Table 1 Telepsychiatry competencies

Medical Expert

Technical skills

Operate equipment and software (cameras, recording, audio, etc.), optimizing use of their unique capabilities and trouble-shooting technical problems

There’s kind of like a beginner level comfort level of telepsychiatry where you just kinda sit and talk to the TV but that’s all you do. And then there is actually setting up presets for all the people on the distant end and moving the camera and all that sort of stuff so you’re actually really making use of it, it’s not just a static looking at TV screen. Like I would follow kids around the room with the camera and I would, if I were doing case conference like 8 people, I set up 8 presets so I can zoom back and forth between different people… it takes full advantage of what you can do with the technology rather than it just being like Skype. [Faculty – 203]

Medical Expert

Assessment

Adapt the assessment process to be carried out at a distance:

a. use distal partners to understand patient baseline and to conduct physical exams and lab work

b. administer assessment tools such as the mini mental status exam

c. conduct a comprehensive mental status exam via televideo (e.g., noting signs of substance intoxication and withdrawal)

d. Integrate multiple streams and sources of information

I was expecting it to be easier than it was… Even with the technology that’s being used, pretty high bandwidth pipe that’s available, there’s still this smidge of lag which is noticeable amazingly enough. And I think within psychiatry when you do an assessment, you’re paying particularly close attention to the response and timing and stuff like that. It’s fairly critical… I had to be kinda cognizant, wait an extra moment to see if it was a response or not and if the patient on the other end understood what I was asking or saying. And then the second thing kinda related is not being able to pick up on the body language and other cues as well as you would if the person is right in front of you in the room. [Resident – 102]

Medical Expert

Medico-legal practices

Adhere to legislation and professional regulatory standards (e.g., mental health certification, consent & capacity law, and privacy law) while providing care at a distance

especially this thing about medical, legal, and risk issues, that’s something that hasn’t come up in my experience with telepsychiatry but I’d imagine that would be a bit anxiety-provoking for both sides, you know when someone is suicidal or there is, you know, a safety issue, how do you address that when you’re not really in the room? So I would think that would require teaching and maybe extra skills, how to navigate that. [Resident – 106]

Communicator

Conduct a psychiatric interview over technology, including forming a therapeutic alliance, demonstrating flexibility in the structure of interview, completing the full interview in the allotted time, and where appropriate incorporating family members

I think it’s overall you have to be more active in telepsychiatry. It’s not like a kind of passive role. You have to really put a little more effort into it I think than doing it face to face. [Faculty – 206]

Craft a useful consultation note, relevant to the community, context and resources

So I think clinically or interpersonally, it requires an ability to form a really rapid therapeutic alliance with the person. Because you’re only gonna see them that one time and you only have a limited amount of time to get through what you need to do to do a proper assessment so I would say that, you know, you really, if you don’t have those types of skills to seem competent in what you’re doing and be approachable and open to questions whatever, that would make it pretty difficult. [Faculty – 207]

Collaborator

Work with interprofessional providers across distance, using them to better understand the community and available resources, and to achieve continuity of care over time

Engage in collaborative models and “indirect care” through telepsychiatry to reach larger numbers of patient and families

Coordinate care beyond the healthcare system (e.g., education system, social assistance system, child protection, etc.)

Consultations are fine for some things but not for everything. And where the consultative model falls apart is if in an ongoing kind of relationship, patients change over time. They’re not the same just because you saw them once. So collaborative care allows that ongoing relationship and continuity of care working through the primary clinician to keep supporting them as they keep doing that… the bottom line is telepsychiatry or any service from a distance by definition has to be a collaborative care service because we’re not there on the ground providing the primary care. [Faculty – 204]

Manager

Administrative abilities

Understand how the technology network is organized, accessed and administered at the proximal and distal ends

There’s a process. It’s coordinated by the hospital or hospitals have a local OTN coordination service and my administrative coordinator had to learn how to book them into through the hospital appointment booking program because the patients do get rostered into our electronic medical record with a chart. And a code that shows that the service was provided by telemedicine. So it’s sort of an added layer of complexity…[has] a reasonable amount of impact on a department’s ability to provide this service in high volumes…Not insignificant increase in the administrative burden of coordination. [Faculty – 209]

Advocate

Community and cultural psychiatry

Appreciate the social determinants of health in distal communities that may influence patient presentation (e.g., large scale layoffs; community event or tragedy)

I wouldn’t presume to know like something about any given community simply because I’ve been somewhere else nearby geographically…What’s actually the structure of the service I’m working with so, is it a family health team? Who’s actually on site? What kinds of things are actually available to patients there? …Because you don’t want to make a recommendation that’s far out strips what can actually be provided. And I want to sort of be aware of sort of what’s there, their knowledge of their community. They may or may not know about some other things that are available in the community. [Faculty – 209]

Demonstrate awareness of/sensitivity to local cultures, beliefs, knowledge systems, resources, healing practices, and views of technology

cultural and social consideration in telepsychiatry. I think it’s a really important topic;…How sitting in front of a video screen would be different for someone in the Inuit First Nations population…[Resident – 102]

Reflect on one’s own social position coming from an academic, typically urban or regional centre

I see a lot of First Nations folks through telepsychiatry… different aspects of their care…whether exploring whether or not they are interested in not just western-based medical practices but traditional-based, you know, healing activities like ceremonies, traditional medicines…not really knowing if someone has access to that. But also not assuming just because someone as an example is Aboriginal is that they’re necessarily going to want to see a traditional healer. [Faculty – 207]

Advocate

Health systems

Use technology to address health human resource problems and systemic inequities in access to care

Promote and respond to the health needs of individual patients, families and communities.

And then better efficiency. We have an incredibly inefficient sort of ambulatory psychiatric system and this sort of has the potential to change that a bit. I don’t think it can take over all of psych care. I do think there’s something to be said about in-person care for some specific cases but I do think it can certainly redistribute sort of vast inequity in the accessibility that’s sort of a geographic barrier more than anything else. [Faculty – 209]

I think there’s a huge potential with telepsychiatry and collaborative care to be an advocate… to talk to the stakeholders… So I’d even emphasize the potential for health advocacy. [Resident – 106]