Telehealth Best Practices: Alexandra Emery of Grit City Psychology On How To Best Care For Your Patients When They Are Not Physically In Front Of You

Ask where your patient is located. It’s best practice to ask for a specific address at the beginning of each of your telehealth appointments. That way, should an emergency arise, you know where to send help.

One of the consequences of the pandemic is the dramatic growth of Telehealth and Telemedicine. But how can doctors and providers best care for their patients when they are not physically in front of them? What do doctors wish patients knew in order to make sure they are getting the best results even though they are not actually in the office? How can Telehealth approximate and even improve upon the healthcare that traditional doctors’ visits can provide?

In this interview series, called “Telehealth Best Practices; How To Best Care For Your Patients When They Are Not Physically In Front Of You” we are talking to successful Doctors, Dentists, Psychotherapists, Counselors, and other medical and wellness professionals who share lessons and stories from their experience about the best practices in Telehealth. As a part of this series, I had the pleasure of interviewing Dr. Alexandra Emery.

Dr. Alexandra Emery is a licensed psychologist who provides telehealth therapy and assessment services throughout the Greater Seattle area. In therapy, Dr. Emery works mainly with adults struggling with stress, perfectionism, anxiety, and trauma-related concerns. In assessment, Dr. Emery specializes in ADHD and mood disorders in both teens and adults.

Thank you so much for joining us in this interview series! Before we dive in, our readers would love to “get to know you” a bit better. Can you tell us a bit about your ‘backstory’ and how you got started? Can you share the most interesting story that happened to you since you began your career?

As so many 2020 grads can attest, graduating in the middle of pandemic was rough. I knew that I wanted to start a private practice after graduation, but to become licensed as a psychologist you must first pass the EPPP (the Examination for Professional Practice in Psychology). Studying for the EPPP is approximately a 3–6 month process (sometimes longer, everyone has their own path). I began studying in August, and waited until October to finally be approved by my state licensing board to sit for the exam. I scheduled the exam on December 18th. I think anyone could imagine how stressful it is to plan for such an important exam. On December 16th, two days before I was to take my exam, I got an email stating my exam had been canceled, with no other details available. I sat on the phone with the testing company for hours to find out that they were canceling exams due to new Covid restrictions, with no ability to reschedule in the area. I was devastated. My partner immediately started looking for the closest exam location possible, and found one for the 18th at a small technical college in Butte, Montana, a 12 hour drive and two mountain passes away from our home in Tacoma. We jumped in the car Thursday and I took and passed my exam on Friday.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

I always like to say “people do the best they can with the resources they have at the time.” This is a mantra I developed out of my research and practice in self-compassion. As a greater culture I think we can be really hard on ourselves, and thus really hard on other people. This quote always grounds me when I’m struggling to have compassion for myself or for others. While it doesn’t fit 100% of the situations I encounter, it fits the good majority. I believe we as humans are inherently good, but we don’t always have all of the resources to do good.

None of us are able to achieve success without some help along the way. Is there a particular person who you are grateful towards who helped get you to where you are? Can you share a story about that?

I met my partner of 10 years, Kolton, when we were just freshman in college. He was a D1 baseball player studying to become a civil engineer, and I was a psychology major because it sounded cool. He was focused, driven, and hardworking, and I was admittedly a bit lost. I had never been a strong student, but I started going to the library because I wanted to spend time with him. The more time in the library I spent, the better my grades became, and the more confidence I gained in my own academic ability. I went from the threat of academic probation my first semester to graduating with honors. He provided endless support through my master’s and PhD programs, and continues to support me as I build my practice. To say I would not be a psychologist without him is a vast understatement.

Ok wonderful. Let’s now shift to the main focus of our interview. The pandemic has changed so many things about the way we behave. One of them of course, is how doctors treat their patients. Many doctors have started treating their patients remotely. Telehealth can of course be very different than working with a patient that is in front of you. This provides great opportunity because it allows more people access to medical professionals, but it can also create unique challenges. To begin, can you articulate for our readers a few of the main benefits of having a patient in front of you?

Accessibility is the main benefit that comes to mind. People who may not have had the time to dedicate toward driving to an appointment, finding parking, waiting in the office, etc., can now log in from any private space that they have, significantly cutting down on the time needed to access care. Patients have been able to make consistent appointment times over their lunch breaks, while their child sleeps, or in between meetings, which has been great for many. Additionally, before telehealth patients were generally limited to practitioners in or around their area, but through telehealth they have access to practitioners who may be in their state but are a bit further away, creating a more diverse range of services that are available to any given patient.

On the flip side, can you articulate for our readers a few of the main challenges that arise when a patient is not in the same space as the doctor?

Our body language often says what we cannot verbally say. It gives so much data to the practitioner, but can also be a tool that the practitioner uses to help the patient gain insight into their own experiences they may not have otherwise noticed. When someone is tapping their foot, crossing their arms, fidgeting with their jewelry, these are often signifying something deeper going on, and are much easier to pick up on in person. Having a space that is fully committed to the work you are doing in treatment can be another plus of in-person care. It can be hard to avoid distractions when you are seeing your provider in the same space where you eat, work, relax, interact with family members, etc.

Fantastic. Here is the main question of our interview. Based on your experience, what can one do to address or redress each of those challenges? What are your “5 Things You Need To Know To Best Care For Your Patients When They Are Not Physically In Front Of You ? (Please share a story or example for each.)

1. Ask where your patient is located. It’s best practice to ask for a specific address at the beginning of each of your telehealth appointments. That way, should an emergency arise, you know where to send help. Asking patients to sign a telehealth specific consent form is a must, and in this form, leave spaces for your client to fill in their emergency contact person, nearest emergency room, nearest police department, and a back-up phone number they can be reached at. Additionally, licensure in some states require that the patient is located in the state at the time of treatment, so this can help with your documentation that you abiding by these regulations as well.
2. Are they in a secure, private space where they can freely talk? Some patients may not think it’s a big deal if they put headphones in and are in the same room as other people, but this can impact their willingness to share. You as the provider also need to be able to consent to who is in the room when you’re providing treatment. Though this point may seem obvious, it’s better to have these conversations up front, and to put your policies in your consent form.
3. Be mindful of how you are presenting yourself, just as you would in an office. Get dressed as you typically would, make sure your background is appealing and distraction free, and attempt to look at the camera when you are talking to the patient (not at the little box of yourself talking, though this is tempting), so that they rightfully feel like your focus is on them.
4. Test out your technology. Ensure the technology you’ve selected is HIPPA compliant. Make sure your internet connection is solid at the beginning of each appointment. Have easy access to the patient’s back-up phone number if technology fails (which it inevitably will sometimes).
5. Just because you are technically more accessible with telehealth, doesn’t mean you should be accessible at all times. Try to maintain the same boundaries you would with your practice in person. If you don’t feel well, reschedule your appointments. Don’t take appointments outside of your scheduled working hours just because you’re technically free. Avoid keeping your work phone or email on you at all times when you’re technically not “at” work. Practicing good self-care, though often discussed in theory, is essential to avoiding burnout as a telehealth provider.

Can you share a few ways that Telehealth can create opportunities or benefits that traditional in-office visits cannot provide? Can you please share a story or give an example?

This question brings be back to the accessibility of a diverse range of care. I recently joined an assessment practice and I’ve been amazed at all that we have been able to do via telehealth. For example, one client could meet virtually with one provider to do the testing in Seattle, and another for the clinical interview and feedback sessions in Tacoma. On the backend, HIPPA secure telehealth platforms have made communication among professionals both seamless and secure. This ultimately makes our work as providers more efficient, but also has the potential to cut down costs for the patient because we are using less of our time scheduling meetings to communicate in person.

Let’s zoom in a bit. Many tools have been developed to help facilitate Telehealth. In your personal experiences which tools have been most effective in helping to replicate the benefits of being together in the same space?

HIPPA secure telehealth platforms and EHRs (Electronic Health Records) have been instrumental in allowing me to get as close to in-person as possible. The video technology has gotten really good, allowing me to pick up on things like body language if the client is in view. Being able to communicate with patients through my EHR, but also to send appointment reminders or important documentation has allowed me to provide all of the same resources (and sometimes even more) that I would offer in person.

If you could design the perfect Telehealth feature or system to help your patients, what would it be?

It’s not so much a telehealth feature, but more the limitations to telehealth on a state-by-state level. Sometimes I have clients who are in my state when we begin treatment, and then the need to move or go back to college in a different state, and as licensure stands right now (at least in Washington), I have to terminate treatment with them. I always try to help them to find a new provider where they are going, but it would be great if we could continue treatment since we are meeting by telehealth anyways. I know there are a lot of discussions right now about therapy across state lines, and I’m hopeful for some changes in the future. While I understand that each state has it’s own regulations, it would be really great to have more unity across states in both licensure and regulations when it comes to healthcare.

Are there things that you wish patients knew in order to make sure they are getting the best results even though they are not actually in the office?

It can be really helpful to do all of the same thing you would otherwise do when attending an in-person appointment. Getting dressed, logging into your appointment on time, and silencing your phone are all little things you can do to get more out of your appointment. I also cannot stress enough how important it is to have a private enough space where you feel like you can talk freely the way that you would in-person. If you are living with others and afraid they may overhear you, try to schedule your appointment when they will not be home, use a sound machine or put white noise on your phone (YouTube has many free options) and stick it by the door to help muffle sounds. Make sure you set boundaries with the people you live with so they are not coming in and interrupting your appointment time.

The technology is rapidly evolving and new tools like VR, AR, and Mixed Reality are being developed to help bring people together in a shared virtual space. Is there any technology coming down the pipeline that excites you?

I have heard it’s been useful for those doing exposure work with anxiety and post traumatic stress disorders. I also could see these tools being useful for testing if we continue with the trend of people wanting remote and accessible care. There are some assessments that we have to meet in person to administer, and having some sort of virtual reality where patients could follow prompts and manipulate objects the way they would in person could be really cool.

Is there a part of this future vision that concerns you? Can you explain?

I think like with any technology or new approach I’d like to see some standards of care developed for their use. It’s my understanding that these technologies aren’t super widely used in psychology yet, so the more development, research, and training available for those who want to use them, the better.

Ok wonderful. We are nearly done. Here is our last “meaty” question. You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. :-)

I would create a movement toward greater self-compassion. I see so many people struggling because they are so incredibly hard on themselves. There is a lot of pop-psychology about constant motivation, pushing yourself, always striving for better, and while these concepts seem okay on the surface and maybe even do work for some people, they can leave you feeling like you are never enough, and you never have enough. Contrary to popular belief, harsh self-criticism is actually self-sabotaging instead of motivating. I’m not talking about taking accountability or owning your mistakes, these are prosocial behaviors, I’m talking about the kind of negative self-talk that is damaging to your sense of self-worth and makes you want to hide away from the world. Self-compassion involves treating yourself like you would a close friend, and incorporates changing your self-talk, using mindfulness to remain present through difficult emotions, and connecting with others, things we could all probably use a bit more of. For more information about self-compassion, Dr. Kristin Neff has a ton of free resources on her website, self-compassion.org.

How can our readers further follow your work online?

I’m in a couple of different places. I can be found at my therapy private practice at www.gritcitypsych.com or on Instagram @gritcitypsych. I recently joined a group practice focusing on assessment, which is www.relationalpsych.group.

Thank you so much for the time you spent doing this interview. This was very inspirational, and we wish you continued success.