Podcast Episode 2: Telehealth

Enlightened Practice Podcast

In this episode of the Enlightened Practice podcast, Dr. Ken Braslow and Kari Kagan discuss setting up a remote practice. Spurred on by Covid-19 and social distancing recommendations, virtual health is on the rise and looks to be sticking around post-pandemic.

Going virtual is more than just a video chat with your clients. There’s a lot to be considered including selecting the right equipment, creating a comfortable space and drafting policies that guide you and your patients.

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Transcript of the podcast

(00:01)

Ken: Hey Kari, today we have a question from a clinician who’s just starting out and they’re asking about setting up a remote practice, and they want us to think about what are all the things they need to be thinking about as they set up a little practice.

(00:30)

Kari: It’s a very relevant topic.

(00:33)

Ken: Yes. So, I think there are different things we could talk about like physical equipment, setting up your space, policies that go around it, technology that goes around it.

(00:53)

Kari: Yeah. Things to review with clients in terms of their space and what can create a safe and comfortable environment over video or at home, or wherever they’re going to be. Those sound like the important things to cover.

(01:19)

Ken: Okay. Well, what would you like to take first or do you want me to go first?

(01:24)

Kari: I think, starting with physical equipment, right? Like what are you actually going to be using to conduct a video call or remote call? So, obviously one option is to have a device that allows for video like a computer or an iPad. Well, what do you use for your video calls?

(01:53)

Ken: So, I use my MacBook Pro, and I have a pair of headphones that would plug into my phone. And I cannot emphasize enough the importance of a good quality internet connection. Sometimes our patients and clients struggle with that on their end. But the least we can do is ensure a good connection on our end. So, I use something called a power line adapter, which is a piece of equipment you plug into your wifi base station and then across your office or house, if there’s a big distance between the wifi and where you’re at. You plug in the second power line adapter, they both plug into the wall. And so the wifi is taken through the wiring in your building. And then I have a router that comes out from the wall right next to my laptop. So, I have essentially my own hotspot right next to my laptop.

(03:11)

Kari: Yeah. I think having a good internet connection is critical where you’re working from. I upgraded our wifi. So, it was like 15 extra dollars more a month. But given that my practice is entirely remote right now it felt like an investment that’s definitely worth it and it has actually really improved the connection. I also use a MacBook Pro, but I do always have my phone nearby because I’ve also noticed that some clients prefer to switch to phone calls as opposed to video calls. If for some reason they can’t be at their computer. So, I do always have a backup option to be able to, you know, conduct their therapy remotely. So video isn’t the only option. I do personally prefer to see the client but at times I think that the phone can be pretty convenient too and effective. So that’s another option for remote.

(04:24)

Ken: Yeah. And occasionally the wifi will drop for no good reason and being able to pick up the phone and have your client’s phone number right there is so important to be able to keep the continuity within the session going. If I’m meeting a new patient over a video, I will start off by talking with them a little bit about video itself, and just that it’s not the same as being in the office. But we’ll do our best and that they should really let me know if the connection is breaking up on their end or not optimal because I don’t know how that couldn’t help but affect their first impressions and their level of comfort while talking with us. I also ask them for their phone number because sometimes the phone number they put in their paperwork is not the phone number that they have right next to them. So I jot that down at the beginning of our sessions if it’s a new intake.

(05:34)

Kari: Yeah, exactly. I do the same as best I can trying to pre-emptively discuss the potential issues that we might encounter when using remote options for therapy. So, that we have a plan in place basically to deal with those issues if we need to. So, part of the conversation I have with clients then covers the space that we’re going to be in. So I think, for them not exactly knowing where I am besides the little couple of inches on either side of me that they see on video and the same for them. I like to reassure them that I’m in a confidential space, in a quiet space. That being said, since so many of us are working from home right now I do also like to inform clients that they might hear a noise from time to time, again, that’s part of the pre-emptive conversations I like to have to just prepare them.

So, if something was to come up or they were to hear a noise that we wouldn’t be dealing with it for the first time necessarily or talking about it for the first time when it happens. And, I also like to know where clients are both from the standpoint of encouraging them to find a place that they feel comfortable talking openly. And sometimes that’s in the car. Sometimes that’s in a bedroom or wherever it is, but I think that’s an important part of doing remote therapy is having a safe place to talk. So, that’s something I talk with them also. Just from an ethical standpoint, I do like to know the address of where a client is. So, in the case that there is an emergency, I would be able to get help to wherever they are. So, I ask them if they’re going to be at their home then I’ll just assume that and I have that address in their chart. And then if for some reason they’re not there, I’ll ask them to let me know where they are just in case there’s any kind of emergency whether it’s a mental health emergency, or even just a random medical emergency that happens while we’re talking.

(08:17) 

Ken: Okay. That’s for new intakes or for all sessions that you do that?

(08:23)

Kari: It’s something I cover in an intake session. And then we’ll revisit if they’re in a new location. I’ll ask them to let me know that today they’re at their parent’s house instead of their house or something like that.

(08:43)

Ken: That’s a good point. One of the things I have clients do is to try to test their own wifi before we meet and to reboot their computer and maybe even their wifi itself. I just hate for us to use up session time on anything other than why they’re there in the first place. One of the things I see my patients do frequently is walk and talk, which is perhaps a nice feature compared to having to sit on the couch in the office, but makes for a horrible experience, at least on my end with the picture breaking up. So, I talk with them about finding a comfy location that they can actually just stay seated for the duration of our session and to get whatever microphone or other headphones it’s typically headphones that I want them to be able to have if they want them and not to have to like go hunt for them for a few minutes at the beginning of our session.

I also think when I’m meeting, I don’t need to wear headphones, but I choose to put them on because I think it sends a good message to the patient that they know at least nobody else can hear what they’re telling me. So, that’s why I go the headphone route.

(10:16)

Kari: Right.

(10:17)

Ken: What about the background? Some clinicians, they literally want the blank canvas, a blank slate, and others don’t want to have to do anything other than just be present. And if you’re in an office it’s never like a blank wall behind you. I think most of the time clinicians have some sort of decoration in their office. So, what’s your take on the background that patients see behind you?

(10:53)

Kari: Yeah. Well, I think that it depends. I think sometimes it’s just a matter of the setup in your home. Like you kind of just have to be wherever there’s space in which case I think that it’s more about just finding the space then making it a certain or like trying to find the perfect background. But I think the things that I consider lighting, I personally don’t mind if clients see a little bit of like, something in the background that might reveal something. For example, my background is windows, which isn’t always the best for lighting but I try to adjust by having lighting that corrects for the lighting behind me. But for me, it happens to be both a spot that pretty much is the only spot I can be in my house, but also, you know, it’s like a serene background. And so, yeah, like it reveals that I live in a place where there’s trees outside my window. But I think it’s usually a talking point with clients. They say, Oh, the trees look so nice. And I think the consideration should be where are you comfortable in your own home? Something that’s like relatively nice to look at for clients and lighting just to make sure that like practically they can see you. What about you?

(12:39)

Ken: So, I happened to have my office set up so that there’s a blank wall behind me. So I keep it pretty bland in that sense. But that’s not when I was in the office, that’s not how it actually looked. There are some room dividers, screen dividers that you can buy on Amazon and put behind you. So, I guess that would be an option if you really didn’t want clients or patients to see anything behind you, but you didn’t have the option of a blank wall per se.

(13:22)

Kari: Yeah, that’s right.

(13:23)

Ken: These are really important things to be covering. What about like policies for your patients or clients do you have them do a TeleHealth consent form? Do you do anything different administratively?

(13:45)

Kari: I do have a separate consent form that’s for TeleHealth. And I believe that there are samples that you can find online or potentially can pull from some consent form that a colleague might have. I believe the things that are covered in there are confidentiality and specifically like the confidentiality of the actual video platform that it’s HIPAA compliant. So, clients don’t have to worry about someone listening in on conversations over there. I think other than that just covering that, the only other unique policy thing that changes a little bit for video compared to when I’m meeting people in person is just what I was talking about earlier, which is me wanting to know from them where they’re physically located so I can get help if needed. But all my policies are the same otherwise. What about you?

(15:12)

Ken: I agree. There’s not much different other than that there is a risk when you’re not in the office and that somehow the technology could lead to some privacy issues. But no, I don’t make a big deal out of it. And the platform I use is HIPAA compliant as it is, so less worried about that, although some patients really just want to use FaceTime. They don’t want to use any other particular platform and at least right now, even though FaceTime isn’t HIPAA compliant it has a waiver so that it can be used. And I guess we’ll have to revisit how well we can or cannot use that once the waiver is lifted.

(16:17)

Kari: Right, yeah. The other thing I was just thinking about is that when I’m reviewing policies with clients, I’ll talk about the potential benefits and risks of therapy that sometimes things can get harder. And so I will talk about that more specifically as it relates to video therapy, that there are a lot of benefits, but there could be downsides. And just to kind of point those out and encourage clients to bring that up to me if they’re finding that it’s not working for some reason, or they’re not feeling like I’m understanding their experience somehow, and if technology is playing a role in that then we might consider referring them to someone who is meeting people in person. So, that is something I’ll talk about that while video usually is an equivalent alternative there are certain cases that it doesn’t work as well, in which case let’s have an ongoing dialogue about that.

(17:34)

Ken: I think that’s a really good point. I really feel for patients whose wifi is not particularly good. I might have a whole series of patients during the day where the picture was perfect and I will periodically do a speed test just to make sure that my wifi is hanging in there, and then somebody where the connection is crummy. And I’ve got to assume it’s their wifi since all day mine was doing just fine. And even though my wifi might be okay, it’s hard for me sometimes to follow them if their wifi isn’t great. And how that adds an extra layer in the experience that it raises my anxiety a little bit, like, I don’t know if I’m missing anything. And so what must it be like on their end if the clinician is breaking up. And will they even tell us? Will they be embarrassed or ashamed, or just think it’s our wifi? There’s so many components or bottlenecks in this process. That’s another extra element. So I will pause the session at times and say, you know, that wifi isn’t so great. Is that your experience also?

(18:59)

Kari: Yes.

(19:00)

Ken: And occasionally I’ve had people either just refresh their screen, or hang up and call right back. And often that helps, but not always. And then I say, let’s just switch to phone and I just call them right there.

(19:19)

Kari: There’s so many things to think about there. I’m curious. How do you feel now that we’ve all been working remotely for several months? How would you rate the overall experience and how do you think your patients feel about it?

(19:35)

Ken: So I had a peculiar set up before COVID, which was that there was construction in the building next door to my building for about four months with jackhammers. So, on day one, appointment one, of the jackhammering, I was done with my office even though it wasn’t even my building, but it was horrific. I literally just went home after that first patient and told all my patients the rest of the day, we’ve got to meet over video. And I had been doing that a little bit. I had been dabbling at it. And so I just went to full-time video. So I’ve been doing a hundred percent video for about a year now. And I would say that there have been some real hidden advantages that I wouldn’t have even thought about. For example, working with kids and adolescents is really challenging for parents to get kids to appointments after school.

And now it’s just not as big a deal, kids are already home. So, the commute aspect has really been wonderful. I would have patients travel quite some distance to come see me. And now they are like, I’m never going to see you again, you know? It’s too easy. And why would you want to have that commute? So I liked that it opened up some possibilities. I would say some patients really just want in-person and I don’t blame them and we’ll get there eventually. But from a practice management point of view, being able to have your commute be 10 seconds allows me to see more patients than if I were hopping on the train every day. So there’s some real value in that also. And I can see after we can go back to the office that some clinicians might just say, I don’t do that anymore. And I can see some clients or patients saying, why would I ever go to somebody’s office if I don’t need to, videos just too easy? What’s your take?

(21:53)

Kari: Yeah, I feel exactly the same that it’s highly convenient. And I think most people prefer it if I would even say at least to clients I’m seeing for the reasons you already mentioned the convenience. And our relationship still feels good and strong over video. It doesn’t impede the therapeutic work. So, I think that coupled with the convenience, I can definitely see this being at least 50%, if not more of my practice going forward when/ if we are able to go back to in-person. And yeah of course I do think that there are steps for some people, it’s not the right fit in which case I think going back to in person will be really great. But I would say that despite all the tech glitches that come up every so often and the wifi issues and some of the inconveniences of it, I would say the benefits and the convenience outweigh the few times that it’s a bit of a bumpy road.

(23:22)

Ken: I think that’s fantastic. I think just the cost of office rent is going to drive a lot of people to stay home, or at least maybe only going on a couple of days a week and then to sublet out your space or to only need to sublet. And so definitely we’ll keep costs down. I would say on the prescribing end, there’s a couple of things I’ve noticed that are more challenging. I cannot take anybody’s blood pressure, which is useful to do for certain classes of medication. So I will just tell them, you need to go buy a blood pressure cuff and we’re going to take it in session, or send it to me right after session as if we were in the office. For certain patients, I would do an aims exam if they’re on a class of meds that are anti-psychotics, which really you can still do over video, except there’s one part of it where you’re moving their arm at their elbow to see if there’s any rigidity in their muscles there. And I clearly can’t do that. So, that’s impacting practice a little bit. But just like you said, there are occasional technological glitches or these aren’t glitches, they’re just not possible, at least in the 21st century to do these things through video. I still think the overwhelming experience has been positive. I’ve got one last question for you. When you were in the office, did you ever take notes while your client is in front of you and how has that changed over the video?

(25:14)

Kari: I always take notes and this is both for when I was in the office and now over video, in the first few sessions for intakes. I usually then, kind of taper off the note taking in sessions, although kind of sporadically we’ll take notes depending on whatever we’re doing in that session. Now over video, I’m definitely more mindful about what it looks like to take notes over video, which is it basically looks like I’m distracted or looking away. So if I do take notes, I still do an intake session. And then if I want to take notes during other sessions, because of something that we’re doing therapeutically, I always inform the client, I am taking notes, when you see me look down or a way that’s what’s happening. I’ll even show them my pen so they can see what I’m actually using. So, I think it’s still possible to take notes and for the client for it to not be too disruptive. I personally feel uncomfortable doing it over video. I’ll say like, I feel even if I weren’t with a client, this is what’s happening and they’re informed. They still feel like, you know, just the look of it is kind of distracting even if their experience isn’t that. So I definitely take fewer notes, but I still do from time to time. What about you?

(27:01)

Ken: So, I take notes. I type. I’ve never handwritten notes. So, I have a second monitor that I have set up like right above where my laptop stops. And so I’ll have their chart open when I come into session and it varies, if it’s a meds patient I’ve got to take notes while they’re talking. We just cover so much material and then I need to be able to send a prescription. And so I have that right above my line of sight essentially. And I haven’t had anyone complain about it, but they probably hear a light sound of me typing. I actually had the old Macs that had the super loud keyboard and I heard a patient using it once and I thought, Oh my God. And that’s what I sound like. I better do something about this.

covering the world. We’re typically honing in on one issue. So I find less of a need. But occasionally it comes up and it’s nice to have the chart open and available. So that’s when I go to the second monitor route and it’s not hard to do. But now if you’re totally invested in the Apple ecosystem, you can have a MacBook and an iPad. And if you have the latest operating system of both, you can use the iPad as a second screen as well over your wifi connection.

(28:57)

Kari: That I didn’t know. That’s really helpful information. And I’ve been on the fence about getting a monitor for video therapy too, just to even have like a bigger picture.

(29:12)

Ken: Yeah, the second monitors are so inexpensive now but they don’t have the webcam built in at least not the inexpensive ones.

(29:25)

Kari: Right.

(29:26)

Ken: So I still use my laptop for the actual visual part of it. And the second monitor for the notes.

(29:34)

Kari: Got it.

(29:35)

Ken: Okay Kari. Well, this was great covering the world of video. So, I really appreciate thinking out loud with you about this. I hope this gave our clinician lots to think about and our listeners, and always open to hearing feedback and I look forward to chatting with you soon. And we’ll cover more of the world of doing great therapy and mental health. So thanks.

(30:05)

Kari: Yeah, thank you.

(30:07)

Ken: Talk to you soon. Bye.

(30:09)

Kari: Bye.


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