Telepsychiatry has several advantages over face to face psychiatry, but undoubtedly the most compelling is the virtual elimination of AFAT.
“AFAT” is an acronym I coined myself and it stands for “Atom Fool Around Time.”
The idea behind this acronym comes from a book by Nicholas Negroponte written in 1995, called “Being Digital.” Negroponte’s book was, and still is, completely on the mark with regard to understanding how the Internet has changed and will change our world going forward.
Negroponte starts with a simple distinction. Most of what is important to us in the world is either something that weighs something (“atoms”), or something that weighs nothing, like information (“bits.”)
Houses, people, chairs, and nose rings are atoms; Music, books, almost all money and the map in your GPS are all bits. Now, to be sure, something like a printed book weighs *something*, but the essence of a book isn’t the paper it is printed on, but the information that it contains. I would argue that my copy of The Lost Symbol on my Kindle is just a much a real copy as the one on sale this week at Walmart. Take your favorite music CD and break it in half. It still weighs the same, but the music is gone–the information that makes the music play weighs nothing.
Weightless bits fly through the Internet to me at close to the speed of light and cost essentially nothing to transport; Atoms come to me by cars, trucks, airplanes, ships and trains and cost real money to move from one place to another.
This is a long winded introduction to what I think telepsychiatry’s greatest advantage is over face-to-face communication. When a patient and I see each other we are usually exchanging information, not atoms. If the most important thing is information, then does it really make sense for the patient to fool around with hauling his or her atoms to come see me for every visit? I don’t think so.
I’ve already made it clear that atoms can be important, even vitally so, but is equally important to notice that seeing people face-to-face rather than via a videocall has big transaction cost which seems to be unnoticed by many people: To have a face-to-face visit, the doctor or patient or both have to drag their atoms into proximity to each other. This has a cost, just like it costs Amazon thousands of times more money to send me a physical book than to send some bits to my Kindle. The transaction cost of a face to face visit is not just gas, parking fees, office overhead and the risk of a car accident. There is also a psychological cost. At times the streets outside my office are jammed with cars and patients come in late and stressed. Sometime their car breaks down. Sometimes they are late to pick up their kids at school. Sometimes they miss something else because of their commute time.
I spoke to a colleague last week who told me clearly that he could see no reason for telepsychiatry and thought face to face was always better. He works in a location which is hard to drive to, expensive to park at, and staffed by so many poorly paid and surly employees that one of my other patients refers to this place as having a “patient prevention plan.” My colleague can see the possible disadvantages of something new like telepsychiatry, but can’t see any of the costs that he and his patients incur by his belief that only face to face contacts could work to help his patients.
AFAT has a big cost, it’s just that most people don’t see it. Telepsychiatry eliminates a lot of AFAT. That’s why there”ll be more telepsychiatry in the future.
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Same comment I left at Voyager: I think you put too much emphasis on HIPAA, and OCR enforces the law, not CMS. Read my post: http://behavenetopinion.blogspot.com/2009/08/its-nice-to-be-nace-not-covered-entity.html
You need to look at MD statutes, too. And what about your malpractice carrier? Will they cover you for this? Can you claim insurance?
I testify in malpractice cases. If there’s a bad outcome it will be very easy for a plaintiff’s expert to hang you out to dry for not meeting standard of care.
Having said all that I wish you the best. H1N1 cannot be transmitted via Skype. People will die this year because they went to a doctor’s office and transmitted it. Shame on our government and professional associations, esp. APA, for dragging their feet on this. It needs to happen yesterday.
moviedoc,
Thanks for leaving comments. I don’t have a forensic practice and I agree that what you do would probably be a lot trickier to do with Skype.
With regard to the “standard of care” question you bring up, I agree with you that someone could probably produce someone who would testify that doing psychiatry by Skype didn’t meet the standard of care, just like I’m equally sure that someone who was paid enough would come forward to testify that every psychiatrist should do a complete neurological exam on every patient on every visit, or that no one should ever try to help out a patient by changing medications after a telephone conversation rather than making them come to the office to see me.
On the other hand, I think that the fact that Maryland is in the process of adopting regulations for telemedicine , that Dr. Rushkin and others at the University of Maryland have done a study showing comparable outcomes for the treatment of patients with depression by telepsychiatry , and that the APA has published some guidelines on doing telepsychiatry would at least help me argue that what I was doing was not as way out as, say, Bach Flower remedies as a treatment for ADD.
I agree that any change comes slowly to medicine, and that I can name a few of my colleagues who feel that doing anything via Skype is way outside anything that they would feel comfortable with.
I haven’t asked my malpractice carrier–as far as I know they don’t forbid telepsychiatry, but I doubt they’ve endorsed it either.
I had not seen your blog post before and found it very interesting. I also agree that HIPAA is terribly confusing to doctors and patients alike, and the unintended consequences of the legislation have been huge.
I appreciate your comment that medical professional organizations are more than a little bit behind on things like telepsychiatry. I’m working on a series of blog posts regarding just how much of a disruptive innovation telepsychiatry will turn out to be. I hope you might find them interesting as a forensic psychiatrist. “Standard of care” is just the beginning of some of the issues that I can see being important here.
I was surprised to see the APA Resource document (not guideline — That’s what we need.) is 11 years old. It is a start, tho.
You should ask your malpractice carrier. I plan to ask mine very soon.
Maybe I’m not reading carefully enough, but why Skype instead of a regular telephone or video conferencing setup? Cost? Maybe the patient should pay for that. In the old days I knew a doc who required patients to reimburse him for long distance calls.
If you haven’t already look down south. Seems like I heard years ago Eastern State Hosp had some kind of telepsychiatry pilot.
It won’t be hard to find remedies more way out than tele-any kind of medicine.
moviedoc,
The reason why I’m so focused on Skype right now is really for the reason that you’ve mentioned. Old-style video conferencing tends to be expensive and cumbersome. I work at Johns Hopkins and have seen technical difficulties with these systems all the time. Skype, on the other hand, is free to use and requires a $50 webcam (which may already be built into someone’s laptop).
I’m just learning about a lot of this stuff–I realize I don’t even know that much about what’s going on here in my own state, but I realize that there’s an active group at the University of Maryland. I’m also beginning to write draft posts on two recent documents from the American Telemedicine Association: Practice Guidelines for Videoconferencing-Based Telemental Health and Evidence-Based Practice for Telemental Health. Lots of good stuff coming out all the time.
Time to pull my head out of the sand. Had no idea how much progress we’ve made. I gotta get me one of those. And here I’ve been trying to determine the feasibility of dispensing drugs from my office. Better to get rid of the office.
The part about firearms is quaint. Do they really think this is a rural only issue? And how many of us are qualified to educate anyone about firearms? And I found way too little attention to treatment of substance use disorders. To me it’s just medication management, but there are special considerations.
What can I do to make behavenet.com a better tool for educating patients during a televisit? I’m converting the whole site to database. Now is the time to make it telefriendly.
Speaking of firearms, a patient can’t assault her psychiatrist via Skype.
I really enjoyed reading this article, keep on posting such exciting stuff!
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