I tried to write it in fairly plain English, unlike my HIPAA form , which is so complicated that I don’t really understand half of what it says.

Although I agonized over this informed consent form for a while, I realized that much of it was fairly straightforward. Many of the risks were technical, the benefit was mostly convenience, and the alternative to telepsychiatry was to do what I’ve been doing.

However, I did put in some language covering specific situations, because I’ve thought about certain potential problems:

• I can’t necessarily get the same information that I would get if the patient and I were face-to-face.
• Emergency care might be harder via telepsychiatry.
• Either the patient or I can call it quits if either of us doesn’t think it is working well.
• Neither of us can make recordings of the session.
• Both of us have to know if there is a potential for anyone else to hear our conversation.

I’m sure that I’ll modify this form as time goes on, but at least it’s a start.

The fact is, the privacy issue isn’t that hard to address. Lots of medical information is encrypted and encryption is the key enabling technology for electronic medical records, so I don’t think it would be that hard to encrypt all the recordings well enough to keep them from public dissemination, at least to the same level of protection that is afforded to paper records. Whenever anyone starts to get excited about medical record privacy, I also point out that, in my opinion, it’s probably a lot easier to get into someone’s medical records by bribing someone in an institution (this is how the tabloids always do it), or to hire someone to burglarize someone’s office than to hack into most medical record systems.

I can think of a lot of good reasons to record people’s sessions. When I had psychotherapy supervisors, I often used to record sessions, and I thought it was a great way for my supervisor to hear exactly what I was doing and saying. More than once I’ve wished for “instant replay” of what happened during a session. Sometimes I’m astonished by what someone thinks that I said during a session, and other times I’ve wished I could listen to what someone said to me. I would also love to go back to recordings of what happened with some of my really challenging cases.

Gordon Bell says that every patient should have the right to have a recording of every interchange with a health professional: every lab, every MRI scan, all medical records, and a video of every interaction.

This sounds like science fiction, but I don’t thing there’s any valid argument against this from the patient’s point of view other than that it’s a little impractical right now. After all, the data are arguably theirs, not mine, and I’ll bet these rights get enshrined in law sooner rather than later. Yes, I know that medical records for my patients are legally mine, but with HIPAA and other laws, patients can pretty much get hold of all their records anyway.

Recording everything might change the dynamic of the doctor patient relationship more than anything else that I can think of. Can you imagine?

Oh, by the way, why don’t I record telepsychiatry sessions now? I’m worried about the law, not security. Can you see how this would play (pardon the pun) in a malpractice suit? I’m not interested in being a test case, but I’ll bet it isn’t very long until someone else is.

In reply, another meeting attendee said: “Why don’t we just put video cameras in the unit, record all the time, and just let the insurance companies drown in the data.” He was, of course, being facetious, but I and others understood exactly what he was trying to say. Much of modern medicine (and, I would argue, most of it in some institutions) consists of “treating the chart” for legal and payment purposes rather than treating the patient.

I recalled this interchange while reading a great pair of books recently: Total Recall: How the E-Memory Revolution Will Change Everything by Gordon Bell and Jim Gemmell and Delete: The Virtue of Forgetting in the Digital Age by Viktor Mayer-Schonberger. You can pretty much guess the topic of the books from their titles, and the authors’ viewpoints on these topics. Bell and Gemmell are taken by just how data about our lives can be collected and stored, even with current technology, while Mayer-Schonberger is carefully warning us to be careful about what we save. Both books are well thought out and carefully written. The authors of the first book are not Pollyannas, the author of the second is not a Luddite. All the authors have thought carefully about how the future will look like in a world with ubiquitous webcams and in which every email, text message, photograph we take and our physical location can be captured and recorded digitally with no intervention on our part required. I recommend both books highly, and it’s definitely fun to read one after the other.

I know there are multiple applications for recording Skype calls, so I know that I could potentially record all my Skype sessions with patients digitally and preserve them. My yet-to-be-approved informed consent form for telepsychiatry explicitly forbids me or the patient from making recordings of our sessions. However, I think the decision to go this way is not a simple knee jerk “patients need privacy so that’s that,” but has some real pluses and minuses that merit some serious discussion, just like the books I’ve been reading.

In my next post, I’m going to blog about the problem of whether interactions between patients and doctors should be recorded. My prediction is that now is not the right time, but that recordings will become part of the standard of care in just a few years.