According to the article, the telemedicine business has been growing by almost 10% annually, and is now a half-billion dollar industry.

One of the issues brought up by the article is a question regarding high end video systems (which are typically proprietary and so expensive that the patient needs to leave home to get to them) and the lower end webcams represented by those that are typically used by people using Skype.

Apparently, members of the Texas Medical Board have raised concerns that “doctors might miss an opportunity to pick up subtle medical indicators when they cannot touch a patient.”

I looked on the Texas Medical Board’s website, but couldn’t find anything there to follow up on the Times article.

I can see plenty of places where the concerns raised by the Texas Medical Board might be valid.

One example would be dermatology. A lot of dermatology is visual pattern recognition, and every couple of months of so when I have a patient with a drug rash, I usually start by looking at the rash under sunlight, rather than under the muted lighting that I usually have on in my office. My eyes are not as good as they used to be, and I think it would be really hard for me to even describe a rash from a webcam image.

Another example would be more prosaic, for example, someone on venlafaxine who needs a BP check. These days, about half my patients have access to a BP machine at home or with a relative, and I have told people to go check their blood pressure and tell it to me. I’m very aware that these drugstore machines aren’t that accurate, but, so far as I’ve been able to see, they tend to be within 10 points or so of what I measure in the office.

The question I would like to ask of the Texas Medical Board would be how many of their concerns would relate to telepsychiatry versus telemedicine.

First, most of the outpatient psychiatrists I know don’t touch the patient often other than to take vital signs, put him or her on a scale, help him or her out of a chair, check for EPS or look at a rash or a wound (with a chaperone in the room if needed).

Second, I know at least three mental health workers with fairly profound visual problems and I’ve never thought for a second about whether their visual problems would affect their care of patients.

It would be hard for me to argue that these mental health workers shouldn’t be working with patients, but that would seem to be a logical extension of some of the Texas Medical Board’s concerns.

With one exception, all the technical troubles any of my patients have encountered have been the very first time that they’ve set up Skype. Although I tell everyone to test it out before they try it for their first appointment, the problem is that some of the people I see don’t know anyone to Skype with other than me. It’s hard to test the system without someone else to help.

I’ve tried to address the problem by now asking people to make one quick Skype call to me before their first appointment if they can’t test things with someone else. Although this wastes a little of my time occasionally, it really hasn’t been that much of a burden (I’ve done this two or three times,  and it never took more than 10 minutes to get everything working.)

The one exception was a problem that turned out to be really hard to fix. My patient had borrowed one of my loaner webcams, got this webcam to work without a problem, and then decided to buy a new webcam for himself. He installed the software for the new webcam, but it wouldn’t work. He did try to call me, but Skype wasn’t working at all. We did the session by regular phone after it was clear that something was wrong and after we had wasted about 10 minutes trying to fix it.

The problem was that he had not de-installed the software from the loaner webcam before installing the software from the new webcam, and that messed up everything until he uninstalled both sets of software (complete with the usual 10 reboots it tends to take Windows to do these things) and re-installed the software for the new webcam.

I’ve actually only had one video call go south in the middle of the session–the person was in a place with a lot of electronics, and I suspect that the problem was on her end, not on mine, but I guess you never know.

So, the score right now is one failed session and 30 minutes of “technical support” time in what have to be 100+ sessions, at least. Not too bad in my opinion. I probably spend as much time keeping my printer working.

I mentioned in my Getting started with Skype for patients post that I was going to go out on Black Friday to see if I could find a couple of inexpensive webcams that I could lend out for patients to try. I wanting to make sure that if a webcam never came back, I wouldn’t be too annoyed.

At Best Buy,  I found a really nice deal on a Logitech C250 webcam for $19.99 (I noticed that it is back up to $29.99 today), so I bought two of them.

They don’t have the face-tracking feature that I like , but I plugged one in and it looks like it will do nicely for a trial run. My plan is to ask the patient to buy a better one if they want to do telepsychiatry, but at least having a couple to lend out makes it possible for someone to see if telepsychiatry is going to work for them.

The only problem that I can anticipate having is that most people use Windows, and I need to remember to tell the people who have used the loaner webcam to make sure they uninstall the loaner webcam software first, before they put on the software for the webcam they buy.

I’ll post again when I have some more experience with this webcam.

Logitech Webcam Pro 9000

which retails for $76.99 at Amazon right now.  I have this camera on my computer in my office. The video quality on this camera and the next one is great. I’ve got a 30″ monitor at home and I don’t see any pixelation on the images from either of these cameras unless I maximize the Skype image to full screen. (When I do this, people almost look cartoonish because their face is about twice life-size!). Audio quality is good, with just a tad bit of echo.

The other is the Logitech 2 MP Portable Webcam C905 / QuickCam Pro for Notebooks

Logitech 2 MP Portable Webcam C905 / QuickCam Pro for Notebooks

the webcam I use at home. Amazon has it for $74.95 right now. This camera is basically on par with the previous one. However, it has one feature, a stand, that makes it my first choice for a webcam, even if you aren’t using a notebook. The camera on the stand looks like this:

Logitech QuickCam Pro for Notebooks on stand

What I’ve found when I set this camera up on its stand, directly in front of my monitor, it really helps the patient on the other end because, as I’m looking at the screen, I’m simultaneously looking directly into the camera, and that means that the video that the patient sees is one where I appear to be looking directly at them. I think that this trick works so well that I’m about ready to give away my Logitech Webcam Pro 9000 and just replace it with another Logitech 2 MP Portable Webcam C905 / QuickCam Pro.

Bottom line: Buy the Logitech 2 MP Portable Webcam C905 / QuickCam Pro. The other webcam is nice, but lacks a stand.

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.

I take care of a patient who can’t always get to her appointments, so I was already doing some work on the telephone with her. I really don’t like to do telephone appointments, but that’s the best a patient and I can do sometimes, and a telephone call beats no contact at all. The problems with telephone appointments are that they take a lot of concentration on my part because I can’t see the person I talking to, and it’s really easy for one of us to misunderstand the other without all the cues that come from being able to see each other.

I had a webcam, and a Skype account already, which I was planning  to use to talk with family members.

The patient and I were trying to unsnarl a minor miscommunication over the phone, when she said:

Wouldn’t it be a lot easier to do this with Skype?”

“Well, I guess we could try it,” I said.

It took about two minutes to get the cameras working, but then we were back to work, and it was clear after about ten seconds that our communication was a lot better than it would have been if we had  both been staring out the window and talking to each other on the phone.

I was really pleased that I had listened to her suggestion.

Through the rest of the day, I though about this Skype call, and by the evening, I was really struck by three ideas:

• I thought that the quality of communication on the Skype call wasn’t quite as good as a face-to-face meeting, but it was amazingly better than  just using the telephone,
• I could see that using Skype for psychiatry could potentially lead, not just to some big changes in my practice, but in psychiatry in general, and
• I had no idea what I was doing.

So, I decided to find out a little more about telepsychiatry, and since I had been thinking about something fun to blog about, I decided to chronicle what I discovered in case other people might be interested.