Rapid Conversion of an Outpatient Psychiatric Clinic to a 100% Virtual Telepsychiatry Clinic in Response to COVID-19

The most important element to our successful conversion was decisive action. Once the psychiatry department leadership analyzed COVID-19 data and evaluated a range of scenarios, the department chair decided to convert all clinic visits to virtual care. In less than a day, a plan was formulated by the chair, chief administrative officer, and practice manager. We focused our efforts on working with front desk staff to call patients in order to notify them and prepare them for a telepsychiatry visit, assessing capacity and redeployment options (e.g., asking clinicians whether they had flexibility to be redeployed to and from other sites), preparing clinical staff for schedule changes (e.g., notifying clinicians of rescheduled appointments due to telepsychiatry conversions), and adapting administrative and clinical workflows. The plan included a 2-week trial period to monitor key metrics, including appointment cancellations and patient and provider satisfaction, to assess the plan’s long-term viability and prospects for continuation.

All staff were informed of the change immediately, and small groups were formed to refine workflows. For example, one group focused on creating a streamlined process for front desk staff to call patients, and another group was assigned the task of reconfiguring workflows to enable residents to be fully supervised by attending physicians during video consultations. Recognizing that working environments varied significantly across staff and providers, we encouraged everyone to communicate their unique needs to their supervisors and prioritized providing the necessary resources and support to each person. This step ensured that all clinicians had the setup they needed to fulfill their responsibilities from their homes once our clinic was fully virtual.

Staff made phone calls and left voice mails to notify patients about the change to virtual consultations. During the call, staff helped each patient prepare for a videoconference by making sure the patient had a compatible device, downloaded the necessary software, and understood the nature of a telepsychiatry consultation if they had not done one previously. Documentation about how to participate in virtual visits was sent to all patients via Epic’s MyChart. Patients who were uncertain about their ability to use the technology as well as those who did not have compatible devices were offered an initial telephone consultation.

Our clinic staff had to notify approximately 850 patients with appointments scheduled over the initial 2 weeks of remote consultation. We started calling patients with next-day appointments first and proceeded chronologically. Each staff member was tasked with calling patients with appointments on a specific day of the week. This procedure helped prevent duplicate calls to patients. As patients were rescheduled to a virtual visit, clinicians were able to monitor converted appointments via the electronic medical record (EMR). This process helped inform our clinicians when they could start working from home, which we encouraged them to do as soon as possible. This process could also be conducted in a shared Excel sheet if a health system’s EMR does not offer this feature.

We were fortunate in having previously trained all clinicians in telepsychiatry. This training included reviewing the clinical skills chapter in a telepsychiatry textbook (1) and observing a faculty member conduct at least one live session. To ensure that our clinicians had appropriate software and hardware at home, which is where we expected them to work for their own safety, we assigned a point person to handle all issues related to software, hardware, and IT support. Training videos were made available on our website, and best practices were shared with the staff (see online supplement for a table of best practices).

We shut down the clinic to in-person appointments for an initial period of 2 weeks, which was then extended. Patients with existing appointments in this 2-week period were given the choice of either having their appointments cancelled or being seen over video. During the first week, we monitored and evaluated operations and refined workflows before committing to a longer-term suspension of in-person appointments beyond the initial 2 weeks.

Overall, we had a very positive response from our patients who used telepsychiatry. Many patients were relieved that their appointments were not cancelled and were willing or eager to try telepsychiatry. Patients with children also appreciated that they did not have to risk bringing their children to a health care setting or worry about arranging child care, which has become increasingly difficult due to COVID-19. Many patients have already told us that they plan on continuing to use telepsychiatry even after shelter-in-place orders are lifted.

Many of our clinicians also benefited from our conversion to a telepsychiatry clinic. Several clinicians appreciated that working from home alleviated child care concerns. Others noted that they liked the time saved by using a dual-screen telemedicine setup that allowed them to chart on one screen while maintaining good eye contact with their patient on the other screen. A majority of our clinicians have commented that the experience has been very positive so far and that working from home has been good for their well-being.

The biggest challenge during the transition was contacting all of our patients in a short period of time. Given the uncertainties about when a COVID-19 surge might arrive in the region, we committed to an aggressive timeline. Although our approach of reaching out to patients by phone starting with the earliest appointments worked well, we initially underestimated the amount of time it would take and the amount of staff required. In the future, sending a mass e-mail or messaging patients through the EMR patient portal could be a faster way to reach a large number of patients.

For the minority of patients who could not videoconference, a phone call was arranged instead. Most were elderly patients who did not have sufficient hardware, such as a webcam or smartphone, to perform the videoconference. This barrier is inevitable, and it is important to train staff who are calling patients to encourage video consultations but remain flexible with arranging phone appointments. Because our staff maintained a flexible and accommodating tone, patients felt more at ease and were willing to try a virtual visit, allowing our clinic to avoid technology-related appointment cancellations.

All of our clinicians had already received training and supervision in telepsychiatry as part of their induction to working in the outpatient clinic. They had become comfortable using the clinic’s dual-screen monitors and high-quality webcams and had all software preloaded on their computers. However, few of our clinicians had conducted telepsychiatry consultations from home using home computers, laptops, tablets, and smartphones. As our clinicians started working from their homes, they had to get accustomed to using their own computers and home setups. Therefore, it was critical to have sufficient IT support readily available early on to assist in the conversion process. Our clinicians worked closely with our IT staff to test every aspect of their clinical workflows from home. We recommend that these checks be conducted well in advance of the first scheduled virtual patient consultation.

Patient privacy was a key consideration throughout our conversion planning. We were fortunate to have had two HIPAA-compliant videoconferencing options already in regular use at the clinic (Epic’s MyChart and Zoom). This advantage allowed us to commit to and execute our plan quickly, maintaining full compliance with HIPAA. A number of privacy and security regulations were ultimately relaxed for the duration of the COVID-19 crisis a week after our conversion was complete (3).

For clinics with no prior experience using telepsychiatry, it is critical to invest time in the planning phase to conduct a thorough assessment of equipment, capabilities, and resources. Many laptops and desktop computers have built-in webcams that can be used for videoconferencing. An increasing number of EMRs are also adding video consultation capabilities, and HIPAA-compliant videoconferencing software can be purchased and installed relatively quickly. We also found that patients were amenable to telephone consultations, which may be a viable first-stage conversion while deciding on a supplementary videoconferencing option.

Although it can be tempting to start converting all future appointments to virtual care, our 2-week trial period was critical in assessing clinic workflows and capabilities before committing to a longer time frame. By starting with a trial period, leadership also sets a tone of learning and open-mindedness, which is critical in empowering staff to offer ideas and suggestions that can result in meaningful improvements to workflow.

We recognize that clinics have different baselines of telemedicine adoption, and patient populations can differ greatly by region. Many of these characteristics need to be considered on a case-by-case basis, so a 2-week trial period is reasonable for any clinic considering a rapid conversion. It is also important to recognize that phone appointments are a viable alternative to videoconferencing for virtual consultations, and it is not necessarily essential to transition as aggressively to video consultations when reimbursement is available for telephone appointments, as in the current crisis.