We’ve had a lot of snow for Maryland this year, and getting around has been a challenge.

Dr Daviss points out that the current regulations would preclude him using telepsychiatry from his home to an inpatient unit and billing Medicaid, primarily because the regulations are totally focused on institution to institution situations where each site is basically a mental health facility or a medical facility, not where either the doctor or the patient is at home.

It’s like Maryland has just caught up to the fact that videoconferencing software exists after it’s been around for decades, but totally ignores the reality that lots of people have access to something like Skype. Hello! It’s the 21st century now. I’m aware that the public mental health system has a lot of economically disadvantaged people in it and that not all of them have Skype at home. However, I’m sure that some do because having a computer is a lot like having a car these days; it’s pretty hard for most people to live without one, even if you’re poor. Yeah, some people in the public mental health system don’t have telephones either, but the majority do.

There is also a “degree of separation” issue going on here. Although I’ve certainly met people who didn’t know exactly what Skype is, I haven’t met very many who don’t know someone in their family who uses it. I suspect that there are plenty of people in the public mental health system who could get some kind of access to Skype if they really wanted to, and if it could save them a long bus trip to a clinic in the inner city, why shouldn’t they be able to do that? If you think about it for a second, giving someone a $30 webcam to use with their computer at home is really nothing. If they get a blood test for screening or a medication level, that costs more than a webcam. Even in the public mental health system I haven’t heard of anyone being begrudged a basic metabolic panel.

I could speculate on whether this would help the no show rate in public mental health clinics (usually astronomically high), but I don’t know if it would really make a difference there.

The situation Dr. Daviss talks about is very striking. Here, he’s got Skype (or something like it, I assume) at home. Why shouldn’t he be able to Skype in to an inpatient unit and do his examinations? I can’t think of any good reason why he shouldn’t.

A few years ago I was one of two attendings on the inpatient service during a blizzard, and ending up being snowed for the weekend at the hospital. I did a little psychiatry, but a lot of paperwork because other doctors couldn’t get in and I was stuck there anyway. The normal contingent of attendings on the weekend was five, so having only two there stretched things pretty thin. The drag wasn’t really being stuck in the hospital or taking care of sick people, it was doing boatloads of routine paperwork so the hospital could get paid from payers like Medicaid.

It was a weekend, so I was covering for other people, and didn’t know any of the patients. It’s hard for me to think that my care of most of the patients in the hospital was better than it would have been if the attending responsible for the ward that month would have been able to Skype in, take care of the routine stuff for the patients he or she already knew, and leave the real emergencies to me.

Last week, I needed to see a patient on an emergency basis, so I made an appointment to see him last Saturday. Unfortunately, it was snowing that day, and my patient had to come quite a distance to see me.

The reason I needed to see the patient was to make enough of an assessment to decide whether or not he could be treated as an outpatient, whether he should go into the hospital when a bed opened up, or just go to the nearest ER and get admitted that way.

Having worked as a resident in the ER in the past, I used to despise all the mental health workers who just dumped their problems on the people in the ER. I became very familiar with certain local psychiatrists, who clearly had no mechanism to handle any kind of minor emergency, so they just sent anyone who called them out of business hours to the ER. I always make some kind of effort to see if the patient’s problem can be settled somehow before telling them to go to the ER.

Anyway, while waiting for my patient to show (delayed because of the weather), I thought about how great this situation would have been for a Skype visit rather than a face-to-face visit. First, the whole thing would have been a lot more convenient for both the patient and me. Second, the visit would have taken place on time, not later. Third, I honestly think my exam was worse because my patient was very stressed by the time he got to my office, and I believe I could have done a better exam if he wasn’t so distressed.

Probably safer to be off the road, too.