress note. It should state the name of the clinician providing the consultation, identify those in attendance, duration, list recommendations, and any technical difficulties. The signed consent should also be kept on file.

Although the consultant should keep his or her records under safe conditions, these notes do not constitute a file in the formal sense. The consultation note sent to the agency becomes part of the formal medical file and is subject to the usual regulations. It should list the questions asked, process of consultation, identify who was seen and the duration, observations, conclusions, advice and suggestions offered, the diagnosis (if one was made), and any technical problems.

It is suggested that video or auditory tapes should not be made of routine consultations. Any tape becomes part of the medical record and is then subject to medical record-keeping regulations (Broder, 2001a; RANZCP, 1999; Shields, 2001). A consultant who wishes to record a tape for educational or research purposes should consult the policies governing both the local and remote telepsychiatry sites. Many agencies suggest using a separate consent form in this situation. The form should specify usage, how long the tape

will be kept, and its audience.

[f] Patient Registration

Questions have arisen regarding the specific location of patient/client registration. The consensus is that registration should occur at the distant site where the medical-legal responsibility resides (Broder, 2001a; Broder, 2001b). Particular institutions that are housing the telepsychiatry equipment may have their own internal policies that demand that a file be opened (registered) on every videoconferencing consultation. The consultant, so to speak, is acting as a private practitioner when conducting a consultation, and regulations demanding dual registration do not exist. The consultant must also keep his own records.

[g] Confidentiality

Regulation 965 of the Public Hospitals Act mandates the well-established principle that patients’ records are confidential. "The goal is to protect the privacy of patients, the confidentiality and security of their health information and the trust and integrity of the therapeutic relationship" (CMA, 1998). Before any information is released, proper release of information forms must be obtained.

Each agency must have in place a mandatory, written consent procedure, including permission to disseminate information from the file for research or evaluation purposes.

The Canadian Medical Protective Association has advised us that ISDN lines for

videoconferencing, and fax or mail for the transmission of information are appropriate vehicles for the disclosure of information (Broder, 2001a; Broder, 2001b). Currently the public Internet does not provide complete confidentiality and should not be used other than for strictly impersonal, technical matters. However, the technical capabilities of the Internet are rapidly changing. An Internet protocol-based system of private and secure networks of connectivity is already in use and will soon be commonplace, providing adequate security and ensuring patient confidentiality through encryption, password protection and accounting.

[h] Licensure

The consultant physician, with rare exception, must be licensed to practise in the

province of the residing patient. Each province in Canada has restrictions on medical licences. The Internet is a special consideration and laws governing the Internet are in an early stage of development.

[i] Liability/Malpractice

Malpractice is a common usage term and connotes a breach of duty owed by someone rendering professional services to a person who has contracted for such services and denotes negligence. Negligence occurs when a physician owes a professional duty to a person, fails in that duty, and harm results which is caused by that failure. The party alleging negligence must establish that

* There existed a physician/patient relationship with the person, giving rise to a duty of care.
* The physician failed to meet that duty by not providing care in accordance with generally accepted standards of care of that profession.
* The physician caused injury or harm to the patient.
* There was a casual connection between the breach of care and patient injury.

The agency and physician consultant should carry adequate liability insurance and membership in the Canadian Medical Protective Association. Insurance coverage should specifically include telemedicine practice.



6. EVIDENCE OF EFFICACY AND COST EFFECTIVENESS

Baer, Elford and Cukor (1997) reviewed evidence of the efficacy of telepsychiatry. They identified five controlled clinical evaluations of the efficacy of telepsychiatry assessments and interventions dating back to 1961, as well as several controlled evaluations of the use of videoconferencing for the administration of standardized psychometric assessments. They concluded that evidence was not strong enough to support the widespread application of telepsychiatry and they recommended its limitation to research settings and to underserviced areas where telepsychiatry exists as the only option. They further suggested more studies of the cost effectiveness of telepsychiatry and of the settings, conditions and age-groups where it would be most useful.

Wootton’s search of the literature produced 969 articles about cost effectiveness of telemedicine. He concluded that little information is available about cost effectiveness. However, he suggested that "where the benefits to patients outweigh the increased costs to the providers, telemedicine is worth considering" (Wootton, 2001).

Roine, Ohinmaa and Hailey (2001) examined and analyzed the evidence for the

effectiveness and economic efficiency of telemedicine by reviewing studies that had been published up to January 2000. They concluded that "further assessment studies in the field of telemedicine are still clearly needed."

Doze, Simpson, Hailey and Jacobs (1999) reported that the use of televideo to provide consultation between the Alberta Hospital at Ponoka and five regional general hospitals would be as cost effective as sending a travelling psychiatrist to each hospital, provided that eight consultations a week were requested.

Trott and Blignault (1998) reported that a telepsychiatry service in rural Australia saved over $100,000 per year in health care costs when there was an established rate of over 40 consultations per month. This was mainly due to a reduction in employee travel costs. In addition, the service potentially saved almost $100,000 per year in reduced patient transfer costs. They acknowledged that equipment maintenance and (future) upgrade costs were not considered.

On the other hand, Werner and Anderson (1998) argued that the provision of rural telepsychiatry by private health care interests is not economically feasible. They based this on factors such as high startup and maintenance costs, the modest volume of consultations likely to occur, and the need for a psychiatrist to be physically present for some duties at certain sites. Thus, they supported the use of telepsychiatry only when no other option exists, or when it is part of specially funded research. They did not compare telepsychiatry to the cost of flying patients out for assessment. They also did not acknowledge that there may be a socio-economic payoff in terms of increased productivity and reduced social morbidity within the otherwise underserviced populations.

The complexity of health care funding means that costs incurred by one player in the health care sector (e.g., a hospital creating a videoconferencing studio for telepsychiatry) may yield savings by another player (e.g., the government program funding patient or clinician travel costs). This means that various parties in the health care system should work together to ensure that rational funding decisions are made. In Canada, the bulk of health care funding flows through the provincial ministries of health, which will therefore need to provide an overseeing and coordinating role for the implementation of televideo services. There is also a need for interministerial cooperation; e.g., in Ontario, between the Ministry of Health and Long-Term Care, and the Ministry of Social and Community

Services, which funds most child psychiatry.

Most studies of telepsychiatry have been consumer satisfaction studies using

questionnaires or focus groups (Dongier et al., 1986; Dossetor et al., 1999). Uniformly, they show high satisfaction by both clinician and consumer. Although face-to-face assessments are preferred, all agree telepsychiatry is an excellent alternative to traveling long distances, or not receiving the service at all.

The Telepsychiatry Program of the Division of Child Psychiatry at the University of Toronto commissioned the Community Health Systems Resource Group of the Hospital for Sick Children to prepare an evaluation design for the Program. As part of the exercise, the literature was reviewed. Boydell, Volpe and Brown (2001) found that most studies were descriptive, documenting pilot projects instead of ongoing programs, and they often used consumer satisfaction checklists. It was concluded that telepsychiatry evaluation research is in its infancy and there is a lack of data on its effectiveness.

The reviewers suggested an evaluation model that was qualitative, involving focus groups from the various stakeholders, and aimed at eliciting information about access to service, contextual sensitivity, utilization, technology, communication, process of delivery of service, time needed to do a competent job, triage system, committee meetings, education and satisfaction with the Program. The study reported that stakeholders were prepared to take part in focus groups but did not wish to complete questionnaires. Quantitative data continues to be collected by the Toronto program about the questions being asked of the consultant, and about sex and age distribution, recommendations, and where possible, DSM-IV diagnosis.



7. FUNDING

Currently, there is no provision for payment of psychiatric professional fees for telepsychiatry assessments through the Ontario Health Insurance Plan (Karlinsky, 2000). In Canada, only Ontario and Quebec are without mechanisms to cover telepsychiatry fees. Where telepsychiatry services have been established, usually with the help of grants or government funding, clinicians are generally paid through sessional fees. As well, some programs pay an hourly rate plus administrative time to read documents and prepare reports.

Given the additional time required for the clinician to participate in a telepsychiatric assessment (beyond the time required for a face-to-face consultation) and the possibility of technical problems causing delays, fees should either be flexible enough to accommodate this extra time and any unforeseen delays, or generous enough to take such factors into account. Fees should not be based on actual "online" time, but should include

an allowance for set-up time, time to review records and obtain informed consent, compensation for cancelled or missed sessions, and any other complicating or delaying factors.

A similar funding scheme should be available for family physicians who wish to attend their patients’ psychiatric consultations. In Ontario and other provinces, family physicians cannot charge the government health plan a fee for telepsychiatry. This means they must participate on their own time.

Funding proposals and plans must address a number of critical costs:

* Hardware and software costs, including the purchase, maintenance and upgrade of equipment at both the rural and urban sites.
* Telecommunications costs, e.g., ISDN installation, usage charges and/or monthly fees, bridging costs for educational sessions if more than one site is involved, etc.
* External consulting fees to research and recommend technological options for system purchases or upgrades.
* In-house administrative coordinator and technical staff support at both the rural and urban sites.
* Professional fees for psychiatric consultants providing the assessment via

videoconference.

* Professional fees or staffing costs for mental health workers, family physicians or others participating in telepsychiatry consultations.
* Ancillary and infrastructure costs, such as space rental charges, faxing and telephone costs related to preparing or communicating the results of a telepsychiatry consultation, secretarial costs, or any other costs incurred by the rural or remote sites

in supporting telepsychiatry services.

* Monies for staff of the consultation program to visit the distant sites.
* Supervision of trainees at distant sites. Issues of supervisor remuneration in this case need to be clarified.

In order to justify the expenditures incurred in implementing a psychiatric videoconferencing service, health care administrators must focus on both the immediate and long-term clinical and economic benefits expected, including

* The provision of psychiatric assessment and care where no other access is available.
* The provision of more timely care to patients who might otherwise experience a long wait for a visiting psychiatric consultant.
* Savings in travel costs for consultants, patients and families.

* Potential savings if telepsychiatry services help avert hospital admission, or if the availability of aftercare by means of videoconferencing facilitates early discharge.
* Decreased need to transport patients and/or their families to urban centres for mental health care.

There is also the possibility that the provision of telepsychiatry will increase overall health care costs, by extending care to patients who might not otherwise receive it. However, there may exist a socio-economic payoff in terms of increased productivity and reduced social morbidity within the otherwise underserviced populations.



8. OTHER APPLICATIONS

Technological advances have led to greater and varied interactions between clinicians and their patients. Some of these usages have been described but others are in early stages of development.

Forensic/legal telepsychiatric assessments are already occurring. However, because there is no precedent in law, a full understanding of the issues has yet to emerge. Clinicians skilled in such work are extremely scarce, so it is easy to imagine the appeal of using technology to facilitate access to forensic psychiatric consultations. At this point, we suggest caution before venturing into this field.

Computer-based formats exist for psychological testing and many clinicians use a variety of checklists to supplement their clinical work. It is anticipated that online psychological testing will experience rapid growth. The scarcity of clinicians makes this appealing as a way to facilitate access and enrich the type of service that can be offered.



9. INVOLVEMENT OF RESIDENTS

Because of the increasing importance of telepsychiatry, future psychiatrists will need to become skilled in providing these services. Psychiatry residency programs should provide opportunities for training in telepsychiatry.

This training should include two components: 1) Review of issues relevant to telepsychiatry (e.g., conducting interviews through videoconferencing; providing consultations to distant communities; cross-cultural issues; medical-legal issues; evidence of efficacy of telepsychiatry); and 2) Direct experience in telepsychiatry, under the supervision of a staff psychiatrist who is experienced in telepsychiatry. Through this training, residents should gain comfort and expertise in telepsychiatry and may be more likely to continue this work in their future careers.

Telepsychiatry can also involve resident training in distant, underserviced communities (APA, 1998; RANZCP, 1999). Residents who are on rotations or electives in distant sites can participate in seminars occurring at their home site through videoconferencing. Residents can also receive supervision through videoconferencing. By increasing and enhancing the opportunities for resident training in distant sites, telepsychiatry may encourage residents to continue serving these communities in their future careers.



9. CONCLUSION

Although telepsychiatry has been used for more than 40 years, most of the practice and methods of evaluation have been through pilot projects (Picot, 1998). Users have been uniformly enthusiastic. However, the ability to finance programs has been limited for many years. We hope that this will change quickly. In the past, set-up costs were astronomical. However, with increased access to adequate technologies, these costs have decreased. Provincial health plans in most provinces, although not Ontario and Quebec, now cover physician costs for telepsychiatry and many provinces are setting up provincial systems of remuneration for telepsychiatry.

The federal government has also been instrumental in financing the development of telepsychiatry systems through Canada Health Infostructure Partnerships Program [CHIPP] grants.

Because there is no precedent regarding medical-legal parameters, the best safeguard is sound clinical practice based on the behaviour of clinicians in face-to-face encounters. This is the standard that will most likely be considered in test cases (Crolla, 1998; Evans, 1997; Granade, 1997; Granade, 1995; OMA, 1985). Comprehensive documentation is also advised.

Telepsychiatry is an exciting new world. It helps make universal access to psychiatric services a reality — even to the farthest corners of our vast land.



Endnotes

1 See Allen, 2001; Bailey, Cerise and Creole, 2000; Brown and Evans, 1996; CPSO, 1999; Crolla, 1998; EHTEL, 2001; Evans, 1997; Granade, 1995, 1997; Karlinsky, 1999, 2001; Kates, N. et al., 1997; Ministry of Health, 1991, 1995; RANZCP, 1999; Shields, 2001.