IACAPAP President’s Message – Sept 2020 – Finding the e in Child Psychiatry

By Dr Daniel Fung, IACAPAP President, Adjunct Associate Professor, Lee Kong Chian School of Medicine Singapore

My first encounter with Telemedicine was in the year 2000.  The turn of the millennium was touted as a potential end of world event because of the risks of Y2K as it was then called.  I was about to spend one full year in Toronto, Canada, understanding the practice of child psychiatry outside the warmth of our Singapore womb.  Thrust into North American and Canadian psychiatric practice, with an entire family of 4 kids in tow (and one to come as my son, Peter was born in the bitter cold of one of Toronto’s coldest winters in 21 years).  But my time at the Hospital for Sick Children (amiably called Sick kids) was really eye opening for me, particularly in the use of the eHealth and telemedicine.  That year, I attended a digital health conference in Montreal; watched a video conference between mental health professionals in Toronto speak with some of the colleagues up north, hundreds of miles away; and started a support group for selective mutism along with a website which I created called the “Quiet Room”.  I learned (a little) HTML and how we could develop WYSIWYG (What you see is what you get) websites and how, even then, the hospital was already encouraging their clinicians to develop web content for the hospital’s website. The use of the web in education and clinical practice was already quite established.  And I was intrigued by the possibilities in child and adolescent mental health practice.  Yet fast forward to 2020, we are still struggling globally to really harness the technology into clinical practice.  When the pandemic struck in the early months of 2020, and we realised the need to continue our practice while reducing physical connections, it was obvious that telepsychiatry would be the way forward.  Yet many detractors emerged and discouraged the use of technology to connect with patients citing risks and dangers as if this were something new.  The concerns ranged from technological flaws (security, bandwidth, and poor access to equipment) to digital hesitancy or even downright phobia.

I thought that I should share a little of what I have learned over the years on telepsychiatry in child and adolescent mental health practice and why this old form of technology enabled treatment may be the new normal.  Let us start by understanding what telemedicine in general is about.

As defined by WHO, the broader construct of eHealth refers to the use of information and communication technologies (ICT) for health. Telemedicine definition adopted by WHO in 2007 was “The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities” Parts of this definition is no longer valid in today’s context with the need for infection control measures.  I would simply say it is the use of ICT to improve connections with patients.  In its simplest form, it consists of a virtual consultation in which the physician and the patient are physically distanced but connected by voice or visuals.  The oldest form of telemedicine would conceivably be that between a doctor and their patient speaking over the phone.  The telephone has been a critical part of medical practice connecting physicians, other team members, patients, and families.  I have certainly remembered having teleconferences over the phone with multiple parties speaking about patients and sometimes with families alongside.  By 1980s, the use of videoconferencing became commercially available and rapidly became popular with the use of voice over internet protocols (VOIP) and Skype.

Medicine was slower in taking this up, but you get the picture.  It was now possible for doctors to connect with patients in both audio and visual means.  One of the biggest problems with medical practice is the considerable efforts that we make in doing things according to respected and time-honoured traditions.  Innovations that disrupt these practices are looked at with suspicion at best and paranoia at worst.  Imagine if you would before the invention of the stethoscope, physicians use to bring their heads onto the chests of their patients and that would be regarded as standard practice.

With the advent of better and faster technologies, the ability to communicate both verbally and in visual contact made it incredibly attractive to see patients across vast distances, restricted only by time zones. In fact, the regulatory landscape is beginning to consider how to license such practices. In Singapore, we have moved away from premise-based licensing to service based licensing with our new Healthcare Services Act (HCSA) which passed into law by parliament early this year.

What are the imperatives for telemedicine today?  The fact that populations are familiar with commercial devices that help them connect in many of their daily activities, whether it is in obtaining goods (shopping) or services (ordering food).  The increasing availability of products that help monitor health such as apps and wearables add to this. In fact, a survey by Foley (check reference) showed that in America, 76% of health leaders are developing and implementing telemedicine technology with 73% satisfied with its use. More importantly, the people want this.  In America, more than 64% of the patients are open to a video visit.

Telepsychiatry is the practice of psychiatry in Telemedicine and we certainly should be the first on this bandwagon because psychiatry is all about conversations and connections. We spend long periods listening and looking at our patients.  These are quite easily accomplished with the present telepsychiatry set ups.  And I say this in the simplest way, for patients using the ubiquitous cell phones, to speak with their doctors and reduce the need for face to face visits.  In fact, telepsychiatry can bring new ways of connectivity and interactions that were previously difficult to arrange.  One example that comes rapidly to mind is the family session and the ability to connect with everyone regardless of where they are, assuming that a quiet, privacy-enabled spot can be found.

Telepsychiatry is also not restricted to a physician patient consult for clinical purposes, it is also about telemonitoring, for remote data collection and response to dynamic emotional states; telecollaboration which is the professional interactions for clinical purposes such as case conferences and discussions on care arrangements and finally; tele support which is case management or information sharing with patients and their families and caregivers.  Many of these things already exist around the world. Project ECHO developed in New Mexico in 2003, at its very heart is a telecollaboration platform.

This year was supposed to be our 24th World Congress in Singapore but instead of the usual meeting, for the first time in our history, IACAPAP will be holding a virtual congress from the 2-4 December.  This too may prove to be another form of telecollaboration.

Child psychiatrists and allied professionals in our field must learn to embrace this new normal and develop new standards to improve global mental health.  The Joseph M Rey IACAPAP Textbook of child and adolescent mental health  is commissioning a new chapter on Telepsychiatry led by two leaders, Kathleen Myers and Patricio Fischman who will undoubtedly bring new knowledge and explanations on how this can be accomplished across the world, safely, accurately and with cultural relevance.


IACAPAP Bulletin, Issue 59