Adventures in telepsychiatry

There’s a good article from last Saturday from Voyager Telepsychiatry,  “Prescribing without Physical Proximity“  on the issue of prescribing in psychiatry without a face-to-face evaluation.

Although of uncertain legality in many states, the article points out that prescribing without a face-to-face evaluation appears to be explicitly legal in:

• New York,
• California,
• Texas, and
• Maryland,

and explicitly illegal in:

• Florida and
• New Jersey.

Clearly, the Federation of State Medical Boards should probably help the states get together on this issue because of the inconsistency.

I assume that the intent of the state boards is to try to make it clear that prescribing for patients with only a minimal “evaluation” is outside the standard of care. (Think filling out a five question true-false questionnaire as an “evaluation” for getting Viagra.)

It seems to me that rather than getting involved with whether face-to-face evaluations somehow magically trump Skype-based ones, the real issue here is whether anything close to a real evaluation is being done, not the medium of communication. I find it hard to believe that any questionnaire with five questions constitutes an evaluation. I also find it hard to believe that if I were to spend 90 minutes talking to someone on Skype that I haven’t done a reasonable evaluation.

In this post and this post I’ve talked about how telepsychiatry may not be ideal in certain situations, but I would also add that many face-to-face evaluations aren’t ideal either, but, so far as I know, few would be willing to argue that this means the standard of care is being violated.

There are sometimes language barriers or communication issues due to the patient’s illness. Sometimes patients aren’t totally candid, I’m not able to build good rapport, or they show up for their first evaluation so late that we have time for a “hello,” a very directed evaluation for safety, and a “goodbye,” before scheduling another visit to finish what we should have gotten done on the first visit.

Circumstances in psychiatry, and in medicine in general, are seldom ideal for evaluation. In my mind, at least, the questions that I ask myself are:

• Did I get as much useful information as I could, given the time available?, and
• Did I recognize what information I didn’t get?

I would argue that these are the key clinical questions to answer before prescribing for someone, not whether the evaluation took place face-to-face or over the Internet.

By the way, this article made me think about my own policy of not doing an initial evaluation over the Internet. Right now, the only issue that I can think of, other than my own uncomfortableness with the idea, is that the Maryland Board of Physicians proposed guidelines say that I somehow have to make sure of the identity of the person I’m prescribing for. I understand that the guidelines are trying to help prevent fraud, but is the situation that much different than when someone comes to my office? I certainly don’t ask to see everyone’s driver’s license before I give them a prescription for the first time. Is this something that I am supposed to be doing? Does anyone know a simple way for me to meet the MD Board of Physicians requirements?