Adventures in telepsychiatry

I’m not a legal expert, but my understanding of what “standard of care” means is that I need to do what any ordinary, prudent psychiatrist would do in my community under similar circumstances.

I guess what I’ve been thinking about is the term “prudent.”

I’m sure that most psychiatrists in my area aren’t using video Skype with their patients, so I guess “ordinary” doesn’t apply anyway, but I’m beginning to wonder whether it is prudent to avoid the use of telemedicine these days.

As I’ve mentioned before, the usual criticism of telemedicine is that it may not be as good as face-to-face in some circumstances. I completely agree that that criticism is true. However, often the proper comparison is not between video telemedicine and face-to-face visits, but between telephone call medicine and video telemedicine.

I would be surprised if there was any valid argument that video Skyping someone would be worse than calling them on the telephone. After all, you get the same information as you would get on a telephone call, but with a video call you also get to see the patient as well as talk to him or her.

I’m aware of plenty of situations where I’m sure that the local “standard of care” would dictate that I really need to see the patient, not just talk with him or her on the phone. I’m aware of at least one physician who got into trouble for basically just refilling patient prescriptions over the phone for years and never seeing the patient face-to-face to make sure that there was some oversight over whether the patient really needed to be taking the prescription in the first place. I’m pretty sure, but not certain, that I can’t just manage a patient indefinitely but talking to him or her on the phone for a few minutes and never really seeing them in the office.

A doctor can’t do everything over the telephone; that’s pretty clear. I’m sure that I can’t do everything with Skype either; that’s pretty clear, too.

But I wonder. There’s a lot of things that I do that I feel pretty comfortable doing on Skype that I don’t feel as comfortable doing on the telephone.

We’re back to the same problem of comparison that I started out this blog entry with. It seems to me that there are some cases where a prudent psychiatrist would do something after having a Skype video conversation but not after a telephone call.

It seems to me that “prudent” is going to include at least the possibility of telemedicine for many psychiatrists fairly soon. Whether or not they want to do it, at some point it’s going to be unavoidable because I believe enough people will adopt it that there will be the same kind of network effect that happened with fax machines. Having the only fax machine in the world is useless, but at a certain point you pretty much have to have one because everyone else does.

I’m not sure that having a fax machine is the standard of care in my community, but I can’t think of anyone who doesn’t have one, and I would sure would hate to try to explain why I didn’t do anything if something went wrong because labs couldn’t send me faxes and everything went through the mail.