I'm really excited to be here with my colleagues today to present on this topic of telehealth best practices. And we have myself and two other folks who are going to be representing various aspects of telehealth practice, and we will ask that you hold any questions until the end. We'll start with just a brief introduction, and then dive into the regulatory landscape, then share a little bit on telehealth practices in large settings and some important considerations, followed by experiences of working in a hybrid telehealth solo private practice, and follow up with some resources. Again, we ask that you hold questions until the end. We do have time. We will make time for those questions. And just when it's time, you can come up to the microphone. I will turn it over to Dr. Kahn to get us started. Thank you so much. Great to see everyone. I'm Shabana Kahn. I chair the APA Telepsychiatry Committee, and I'm faculty at NYU Langone Health, Director of Telehealth for the Department of Child and Adolescent Psychiatry. I don't have any disclosures. We'll start with a discussion of licensure, controlled substance prescribing, informed consent considerations with telehealth, malpractice, documentation, and then we'll save questions until the end. So just to give you a sense of the rapid expansion of telehealth that we all saw in the last three, four years, at NYU Langone, if we look at all of our virtual health visits across specialties across our campuses, in 2019, we had a little over 15,000 video visits, which we were very proud of, and then, of course, in 2020, a lot of it was because of the legal regulatory reimbursement changes that we saw. We expanded to over a million visits across the system. In 2021, about 700,000 visits, and in the last couple of years, we're steady at that 700,000, so still way more than we were doing in the past. So if we look at telehealth policy, there are changes that we may see at the federal level, changes at the state level. There are certain things that are going to be primarily federal, so for example, Medicare, and then there are certain things that might be both, that might be an interplay of both federal and state. So for example, controlled substance prescribing, which we'll talk about. There are some changes that we saw at the federal level, and you also have to review your state rules around prescribing. So if we look at kind of bird's eye view of what were the Medicare telehealth changes that we saw during COVID-19, before the pandemic, there were a lot of restrictions on telehealth for Medicare. So there were only about eight different types of practitioners that could be reimbursed for telehealth for Medicare, and then there were only eight different types of sites that patients had to be in at the time of the visit in order for us to be able to bill. Patients for the most part, outside of one or two exceptions, had to be in rural areas, so outside of a metropolitan statistical area. And then for the most part, other than one or two exceptions, you had to use video. You couldn't do audio only. So during COVID-19, and a lot of these major changes, some have expired, but a lot of the big ones have continued, have been extended through 2024. So first, geography, that requirement that a patient had to be in a rural area, that was waived. The sites, so patients didn't have to be in one of those seven or eight sites. They could be seen in home, that's still in place. The types of modalities that we could use, significant expansion there, I'll talk about that. And then significant expansion of the types of practitioners, so it wasn't just those eight as it was in the past, but a lot more could be reimbursed for telehealth for Medicare. There was an expansion in the codes for telehealth services. Some licensure requirements were relaxed, but of course, licensure for the most part is at the state level. And then supervision, we'll talk about that, supervision of trainees and some flexibilities that we still have, at least temporarily. Some visit limits were waived in certain types of sites. And then even before COVID, like maybe a year or two before, a year before COVID, there was a new designation, communication technology-based services that weren't considered telehealth, but there were things like virtual check-ins, things like that, where we could be reimbursed. And so that was helpful as a workaround for some of the limitations that we had. So some of the changes we saw at the state level varied state by state, but similar to what we saw at the federal level, the types of modalities that could be used, patients' location, being able to be seen in-home by some payers, relaxing consent requirements, services, the types of services that were eligible, again, practitioners, and then of course licensure requirements. Most states had some kind of waiver, which at this point, most, if not all, have expired. So with licensure, the general rule is that you do have to be licensed in the state where the patient is at the time of the visit. There is an interesting court case that has come up recently that I think is good for us to track, which I'll talk about. General rule is a clinician has to be licensed where the patient is, but it's not just about licensure. In addition to licensure, if you're doing telehealth, you also have to be compliant with each state has a medical practice act or the equivalent of a medical practice act and practice standards. So things like how do you establish that doctor-patient relationship, what constitutes a patient examination, what are some remote prescribing requirements. So in addition to licensure, you also have to look at that. There are some rules, special rules for the VA, where if you're licensed in one state and you're providing care through the VA, you don't have to be licensed in that state where the patient is because of something called federal preemption. So that's one exception. And then special rules for U.S. military, if the patient is located on a base. And then there's exceptions that were there even before COVID, some that are relevant to telemedicine. So for example, consultations, if you're not assessing the patient, you're providing a consultation to a doctor that's in another state. Every state is different in terms of how they define that and what you can do, but consultation would be a potential exception to licensure. Follow-up care, not very commonly used, but maybe four or five states have some kind of follow-up care exception for licensure where if a patient comes to see you, let's say you're a surgeon, they have a procedure and then they go to their home state, their state might allow you to do some follow-up visits. Some states have special registrations, not a lot, but Florida is one example where you could get a telehealth registration as long as they verify your license. In another state, and you can see patients as long as you have malpractice coverage and some other requirements, that would be an example of a state that has a special registration to be able to do telehealth. But outside, and then some states have bordering exceptions, so if two states have an agreement, they might allow doctors to practice in that other state, in their state, if it's a bordering state without a license, but there's not a lot of exceptions like that. Outside of these, you do have to be licensed where the patient is. A lot of professions have licensure compacts, so the Interstate Medical Licensure Compact has about 40, 41 states that are part of that compact. And unlike most other licensure compacts, the medical one, you still have to get a full license in each compact state, you have to pay an additional administrative fee of $700. So it doesn't really save money, you still have to keep up with the education, the regulatory requirements. It potentially makes it quicker, it expedites the process of being able to practice in another compact state, but other professions might have what some would consider a better model where you don't have to get that full license in that other state. So it's something called mutual recognition or reciprocity, but the medical one, you still have to get the full license in the other states. This was the case I mentioned, so McDonald v. New Jersey State Board of Medical Examiners. This was a U.S. District Court for New Jersey court case. This was filed in December a few months ago. And in this case, they argued that the licensure requirements in New Jersey, medical licensure requirements that require an out-of-state doctor to get a New Jersey license, they're saying this violates the U.S. Constitution. So because they're using the U.S. Constitution in their argument, it becomes a federal case. And over the years, as I mentioned, licensure is pretty much state-based, but over the years there's always been a discussion of can we, at the federal level, try to bring this up as an issue. So this is the first time that this is being done. The four arguments or the four parts of the Constitution that they're using in their argument are the Commerce Clause, Privileges and Immunities Clause, First Amendment speech, and then 14th Amendment Due Process Clause. And it's basically two physicians. One is at MGH, one is at University of Pittsburgh Medical Center. They are treating patients that reside in New Jersey. One is a pediatric patient who needs specialty radiologic oncology care. And in order to be able to do those follow-ups, their doctor would have to be licensed in New Jersey, and they don't have that license. So if we have time, we can talk through these four parts of the Constitution and how they're arguing it, because it is interesting. But we don't know where this is going to land, how this is going to play out. The New Jersey State Board of Medical Examiners recently responded to it, so they are moving along in the process. But it could take a while, and it could play out in a number of different ways. So the plaintiff could withdraw the case, or even if they do win, New Jersey might appeal it, and that appeals process could take a long time. But since licensure laws in New Jersey are very similar to licensure laws in other states, depending on what happens, that could have implications in other states. So just something to be aware of, that first-time licensure is being challenged at the federal level. So controlled substance prescribing, as I mentioned, federal levels, and we also have to look at our state rules. Before COVID, because of the Ryan Haidt Act, generally, and there were a few exceptions, but generally, we do have to conduct an in-person exam before prescribing a controlled medicine through telemedicine. There's seven exceptions in the Ryan Haidt Act, which was passed in 2008. The seven exceptions are a patient has to be in a DEA-registered clinic, or they have to be in the physical presence of a DEA-registered practitioner, or if you're providing care through Indian Health Services, tribal organizations, or through the VA in emergency situations, those might be some exceptions. One exception was if there's a public health emergency, and that's because of COVID, that is the exception that went into effect. There was also an exception of a special registration, which even though it's been 16 years, they never defined it. But that's one that maybe we'll see something with regards to a special registration. So those are the seven exceptions that we had. Because of COVID, one of those went into effect. And as of March 2020, the DEA at the federal level said that you are able to prescribe a controlled medicine without that in-person exam as long as you're doing it for a legitimate medical reason within your usual course of practice, and you're doing it using live interactive video. And this is at the federal level. You also have to look at your state laws. And after a lot of back and forth, a lot of extensions, ultimately this has been extended through December 2024. So we are waiting for the DEA to put out something on this, hopefully soon. They did put out a proposed rule in March 2023 in advance of the public health emergency expiring, but there were over 38,000 comments on that rule. There were a lot of people that thought it was very restrictive for various reasons. There were a lot of people that were concerned. So they had a listening session as well, got some feedback, and then they didn't have enough time to review the 38,000 comments. They said they want to be thoughtful about it. So they extended it through December 2024. And they did indicate, the DEA indicated that if they do put something else out, or when they do, they will, they will open it up for public comment. So definitely an opportunity for us to contribute since it is so relevant to our field. I mentioned these seven exceptions, so I won't go through them again. So with informed consent for telehealth, do we have to get it? Is it required? When considering whether or not you have to get telehealth consent, you have to look at your state. They might have a requirement. A payer, like a Medicaid policy, there might be a requirement by a payer to get consent. Your institution, your practice might have a requirement. So there's various, either state, payer, institution considerations. And in terms of broadly, if you look across states, about 47 states have some sort of informed consent requirement. And the nuances are very state or payer specific. And it could be written. It could be verbal. It could be both. So some people might just build, some individuals might choose to just build that into their documentation that consent was obtained. With malpractice, we can't assume that our malpractice will cover the telehealth that we're conducting. Definitely in the last three, four years, malpractice providers are more and more comfortable covering it. But some things to keep in mind, clinician and patient may be located in different states. So there might be different liability laws, statutes of limitations, standards of care. There could be different damage caps. So you want to make sure that first, whatever you want to do is covered. Your malpractice provider might want you to put something in writing. They might say it's covered under your standard coverage, or they might add a writer. So you kind of want to know these things ahead of time. And then the last thing you want is, let's say you saw a patient in another country, in another state. If there is an adverse event, your malpractice might say, we didn't know about this activity so it's not covered. And then, many malpractice policies exclude unlicensed activities. Important to know applicable state laws, coverage requirements. I guess the good thing is, there isn't a lot of case law to draw upon when it comes to malpractice cases with telehealth. The ones that are out there, even with the significant expansion we saw in the last few years, the cases that are there are most involved prescribing across state lines to a patient that was not previously examined. So how do you define that doctor-patient relationship? What constitutes a physical examination? Most or all states' boards are going to say you should not prescribe solely based on a questionnaire. So what is that assessment of a patient that has to be done before you can prescribe? And if the state requires a pre-existing doctor-patient relationship before you prescribe, how do they define that relationship? Can you use video for that to perform that patient examination? Some general safety considerations during telehealth. I know most if not all of us in the room are very experienced in the last few years especially. But safety considerations confirming identity of patient and guardian. I know that came up with the DEA as they're working on that special registration, possibly defining it. One of their questions was, how do you confirm the identity of a patient? So I know they're thinking about this if they're going to put in guardrails for that special registration exception. That might be one of the things that they're thinking about. Ensuring privacy, both that environmental privacy and the technology. Patient location and contact information. Any contingency plans if there are safety concerns that arise since the patient may not be in the same area as you are. What are the local crisis numbers, police department, local resources? As we would do for in-person visits, that screening for clinical risk, any access to lethal means. Another thing to keep in mind is if a patient is in another state, the civil commitment laws are going to be different. The consent, confidentiality, duty to warn, duty to protect, and then the mandatory reporting requirements can be different as well. If a patient is in a clinic or other site at the time of the visit, helpful to collaborate with the on-site staff there to have a direct communication method like secure chat. I know that's helped me out in a lot of settings in the past where we had telehealth visits where there were safety concerns, having that way of connecting. So telehealth documentation considerations, generally same documentation requirements as those for in-person visits. Some additional components based on state payer practice requirements, where is the location of the patient, the location of the physician at the time of the visit, what technology did you use, the individuals that were present on both ends of the connection, did you obtain consent, and then just considering ways to, as many of us have done, streamline that in the EMR, whether it's templates, smart phrases. Privacy and security, as I mentioned, technology and environmental considerations, so making sure you have a secure point-to-point connection, safeguards for protected health information. There's HIPAA that we always talk about. There are other regulations at the federal level, high-tech as well, and then your state may also have rules around privacy and security, making sure that that connection is fully encrypted. I think Dr. Blevins is going to discuss this, but if you are partnering with vendors, making sure that they're also going to keep that data, that patient information secure like you're supposed to because of HIPAA. And then environmental considerations, so always helpful, I like to start any telehealth visit with the patient or with family by saying, just so you know, I'm in a room by myself, doors closed, AirPods on, and what about you, just to make sure you know who all is in that space. All right, so I will hand it over. Thank you, Dr. Kahn, for setting us up to kind of understand the landscape of telehealth. I am going to pivot and talk about practicing in a large setting. Just as a disclosure, I am employed by Lyra Health and have equity in the company. I'll briefly go through a timeline history of telepsychiatry and how we got to where we are today, and just a brief review. I'm sure you all already know why there's a need for telepsychiatry. And then really dive into a case example using Lyra Health to highlight some important considerations when you're working in a large setting. So we have over roughly about 60 years or so of telehealth sort of getting to where we are today. Started in 1959, Nebraska Psychiatric Institute used video conferencing for group therapy, consult liaison, psychiatry, and training that was being provided to a local state hospital. And in 1969, MGH used a two-way interactive television to provide consultation to a remote clinic. By the 1990s, we started to see some international adoption of this, but I think there was still a lot of skepticism and wasn't considered part of sort of the traditional practice of psychiatry, if you will. We also started to have more research being conducted at this time, looking at outcomes and effectiveness of telehealth. By the 2000s, we had developed guidelines. So the APA and the ATA were able to develop guidelines based off of outcomes research. And we still use those today. By the 2010s, we started to see more technology improve, and that created more access to telehealth as an option. There was more interest in adoption in various spaces. And then as we are all very familiar, when 2020 came around and the pandemic, many, if not all of us, probably had to pivot to working in a telehealth space in some manner to deliver care. And around this time is when we also saw a real increase in the number of telehealth offerings in various academic and private institutions. So just, again, why is there a need for telepsychiatry? There are a lot of people in this country who are experiencing mental illness. 23% in our recent survey, 6% of those reporting a serious mental illness, and 5% reporting having had serious thoughts of suicide. So there are a lot of people that are really struggling and in need of care. Only half of those, unfortunately, have reported accessing any form of care. And this is really where we have the opportunity to use telepsychiatry to help fill the gap. The research that has been conducted has shown that it is effective. I know this was one of the things early on, particularly in the 90s. People were wondering, can it be comparable to what you provide in person? Research shows that it is comparable, particularly in terms of assessing, diagnosing, and when we look at clinical outcomes. There are various models of care delivery that have shown to have good evidence. This includes direct patient care, collaborative care, and consultation to primary care. And I would also add hybrid care in there as well. Both patients and providers are satisfied with the care that's being provided via this modality. And then we are seeing, in some spaces, that it can be cost effective as well. I'm going to turn now to talk a little bit about Lyra Health. Lyra is a company that was started in 2015. And the goal was to partner with large employers to provide mental health care to their employees. So there is an EAP, or Employee Assistance Program, component to it. And then we have what we call health plan integration, where we can build the health plan, essentially. We currently partner with over 1,500 employers across the country. And we provide coverage in all 50 states, as well as we have an international arm of the companies. What's been really fascinating as I've been working at Lyra is just to see the growth in a pretty short period of time. As I mentioned, we started in 2015. And these are large employers. So we see a very large number of patients every day. We consider ourselves to be a tech-enabled company, meaning that we are providing clinical care, but we do use technology to enable that care. We have a digital platform that helps us engage with patients. But we ultimately rely on the clinical care that is provided by our providers. Another important thing that we emphasize here at Lyra is combining evidence-based care with ease of access to care. So some folks have a difficult time connecting to care because they work. Telehealth is wonderful because it allows people to take a break from work. They can see someone on their lunch break, just not have to take a whole day or a half day off of work to go to an appointment. We also really focus, again, on evidence-based practices. We follow guidelines in terms of those practices to make sure that we are really trying to achieve the outcomes that we seek. And as is mentioned here, a North Star really are clinical outcomes. Our foundation, again, for delivering this type of care is rooted in evidence-based practices. So we review when we onboard and train our providers, our physicians. We have therapists and coaches as well. We review guidelines. We provide a lot of CME opportunities before they even start seeing patients so that they are fully aligned and aware of best practices. So similar to what you would hopefully be doing in an outpatient, in-person setting. We use measurement-based care as well. In order to demonstrate that we are effective, we have to measure outcomes. We use PHQ-9, GAD-7, and other scales to measure our care. And we use that to help guide our providers in the treatment plan as well. We also have an emphasis on culturally responsive care. Because we are providing care to such a large patient population, we want to make sure that our patients are able to engage with a provider who is culturally responsive, who is aware of those unique experiences that they're bringing to the visit. And then we have clinical oversight. And I'll share a bit more of what our clinical oversight looks like. So in terms of our care model, we have a full, I would say, continuum or suite of clinical offerings. Everything from self-guided care, which is really someone who wants to pick up an app or learn or read about major depression or SSRIs, to coaching. Then we have therapy. We have medication management. And we have complex care. I'm going to focus for the rest of my time on our medication management model. And I'm the medical director for Lyra's med management program. We use a collaborative care approach. We hire primary care physicians and psychiatrists who work in a clinical supervisory or consultation fashion with those primary care providers who are seeing the patients directly. We also provide consultation support via a one-to-one model so physicians and psychiatrists will meet on a regular basis, usually every one to two weeks, and also have biweekly consultation groups. And this is part of our clinical oversight model that really allows us to make sure people are practicing in the best manner, that we can address tech issues, that we can address any challenging cases that may come up. We focus on what we say is clinical care focus on what we say is clinically appropriate care. So doing the right thing for the right person at the right time. And identifying those times when Lyra may not be the best place for someone, or telehealth may not be the best setting for someone to engage in care. And being able to connect them to someone in person or to a higher level of care if needed. We have a care navigator team who helps us with that and really helps us to, again, provide the appropriate care at the right place in the right time. And then as I mentioned earlier, we have an integrated digital health platform. And on the left, you'll see just a graph of PHQ-9 scores. So our technology allows us to send out scales or measures to our patients ahead of time so that we can gather data and information to help guide the care. It's an opportunity for us to also share information back with the patient about how they're doing. We may review this and discuss where there may be challenges. So we track our outcomes. We can assign activities in between visits. And it could be as simple as, again, a patient education sheet, or it could be a journal activity. We will coordinate with our therapists in assigning these activities at times. But again, to keep the patients engaged in between visits. We have messaging, which is also part of our platform. And then we can use this for cross-team collaboration and support. Our collaborative approach is quite interesting. And I'm going to call out two of my psychiatrists here with me today. We really take clinical oversight serious at Lyra. We want to make sure that we're providing high quality care. We hire primary care physicians, as I mentioned. And we chose to do that partly because of when you're in a large setting, thinking about if you're working with nurse practitioners and you're working across 50 states, collaborative agreements, it can be, there's a lot to manage. So we hire primary care physicians. And they may be licensed in multiple states. We have a wonderful team that supports the licensing and making sure that people are renewing their licenses on time. There's a lot of coordination that goes in on the back end. And then in the clinical side, again, the physician will work with the patient. And then they will collaborate with the psychiatrist, discussing these challenging or complex cases, reviewing guidelines. So again, there's a lot of active learning that's occurring in between visits. And then we'll even do deep dives into specific topics. We often will often use a second opinion of the psychiatrist. We have the opportunity to record sessions with the consent of our patients. So as Dr. Khan mentioned earlier, informed consent is really important. We make sure every video visit starts with informed consent. And we also ask if they consent to being recorded. This allows us to review videos with the psychiatrist, again, for quality control, for a second opinion, and to make sure that everyone's aligned in terms of best practices. We also will review notes and other communications that may occur, again, as part of our quality assurance. So I just wanted to use that to paint the picture of what we do at Lyra. We see people every day. We have full-time physicians with us. And again, we're providing care across all 50 states. When you're working with such a large group, it's really important to follow the law. So I'm not going to go back over all of the things that were already shared. But I just want to highlight, just emphasize the importance of following the law. Controlled substance prescribing is something that was considered. And we decided not to pursue providing controlled substances even during the pandemic. Again, thinking about how to keep everyone safe in this space, we felt it was best to not provide controlled substances. But we do partner with providers in the communities in which our patients live to be able to refer them to an in-person provider if needed. In terms of licensing, I already mentioned this a little bit. But we emphasize that, again, following the law, making sure your patient is in the state in which you're licensed in. And we have a process for trying to confirm that. And then we also make sure that the providers have all the licensing support on the back end. Again, following the law, you want to make sure that you are aligned in terms of supervision or those collaborative agreements if you're working in a large setting where you may be working with various types of providers. And it can vary by state. So it's really important to make sure your team or in a large setting, often you'll have a legal team. And I'll talk about our legal team soon, that everyone is aligned on what the rules and laws are for each state. Privacy and consent is another thing that we take serious. So we consent at the beginning of every visit. We use a HIPAA-compliant EMR. And I know Dr. Blevins is going to talk more about that in his practice. But I'll just emphasize again, that's another very important part, as well as even in our email messaging. Or we use encryption. So we just want to make sure that we're being as compliant as possible and being mindful of privacy and consent in this space. Release of information is a really big one for us. And I'll just say that it's been very interesting when you think about the ease of having someone sign a release of information form in an in-person visit versus trying to coordinate that in a telehealth space, particularly if you want to share information with a third-party vendor or with another provider. You need to also make sure that the patient and that other provider are able to receive electronically your release of information to confirm that you have the ability to talk. So there are all these things that come into play and can, at times, make it challenging. And we have to be very forward-thinking when we're working in this space. And then you may have some unique populations where you're thinking about consent to care. Specifically, I will just call out, if you're working with children or adolescents, and how do you consent the parent? Or who do you consent? And how do you do that in a virtual setting? So it's really important before you get started in a practice like this to really have all of that fleshed out. And then lastly, I'll just highlight the accountability. So when you work in any setting, but I'll particularly highlight in this large practice setting, it's important to hold yourself accountable. How do you do that? I mentioned measurement-based care. So just measuring our outcomes. Are we doing what we say we do? Is it simply OK enough to say, I saw the patient get better? Or do we have data to support that? We do, at Lyra, we actually look at data at the program level and report out in terms of research. And then we report out to our stakeholders. So whether it's the board or the employers that we contract with, how do we report out this information in a way that helps everyone know that we're doing what we say we're doing in terms of practicing safely and achieving good outcomes? And last, I'll just end with this. Some practical considerations, and I know we're going to talk about this a little bit more in the next section as well. But a few things I would just say to anyone that's considering working in a space like Lyra. Know who your defined patient population is. Companies, particularly I think since the pandemic, have grown quite fast. And it's really exciting to be able to say, oh, I want to do this. I want to work with this patient population. But it's important to carve out who the defined patient population is. Know who you're treating. Know what you need in place to treat that population safely and effectively. And then really be able to define what your role is. As a psychiatrist or someone working in this space as a provider, there are so many options out there. So you can provide direct care. You can be a consultant. You can work in a supervisory capacity. You can be a medical director like myself and work on program development and growth. Or you can be a CMO. So there are a lot of different ways that you can be a part of the telehealth landscape in a large setting. It's important to know what your defined role would look like. Another consideration is just, are you going to be an employee provider? Are you going to work in a contract capacity? And how does that impact the way that you see patients or that you provide care? Or can you work with another? Can you have a second job on the side? So all of these things are just things I want to share out if you're considering working in this space. And then the last thing I'll just end with is, what do you need in place to safely treat patients? So in a large setting, it's really important that you have a legal team or a lawyer or someone that you can consult with, particularly when you're working across multiple states. We are very fortunate at Lyra to have a wonderful legal team who is very accessible to us. So whenever there are questions or things we need clarity on, we can reach out to you and get a quick response. We have a credentialing team. So we credential all of our providers, just as you would in any hospital or academic setting. And we have what we call our partner provider network. So we work with people in the community that we identify as being aligned in terms of best practices. So if we do need to refer someone to in-person, that we know who we're referring them to. So we don't just go to the health plan necessarily. We will try to get them connected with somebody that we know is going to be able to practice in the same manner in which we would practice. Again, cross-licensing support I mentioned. IT support is the other one that I will just say is really crucial. When you're working in a setting like this, we're all working remotely from home. So we don't have the ability to just walk down the hallway to our IT team and say, hey, can you help me with my computer? Or can you help me with the sound on my video or something like that? So it's really important that if you're working in the setting, you know who your IT team is and how to contact them. If you're working in multiple states, they may be on the West Coast and you may be on the East Coast. Very practical things like that are important to understand before you start working in this space. Know who you can go to, who you can call for help. And then quality and safety committees are also very important in a space like this. Again, it's part of holding ourselves accountable for what we do to make sure that we are staying aligned in those best practices and that we're practicing safely. So I will now turn it over to Dr. Blevins. Thank you both. I was just sitting there thinking, I wish I heard this talk in 2019. Probably 2020 would have been a little bit easier and less scary. So a little about myself. So I'm a psychiatrist at Columbia. I'm a psychiatrist at APA, right? At Columbia, I'm an assistant professor there. And my role is actually as a research psychiatrist. So I don't see patients there except in a clinical research setting. But when I started my fellowship in New York, I started a small private practice. And it was a kind of one patient at a time situation, a couple of hours a week starting out. And now I see patients for about 16 hours a week. And I'll talk some about some of the things that I've learned and things that I would consider in either starting a small private practice or smaller group practice that you might use a hybrid telehealth model, some of the things that I've learned and just some things to consider as you start or grow that kind of practice. So this is kind of what my practice looked like probably like most people before COVID. Mostly seeing patients in the office every day, having a few patients that I would see remotely. I did have some experience in residency providing some telehealth from the academic medical center to more rural areas that didn't have a psychiatrist. So I did have some comfort level with it. But I was mostly seeing patients that either couldn't make it into the office because they couldn't catch the train. They lived a little too far outside of the city. Their parents couldn't bring them in. They were stuck at work. And at the last minute decided they needed to have a remote visit. They were kind of between classes at school or just because they were kind of brief medication check-ins that weren't going to take a lot of time, so they didn't wanna spend an hour and a half on the subway commuting back and forth. And then of course, everything flipped, right, during COVID and pretty much everyone became telehealth and the few patients that I was seeing in the office were patients that I was giving injectables to. And I should say with a small private practice, I mean, I literally do everything. I do the prior office, I do the injections, I do the scheduling, I respond to the emails. So patients that I was giving injections to, I was seeing in the office. I am an addiction psychiatrist, so I do some urine drug testing in the clinic, some vital sign monitoring, also around often addiction treatment, starting medications, buprenorphine, or thinking about withdrawal management, or seeing patients who just were totally uncomfortable with the idea of seeing a provider by video. And that was a couple of people during the kind of middle part of the pandemic. And then now it sort of looks like this. It's about kind of half and half, about half the patients come into the office for some of those same reasons, but other reasons that patients say they come in is they feel like they can develop rapport better in person, and they just have this preference for coming into the office. Sometimes it's a good excuse to leave the office at four or 4.30 instead of staying until five or six for them, not for me. For other people that come in for telehealth, of course, convenience reasons. If they live out of town, maybe in upstate New York, for example, but not out of state, as we've heard, because you do have to be licensed in the state where the patient is located. I do have a few patients, so as far as I'm aware, Florida and Minnesota are the only two states that offer a telehealth specific license that's fairly easy to obtain. I do have a few patients that I see in those states. And then again, same reasons, the commuting, stuck at work between classes, or for shorter check-ins. So some of the things to consider, again, when you're starting or growing a practice, I kind of split this into patient considerations and then provider considerations. So patient considerations, insurance coverage issues. Pre-COVID, there were certainly lots of issues with not paying equally for telehealth visits, or perhaps not paying at all, and that's for working in network. Working out of network with someone, give the insurance company another reason to not pay for it and probably it's gonna be declined also. This has certainly been much less of an issue recently, but I have seen some insurance panels transitioning back to either paying less or not paying for telehealth visits at all. As has been discussed, thinking about psychopathology, who is an appropriate patient to see remotely? If patients do have more severe mental illness, like more severe schizophrenia, maybe a patient with an eating disorder, is it the best practice to see that person when they can really control exactly what you're seeing for the duration of the session? Other things like personality disorders or substance use disorders that might benefit from more kind of structure and in-person engagement. And then thinking about patients with cognitive disorders, but also patients with just normal age-related cognitive changes that might make it more difficult for them to engage with technology in the same way as a 25-year-old patient. And then what sort of medications are they on? We've talked a lot about controlled substance prescribing and especially patients that are on multiple controlled substances, combinations of stimulants and benzodiazepines, patients that are on buprenorphine and benzodiazepines just as examples. Are those people that would benefit both from your perspective and theirs from more in-person engagement? And then things like vitals or urine monitoring. Vital signs, certainly we prescribe medications that do affect blood pressure and it can be very difficult to obtain. Go to your PCP's office and send me the blood pressure reading or order a cuff on Amazon that you don't know the quality of and send me your readings as you're on 300 milligrams of venlafaxine. So just things that I would consider from the patient perspective. This has been discussed so I won't go into too much detail, but just want to point out that controlled substance prescribing is a decent amount of what we do as psychiatrists. So especially if you're thinking about having a small or smaller private practice, it is gonna limit the patients that you can prescribe to if you do make the choice to not prescribe controlled substances because of the regulations around needing the in-person evaluation. It's still, as has been said, to be determined in terms of what's gonna happen. It looks like they may differentiate schedule two drugs like amphetamine and methylphenidate to the three through five, and there might be some specific flexibilities for buprenorphine to increase access to buprenorphine, but we just don't know yet. They haven't released the final rules. But yeah, this is definitely something that you want to really consider if you're thinking about either having an only telehealth small private practice or even doing a hybrid practice. And then some of the provider considerations. Issue of our mental health also came up, which I'll get to, but thinking about space. If you're gonna have a private practice and paying a premium rent for a private practice in the middle of Manhattan, it doesn't make sense to see half of your patients by telehealth. Or do you have your practice half the days of the week and then you work from home the other half the days per week? Then you're working at home. Do you have a studio apartment or a one-bedroom apartment and what's your kind of setup? What is behind you? Do you have the option of sort of a green screen kind of situation? But these are all things that you have to think about when you're starting out. Insurance or fee structure. Do you want to differentiate your fee structure for patients that live in a city with a higher cost of living versus having a lower fee structure for patients that might live in rural areas or offering a sliding scale? Certainly it allows us more scheduling flexibility when we're seeing patients remotely. Do we want to have just one state or multiple state licenses? As I said, for most states, it's kind of the standard process to obtain a full license with the exception of Florida and Minnesota as far as I'm aware. Note writing and other tasks. So when you're seeing a patient on video and there's an option to have the note in front of you and you can type some notes out versus handwriting everything and at the end of the day, going back and documenting or dictating notes. I'll show some of my examples of screen distractions but just also more screen time. I mean, it's certainly something that we've been hearing and thinking a lot about is how much time we stare at a computer or a phone and the impact that has on us. And then what your work day or work week might look like depending on kind of different hybrid models. So this is what I mean when I say like the distractions on a screen. This is me interviewing myself on my telehealth platform and sometimes what my computer looks like and it can be very difficult to focus on what the patient is saying when you have all these notifications at the bottom. You know, the CNN news, breaking news is popping up every three seconds can be challenging. Some of the computer systems now have these kind of focus modes that can help reduce some of these distractions but it's just very easy to get to this point by three or four o'clock in the day. And then the other alternative is this. This is what I see my patient sitting directly in front of me, you know, on a couch and I'm fully able to focus and concentrate on what they're, almost fully able to concentrate on what they're saying. These are some just kind of examples of what your work schedule could look like. You see the all green kind of top left corner, kind of a standard nine to five, an hour, half an hour lunch break each day, go home at five or six o'clock. With this hybrid model, it does give you some flexibility that you can change some times around. Maybe you work from home on Fridays and in the office Monday through Thursday but you also have this possibility of this kind of creep or encroachment in your schedule, right, that suddenly you're seeing patients at eight o'clock because they get off work at seven and you agree that this one time, just this one time that you'll see them at eight and then before you know it, you're seeing patients on the weekends too. So these are just, you know, you have to really think about these things from the beginning because once it starts happening, it's kind of hard to stop. So this has been discussed pretty well, I think, the HIPAA and privacy considerations but thinking about what your electronic medical records capabilities are, both, you know, what it's like to interact with it in real time while you're talking to a patient on video and some medical records or EMRs do have an integrated telehealth system now. There are a number of different telehealth platforms. I'll just give some examples on the next slide but this business associate agreement is a very important component of the telehealth platforms that some programs that are audiovisual programs, this is not sort of like a standard, right? You have to add this on, this BAA. Thinking about costs, there's range from free to very expensive, lots of different capabilities in terms of the bells and whistles and then a very important one for me is this, what it looks like when you first engage with the patient. So there are some telehealth platforms that are this kind of waiting room where the patient logs in, it shows the list of patients and you select when the session starts, right? Other people may send out 50 Zoom links each week and then you're managing a Zoom calendar and an EMR calendar and it gets very messy and then there are some programs that you can send a direct text link at the time of the appointment, it sends a text to their phone, your provider's waiting for you. You know, my preference is this waiting room, I think that it's sort of what patients are used to, it's kind of the traditional model, it puts the responsibility on the patient also to show up for their appointment versus waiting for you to send them a text and then who knows where they are when they get the text message. These are some examples of both HIPAA compliant and non-HIPAA compliant AV platforms, so easy to start with the non-HIPAA compliant ones, so FaceTime, Facebook Messenger and Instagram, good examples of ones that are not HIPAA compliant. I believe WhatsApp probably also fits in that category and then there are a number now of HIPAA compliant, a few of the common free ones, Doxy.me is free, this is one of the waiting room versions, it does have some upgrades that add some bells and whistles to it. Doximity also is free for physicians, this one is one of the push, so you send the text at the time of the appointment and then the patient clicks the link and it opens the video session and then others like Zoom, Google Meet and WebEx have the option of adding on a BAA, but again, you need to make sure that, so when you sign up for Doxy.me, it's like from the beginning, right, there's a BAA, but when you log into Google Meet, they're not gonna ask you, do you need a BAA for this session? So it is something that you have to be more proactive about and then as I mentioned, there are some integrated EMR options. And these are some quotes that I think are probably self-explanatory in terms of some of the challenges that come up in doing this kind of work. I promise I'll come in next time for the urine test. My camera isn't working is a favorite. Sorry, I'm in the car or train, can we just talk on the phone this time? Oh, I'm actually in California today, so let's just meet by video since I'm not in the state where you're licensed to practice medicine. I hope you don't mind that my mom's here, as the camera comes on. Sorry, I think my girlfriend is listening in the stairwell, I'll be right back. And then having a self-driving Tesla makes this easier. And all real quotes are at least paraphrased. So some of the harder limitations with telehealth, so doing injections, of course, extended release naltrexone, buprenorphine, as I said, I do these injections in the office. I don't have any patients on antipsychotic injections, but that would be another thing to consider. In-office ketamine, whether nasal spray or infusions, would be sort of out of the question for this kind of practice. In-office lab screening or diagnostic testing, so you're then relying, if it's urine screening for addiction treatment, relying on them to go to a Quest Diagnostics Lab Corp type lab and then waiting on those results. And then also the issue of getting real-time, if you're a fee-for-service provider or copay collection, and then this kind of adds to the administrative burden of following up with people for their $20 copay or whatever their payment is for your appointment. Some other considerations, so certain assessments, of course, are gonna be better done in person or would need to be done in person, like the AIMS, CALS, CEWA, and there are versions of these that you can kind of estimate, but the original versions of these scales are all done in person. Physical neuro exam, other scales that require this sort of a direct observation. You know, another thing is observing patients in their environment versus them getting ready, buttoned up, coming into your office, and allowing you to sort of see maybe what they wanna see or what they want to present to you, right? And seeing them at home can give you the opportunity sometimes to see other things that can be helpful in the assessment, but there are limitations to that too, right? I mean, they can sit in front of a white wall and just show you from their shoulders up. And then thinking about some of the psychodynamics, and even if you're not a psychodynamic therapist, it's happening, right, regardless of whether you're a therapist or not, and thinking about what it means for the patient to observe you in your environment versus being in the office, and you can mostly control what they see also. You know, as we were talking about this meeting before we were having a conversation to plan for this, and I was on my computer on Zoom, and I tilted it like five degrees, and you could see like my entire bed in my bedroom versus like this way, right, and it's just like kind of a curtain in the background. So thinking about, you know, psychodynamically what that means for a patient to see that kind of level of detail of your life too. So in summary, their hybrid outpatient psychiatry work models have advantages and disadvantages. The model you choose should work for you, hopefully, and also contribute to better work-life balance, but it can happen the opposite. Some patient factors may mean that telehealth is not the right treatment modality for them. You really wanna think ahead when you're setting up a practice, and you don't always wanna choose the cheapest or free options from the beginning, even though it's very tempting, because you'll regret it later when you transition to something that's better quality and more sustainable. And you always wanna keep HIPAA privacy, confidentiality, and the regulatory environment both at the federal and state level in mind kind of with every decision that you make along the way. That's all I have. So I can quickly review some telehealth resources and then we'll take questions. The APA has a practice management helpline, which I think is very helpful. You can contact them by email, practicemanagementatsych.org. It's available for all APA members and it's a helpline where staff will assist in resolving any practice management questions. APA staff, the advocacy staff, practice management, across the board, they're very closely tracking any changes, whether it's like legal regulatory changes, reimbursement. So they're a really, really great resource for us and they can help us in our advocacy efforts for telehealth. The APA website, there's a telepsychiatry toolkit, including a blog. There's a COVID-19 and telepsychiatry frequently asked questions. And then HIPAA support, so APA members have this new benefit. The information is here, practice guidance on HIPAA. There are a series of recorded webinars, for example, Advocacy 101, AI and Psychiatry, HIPAA Adherence for Telehealth, Healthcare Policy, Reimbursement, and these are available to APA members. In addition to APA, the American Academy of Child and Adolescent Psychiatry has a telepsychiatry toolkit. The Center for Connected Health Policy, there are 14 national telehealth resource centers and 12 of them are regional and they do offer free support. They're federally funded, so if you have any telehealth-related questions, I use them frequently, they're very helpful. The American Telemedicine Association as well. I mentioned the telehealth resource centers, CMS website for any of the updates that we discussed. The things that we discussed are updated through today and things are changing pretty quickly, so it's good to go to these sources directly. Center for Telehealth and eHealth Law has done a lot of advocacy as well for telehealth. And then the Federation of State Medical Boards is a great resource and the Interstate Medical Licensure Compact website. Okay, I'm going to step off to the side so I can see you all, I'm so short. So this concludes our presentation. We do want to open it for questions. So if you have questions, please come up to the mic and we'll answer them. I had a question on the last lengthy presentation. I was wondering if you could talk a little bit about what you're doing I had a question on the last lengthy presentation. You didn't mention vital signs and I do some outpatient telepsychiatry and many of the medications that I prescribe have important vital sign implications and I wonder how you handle that. Yeah, sorry if I went over it too quickly. But yeah, vital signs, urine drug testing, things that would need to be done in the office. It's hard to manage it. I think that some people do have patients order a blood pressure cuff online but then the quality of that, right? And if in a medical legal situation whether that would sort of be enough I think is a good question. But I think, yeah, I mean that patient may not be the most appropriate person to see or they need to have more regular follow-up with the primary care physician that can give you blood pressure readings, right? That you can then document. And then just to add to the blood pressure cuffs for home monitoring, the AMA does have a list of validated devices. So there are about 25 or so blood pressure monitoring devices. Some of them are pediatrics, most are adult but if you want a resource to start with, that's a good one. And some are not that expensive. So that's one resource. And then like you said, pediatricians, PCPs, school nurses will collaborate to get what we need. Thank you for amazing presentation. My question is about regarding follow-up patients. Like some patients who are not able to use video platform or interfaces and they choose only to use audio. I mean, is there any regulation surrounding their use for the follow-up visits or even billing or coding? How do you practice? The question was around, can you just repeat the second part of the question? So follow-up visits for the patients who prefer only to use audio interface not the visuals. That want to use audio. Yes. Yeah, I can speak from in a large setting. So we, there are occasions when video may go out or they have a preference for audio as one-offs that we may do audio. In larger settings, oftentimes where if they only want to do audio, then I think similar to the blood pressure, vital signs monitoring it's about is this the right setting for the patient to be in would they better be served in in-person setting so it really just depends in terms of similarly with video there are patients that we have who may you know initially want to be on video and then not be on video I will sometimes compromise and say if can you can you stay on video for 10 minutes so I can see you and then if you want to go off video but I need to at least have a little bit of a visual and again if it's something where it's just too difficult then we would talk about whether it would be better for them to be seen in person or if there are other reasons why if they're paranoid you know so there may be clinical reasons why they don't want to be on video so we would try to address that and there you know there are CPT billing codes for audio only sessions but certainly they're not reimbursed at the same rates as the with the evaluation aspect right which is what that when the video is kind of required anyway to bill for a nine nine two one three nine nine two one four appointment even for the medication follow-ups sorry even for the medication management follow-ups yep thank you and you would have to look at individual payers as well so during kovat Medicare significantly expanded allowing audio only and they're gonna make that permanent actually for mental health and substance use disorder treatment but individual payers may have their own rules around whether or not they're gonna cover audio only and then also states some states allow coverage for audio only but there may be nuances state-by-state Medicaid plans commercial payers you really kind of have to check with those as well thank you for a great presentation my question has to do with prescription of controlled substances is there any state that has not gone along with the DEA extension of prescription over video in particular does New York State have any problem with this example was in one of the slides I can't remember apparent I mean I'm not sure I saw this now but apparently Georgia has put stricter regulations than the federal government has on prescribing and have has flip-flops on it so they originally said there was going to be a deadline for in-person appointments and then now they have gone back and said that it'll be the end of December following the federal guidelines so yes there are some examples I think largely the states have followed the federal as far as you know New York State has gone along with the DEA as far as I know yeah thank you so malpractice and risk management just have them reach out because there's the federal then there's a state DEA kind of divisions so good to have them kind of help navigate that because we are hearing I don't have specific states but there are some DEA kind of regional DEA's that might say even though that at the federal level we have this extension because the public health emergency is over we want you to start seeing patients in person and the other issue is even if the DEA comes up with something that's very helpful for us a lot of states already have these laws that are very restrictive so we might still have issues after yeah I know New York yeah they are doing more clinic site visits as well about this issue so yes and your medical malpractice is a great resource also I mean they're excited to answer questions like that for sure for you or at least mine mine has been do any of you work with college students how are you currently handling things with college students who go out of state particularly those on stimulants for ADHD no one wants to give a college student four months worth of stimulants nor can you no one wants a college student to have access to four months without being seen it's very often hard for them to get seen at their local college health service etc yep that's a tough one you know I'd say that the answer is that they need to be seeing you in person right for a visit or not necessarily in person but seeing you while they're in New York State or in the state where you're licensed they need to be in the state to have that appointment I do have some patients that come home frequently enough to go to the pharmacy or their parents go to visit them frequently enough to take their medications but I don't send the prescription to the out-of-state pharmacy yeah and I make it pretty you know up front with them when I start seeing them that that's how the arrangement will have to work and if it doesn't work then they may have to see someone in their college town or city yeah I think the other thing that even though we read we don't prescribe controlled substances we do work with college students who may then need something when they go home for the summer and we'll recommend partnering with a pediatrician or local PCP and offering treatment summary letter or just being able to collaborate with them so those are sometimes other workarounds when they're traveling or off for the summer and the stimulant shortages don't help even when you have a plan in place thank you for your presentation this is regarding prescribing controlled substances in the setting of nursing homes and group homes especially PR and medication on tele psych visits do you have any experience with that is there any restrictions I don't have any experience with it I don't have experience with it but I think it would be similar just I mentioned those Ryan hate exceptions right now it's waived right the are you talking about telehealth into group homes yes okay so right now at the federal level at least that is waived the in-person requirement you would also have to look at your state as we discussed hopefully not the case for you but a state might be more strict and then if that you would have to find out if that practice that group home or facility is a DEA registered setting how to register D I think your admin malpractice just to clarify if it's considered because most community mental health centers won't be considered a DEA registered clinic it's a very specific designation so I think just clarifying is this a DEA registered hospital or clinic my guess is it may not be maybe but that would be another way to be able to do that by video without having to do that in-person exam once the flexibilities expire or if there happens to be a DEA registered practitioner on-site their internal medicine and other specialty someone who has a DEA once the flexibility expires if they're in the physical presence of the patient during telemedicine you might be able to do it thank you just want to highlight two advantages of telepsychiatry from the point of view of somebody who specializes in complex trauma one is through the video a lot of my patients who've had various boundary violations actually you feel safer because the therapist can come through the screen and that provides another layer that I've seen and another is those who some sessions at least prefer to do phone the advantage of not being seen that helps kind of navigate some of the shame aspects so I just wanted to offer that thank you yeah thank you for sharing well thank you for your lecture I have a question for dr. PA is that as the medical director of Lira yes I moved to Europe about a handful of years ago and trying to work in telehealth has been a nightmare I actually have joined a community of other psychiatrists who also live abroad some of whom have managed to successfully set up telehealth private practices which are cash only but my main question for you is what is the deal with so many corporate corporate telehealth companies that you have to be located in the United States yeah it's great question so one of the big issues is actually around privacy and just how information is shared over technology so even you know when we have physicians who want to travel and still work abroad it's thinking about the technology and making sure you have a secure platform so that's one big thing I know we talked about it Lira and then just knowing the landscape you know like the legal regulatory landscape can be tricky Lira has for example I mean I I had licenses in four different states when I moved over there I've since I've let since I've let a few laps but you know what I basically had to resort to doing is coming back to the US and doing local tenants work because finding something that I can actually do from there has been other than setting up my own private practice which I'm just not quite I'd rather work for a company than set up my own private practice but yeah yeah it's just it's challenging I mean Lira we have an international offering that is not actually on the management side so we've we just started it and it's on the therapy side as we try to explore how do you do it safely I would say in large settings a lot of it is how do we practice safely how do we keep you know we always think about keeping the patient safe but also how do we keep you safe how do we make sure that you know if you're international company that's international and you have various countries there may be different rules regulations we want to make sure that we're aligned I mean similar to actually if you're a multi-state here so to give an example you know if I'm licensed in New York State and I'm but I happen to be on vacation in Florida I can still see my patient that's located in New York State but if I'm in London I can't see my patient I think the other piece of that yeah I mean I can only speak for Lira for all large settings I would say the other piece of that might be malpractice the malpractice you know I would check with them to see if there are limitations there that's what I've heard I've heard different things I've heard we've within our community we've heard yeah we've heard that it's insurance companies not wanting to yeah I thought maybe you would know since you work for it well it's a it's a there are multiple factors and I think I think there's an appetite to be able to provide care I think we're still in a new space with this you know COVID theoretically was you know four years ago which is hard to say I can't believe I'm saying four years in 2020 but we're still really navigating all of this and I think it is important to ask these questions and you know as I said Lira has started in an international space on the therapy side but we actually partner with folks that are local to the various countries in which we work internationally so that's how we've been working through it but a big piece of it is like I said sort of the HIPAA stuff the malpractice stuff and then technology you know making sure that you have a secure platform so that you know nothing is you know that we are just really tight in terms of privacy so hopefully we will get there there are a lot of people who share your frustrations some other doctors there's a lot of us yeah yeah absolutely absolutely thank you I think this like the idea of like international data sharing is like complicated right I mean there's aren't necessarily agreements between maybe the United States and Turkey right in terms of like what's safe data sharing and in some if you have a medical record that's web-based sometimes we go to another country it won't actually work or if you try to send a prescription and it requires a two-factor authentication it won't it won't that won't work either so they're like many you know technology pieces I think are very complicated okay so the companies just haven't updated the technology or figured out the technology between where they maybe there's not like a legal consensus right on like what is can be shared in what way through the internet right yeah beyond what I yeah no that's I mean it's a lot it's complicated it's you know it's it they're just a lot of pieces to the puzzle essentially but I think you're asking great questions and I think that's that's how we get you know move the needle in this space and there certainly is an appetite for being able to get to a space where you know you're able to live abroad and you know be licensed in the States but and it will may still vary by country dependently and I think that speaks to what Dr. Levins was saying okay and just like we have HIPAA like for example European Union has GDP our general data privacy regulation and in some cases it's more strict than HIPAA in terms of keeping patient data secure so a security team would have to go through the risks of what country what region are you in what are the data privacy regulations there because it's not just HIPAA are we adhering with that because companies like Google were fine like millions and millions of dollars for violating GDP are so a hospital system is going to worry about that if they're doing telehealth and in a particular region Medicare Medicaid says that you know if you're not billing that's different but Medicare Medicaid doesn't allow a practitioner to be out of the country you have to be in the US so there's just all the layers that we discuss okay I thank you very much for that discussion this message is for you dr. Khan you mentioned some of these special exceptions for the US military population our clinic we actually deal with that population specifically but do you have specific examples of how those exceptions rule work if they're in different bases like say if they're usually working on a base in Texas but then they happen to go to like Florida for temporary period am I then able to see them or is it a different type of exception I'm not sure about the specifics I know if you're on a military base I've heard that's an exception but yeah I don't know the nuances I can look into it though it's an interesting question yeah absolutely hi thank you for your presentation I'm more than a question it's gonna give some observations and share my experience so I have been doing telepsychiatry work in Canada and Vancouver and I've been doing telepsychiatry for the last five years very much pretty much in the pandemic and in Canada is super relaxed like most of these family doctors don't even want to see patients in person they still see people through the phone so it's actually the opposite it's like very relaxed people most people are still doing virtual I just wanted to ask you how about with you didn't mention teams for approval HIPAA and also signal are they approved Sigma was at the last signal it's one of the new apps signal yeah the other one is teams MS right with teams would have a BAA also like it just as a regular teams is not not HIPAA compliant but you'd have to have a BAA you know the agreement signed yeah and I signal I'm assuming probably is not and I also noticed you didn't mention having a zoom you can have backgrounds like you can actually have a nice background I can office background you guys use that you didn't mention that I have mixed feelings about it I mean I think it's sort of to me it sort of creates this like a little bit too fake of a scenario and I just personally feel like having a more neutral you know a neutral background that makes me look like a human still and not like a you know bot it's just more like a personal preference nothing like it's contraindication to use no okay and some have like a kind of blur feature that may you know yeah you'll use those occasionally but yeah I mean I think it's really your preference yeah thank you yep answering that question I heard some hospitals are not allowing background effect anymore oh really yeah I haven't heard that either yeah I know that the policy I have a very quick question thank you so much especially for lira if individual practice or a group practice is trying to provide care to patients in different states now or expanding do you have to register your business in those particular states to apart from licensing physician for example if my practice is in New York but I want to see patient in New Jersey or Virginia or Maryland do I have to register my practice also from having no license in those states my practice also like they may do it but do you have to register your business LLC or whatever in those states so generally not you would want to check with that particular state if you're prescribing controlled substances then that down the line could become an issue because before kovat the DEA did require a separate practice address business address in every state where you're prescribing so if that comes back then you that might become an issue so for controlled substances you might need to but generally unless a specific state might requirement I'm not aware of that you don't need a separate like practice address in another state just that full licensure make sure your malpractice covers it and same for collaborative care I'm just last one do you need to have license to supervise practitioners in different state supervision in that state we work with so we don't at Lyra we have we call our partner provider network where we may have psychiatrists who also have like a collaborative agreement with that with a nurse practitioner and their collaborative agreement has to align with whatever the state rules are and in our practice all of our psychiatrists we do require them to also be licensed because of you know how the collaborative agreements are structured so but there are some things that are state their differences by state so it gets really complicated I would say is the easiest thing to say and you really just need to know what the rules are for each state I would say the safest thing is yes I've always seen every the psychiatrist if they're providing supervision or they're working in a collaborative way with a nurse practitioner to always be licensed not all may have a DEA but typically if the psychiatrist doesn't have a DEA in a certain state that nurse practitioner is likely not prescribing controlled substances so that where you may have you know be able to get it with that additional that registration but by and large I've always seen the psychiatrists having a license and then again the big piece is the collaborative agreement with the nurse practitioner and the physician thank you hi is New York State still allow out-of-state practitioners to provide telehealth without a New York license I know there was an emergency regulation where that was allowed that's still valid or that yeah I don't I don't think so no I think you have to be license-free I would specifically New Jersey right across the same thing yep that one I know for sure yeah you need if you're if you'd provide telehealth service from New Jersey to New York you need actually a New York license now at this time yep okay thanks thank you everyone for such wonderful so much

telehealth

best practices

regulatory changes

COVID-19

licensure

controlled substances

informed consent

mental health

digital platform

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insurance considerations

HIPAA-compliant