With Appropriate Vigilance, Telepsychiatry Offers Ecological Validity

Amber Hoberg, NP, Centric Physicians Group, San Antonio, Texas, talks with Psych Congress Steering Committee Member Edward Kaftarian, MD, CEO of Orbit Health Telepsychiatry, Encino, California, about what clinicians can learn about their patients during telepsychiatry visits, while ensuring confidentiality and adequate privacy. In this discussion at Psych Congress 2021 in San Antonio, Texas, Hoberg and Dr Kaftarian also delve into the “ecological validity” of seeing a patient in their natural environment through telehealth visits.

In the upcoming part 2, Dr they consider the legalities of treating patients remotely. They also exchange views about whether telepsychiatry is superior or inferior to in-person treatment and how it impacts both the patient’s and clinician’s life.

Read the transcript:

Dr Edward Kaftarian:  Hi, my name is Dr Edward Kaftarian, steering committee member and CEO of Orbit Health Telepsychiatry. I'm here with Amber Hoberg who is a psychiatric nurse practitioner who has a lot of experience with telepsychiatry. Let's talk a little bit about telehealth and telepsychiatry. What do you say?

Amber Hoberg:  Absolutely. I think that would be great.

Dr Kaftarian:  How have you found it to be now that you do so much on telehealth?

Hoberg:  When I first started, it was during the COVID time frame with doing a lot of telepsychiatry. I used to go in‑person quite a bit. I had to adapt a little bit when I went into COVID‑19 because, again, it was learning the technology, learning all the different things on how that works.

But now I really enjoy it. I really don't want to go back to seeing patients in‑person because I really like the realness of seeing patients in telepsychiatry.

Dr Kaftarian:  I agree with you. Once you get a taste of telepsychiatry, it's hard to go back to fighting traffic and all that. Is there a place for telepsychiatry long‑term? Or do you think this is a temporary thing, and we're all going to go back to on‑site?

Hoberg:  No, I absolutely think long‑term this should be something that we should do. One of these things is, what happens all the time when we go back to in‑office? Patients don't show up. They don't come in. They don't feel comfortable to come in, or they're not feeling well.

It's really nice that we're able to go to them and be able to see them in their home. We can see them in their environment. I love that because, like I said, it's the realness of them. I get to see where they live. I get to comment on, "Oh, you're in your bedroom. Look at the colors and pretty things you have!"

Really get to see what does their [activities of daily living] ADLs look like. What is their hygiene looking like? Who lives with them? What does their housing look like? If it's really noisy and problematic, or is it something where I'm noticing people walking in the background? Being able to identify who those people are that are living with the patient. I really, really enjoy that aspect.

Dr Kaftarian:  It's like the ecological validity of it, the validity of seeing a patient in their natural environment. It's definitely very informative I've found.

But what about confidentiality? You got people walking around in front of the camera. Do you think that's going to affect how the patient is going to reveal themselves to you? Or do you think that it's not an issue?

Hoberg:  That's a great question. Depending on who's walking behind them, most of time, if I'm asking them a question, I'll see somebody walking behind them, I'll stop asking them questions. I'm like, "I see somebody walking behind you. Tell me who that is. Who is this that's living in‑house with it? Is it your girlfriend, boyfriend, mom, dad? Who is it?"

I give them a chance to introduce them, tell me who they are. Then I'll let them know I'm going to continue on with the interview. "Are you comfortable with that? Do you want them to join? What do you want them to do?" Some of them will let them join in, say, "Yeah, let them come in and join." Or some of them will say, "Hey, mom, can you leave the room so I can finish talking to my provider?"

I use that as a way just to stop where I am, talk to whoever it is that's there or talk to the patient about who's there, either to get them to join or, again, to let them know we're going to continue on with the session and that the patient would like their privacy.

Dr Kaftarian:  I agree. I think it's probably important in the beginning of the session to say, "Look, ideally, this is a confidential appointment. If you want other people to be a part of it, then that's fine with me, as long as it's fine with you."

But we would also have to be careful for people who may have an intellectual disability or some sort of disorder, maybe a psychotic disorder, where they might not fully be able take agency over that process. So, you might want to give them more of an opportunity to be in a confidential space in that sense.

Hoberg:  Absolutely, I agree. Sometimes, if I have patients that have intellectual disability ‑ I take care of quite a few of them ‑ or have patients that have really severe schizophrenia, I try to give them their space or give them that area where they can provide the information to me.

But sometimes if they're so disorganized or having such problems, often I'll ask them is there somebody in the home or somebody that could participate that they would allow. Some patients don't. But a lot of my patients will allow it to help me get the full picture of what's going on with my patients.

Dr Kaftarian:  Exactly.

Edward Kaftarian, MD is a nationally recognized psychiatrist and leader in the field of telepsychiatry and healthcare technology. Trained at the Johns Hopkins Hospital, he is board-certified in Psychiatry, Forensic Psychiatry and Addiction Medicine. Dr Kaftarian has served in a variety of executive roles within the California prison system, including chief psychiatrist, senior psychiatrist, medical director, and director of pharmacy. He is the founder of California’s Statewide Prison Telepsychiatry Program, which is the largest correctional telepsychiatry program in the world. Dr Kaftarian is currently the Chairman and CEO of Orbit Health Telepsychiatry, a company that provides telepsychiatry services to jails and prisons.

Amber Hoberg, FPMHNP-BC, is a Nurse Practitioner specialist in Boerne, Texas. She graduated in 2010, having over 12 years of diverse experience, especially as a nurse practitioner. She is affiliated with many hospitals including Nix Health Care System. Hoberg also cooperates with other doctors and physicians in medical groups including Centric Physicians Group Pllc.