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.

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?

So, a video call is probably almost always preferable to a telephone call for psychiatry. I can think of a few exceptions, such as when it isn’t appropriate for one of the parties on the call to show themselves or their environment. For example, I’ve certainly answered a telephone call after just getting out of the shower but that wouldn’t be the right time for a videocall!

So, I think it is hard to argue that whatever standard of care exists for conducting psychiatric care via a telephone is being compromised by a videocall. In fact, I could easily see an argument someday, not so far in the future, when a doctor is being questioned along the lines of “did you think of a videocall to the patient rather than a telephone call?,”  just like the question that comes up now sometimes, “did you think that maybe you should have seen the patient rather than trying to handle this over the phone?”

The interesting comparison here is thus not between a telephone call and a video call, but between a videocall and a face-to-face visit.

All the information that comes through in a face-to-face visit comes through my senses, so going through them one-by-one:

Hearing

Voice quality on most telephone and videocalls is pretty good these days. As long as the microphone is of reasonable quality, close to the speaker’s mouth, and the line isn’t too noisy, I can’t see that there would be much difference in how much auditory information gets through when the visit goes through a videocall versus what I hear when I’m face to face with them.

Smelling

Well, nothing like this comes through the Internet, so face-to face-wins  here. Most of what I do as a psychiatrist doesn’t involve scent, but I can think of three examples:

• Smelling marijuana or alcohol on someone
• Noticing an excessive amount of perfume on someone, and
• Noticing that someone is not being attentive to personal hygiene

Tasting

Can’t taste through the Internet, but I can’t think of any time that I can remember getting any important information that way when I was face to face with someone, except once when a patient brought me one freshly made chocolate chip cookie when she came for an appointment.

Touching

Tactile information doesn’t come easily via the Internet. (I understand though that tactile feedback is extremely important  in situations like robotic surgery.) For psychiatry, there are a few times that touch is essential.

• I can’t get a blood pressure or a pulse on a videocall.
• I can’t push on someone’s ankle to see if he or she has pitting edema.
• I can’t do a point-to-point movement evaluation. (But I can think of a sort of comical equivalent.)

Although touch can sometimes be important, there isn’t much psychiatrically important information that comes that way through in a face-to-face interview.

Seeing

This is where almost all the the potentially clinically important differences between telepsychiatry and face-to-face psychiatry arise. I need to write about this in more detail later, but two things are obvious right away.

First, the visual information I get in a face-to-face interaction is much more detailed. When I first started doing Skype, I was delighted that video quality was good enough to see someone’s eye color or the shape of the earrings someone was wearing. I will bet though that this kind of degradation of visual information isn’t going to be very important in a short time–just look at any decent HDTV these days and you can see the pores on someone’s face. It’s pretty easy to predict that technology will close this gap relatively soon.

Second, if I’m face to face with someone I can glance over towards  her hand as  she reaches for a cup of water and see if she has a tremor without calling this bit of information gathering to her attention. Technology to remotely control a camera already exists and I don’t think it would be that hard for webcams to have a remotely controlled sensor. I’m not sure this will catch on.  I can imagine a scene like a bad science fiction move with the little robot eyeball looking around.

In summary, it looks to me like there’s really not much difference between face-to-face and telepsychiatry in terms of sensory input most of the time.

I’ve not talked about here something really important—the psychological impact of face-to-face versus telepsychiatry—and I need to think about that some more.

• Does it work?
• Is it legal?

I wasn’t as concerned about the first question right away–after all, every doctor I know makes decisions based on telephone conversations with his or her patient–so I doubted that using Skype instead of a telephone was really going to get me in trouble as long as I checked to make sure that Skype met HIPAA standards.  I decided to put the Skype question aside for a bit and go to the  Maryland Board of Physicians website to find out whether they had anything on regulations relating to telepsychiatry. The website didn’t have a search feature, so I decided to I used the advanced search feature of Google, typed

telemedicine site:http://www.mbp.state.md.us/

in the search box, and got three results.

The first result, from 1999, was useful, and contained a half-page titled, “Internet prescribing does it meet the standard of care?”   and subtitled “We don’t think so!”  Basically, what the article said was that licensing boards across the US were becoming interested in telemedicine and that each board needed to decide exactly where medicine was being practiced when the physician is in one place and the patient is in another. According to the article, the Federation of State Medical Boards took the position that:

The practice of medicine occurs where the patient is. Thus, an out-of-state doctor using telemedicine to diagnose and treat a patient residing in Maryland would have to have a Maryland license or be acting as a consultant to a Maryland physician who has a bona fide doctor/patient relationship with the patient. Maryland physicians also should remember that if they practice medicine on patients elsewhere in cyberspace they are practicing in Maryland.

This made some sense to me because it that’s the way medical licensing works—doctors have to get licensed in every state they see patients.  So, it looked to me that so long as both the patient and I were both in Maryland when the telepsychiatry session took place, I wasn’t breaking any laws so far.

The next paragraph in that first article brought up another interesting point:

And now another issue has presented. Web sites have sprung up which advertise the availability of prescription medications on-line. No prescription? No problem. For a fee, an on-line consultation is available. The patient fills out a questionnaire which asks a number of health related questions. The questionnaire is submitted to the medical consultant and if the patient is approved, the patient is then assessed a fee for the consultation (generally $75) and the desired medication is subsequently provided by mail. All one needs is a credit card and the “right” answers, and medication is speeding on its way to his or her home in a “plain naked mailer.”
The BPQA has serious concerns about this practice. Let’s say the patient wants a drug like Viagra. Is an on-line questionnaire about the patient’s past medical history really a medical consultation? Does a bona fide doctor/patient relationship exist when a person, previously unknown to the consultant, provides subjective answers to such questions as: “Do you have a heart disease?” Would a physician providing prescription medications to a patient based on a questionnaire be meeting the standard of care?

Well, I knew I wasn’t interested in slinging out prescriptions over the Internet, and I couldn’t really imagine doing telepsychiatry with anybody whom I hadn’t examined in person, so I was decided to find out about prescribing over the Internet on another day.

The second article that Google found was just an annual report from 2006 saying that the board was going to propose some regulations for telemedicine.

The third article had some proposed regulations, but I was unsure whether any of these regulations had actually been adopted. Basically, the regulations said:

• I was OK with a Maryland license as long as the patient and I were both in Maryland, and
• I had to disclose some things to the patient like my MD license number, and a few other routine items,
• That I had to do a real evaluation of the patient, but that doing an evaluation via telemedicine seemed legal,
• I had to get an informed consent form together, and
• I needed to keep the usual medical records and obey the usual laws.

However, I had no idea whether these regulations were in force, so I wrote an email to a person named in the third article, and asked whether these regulations were in effect or not.

So far, so good. It looked like telepsychiatry was probably legal in Maryland, but I still wasn’t sure. I was surprised that the Maryland Board of Physicians didn’t seem to have done much of anything since 2007.