Dear Dr. Mossman:
I practice in a region with few psychiatrists and very little public transportation. For many patients, coming to my office is inconvenient, expensive, or time-consuming. Sometimes, their emotional problems make it hard for them to travel, and sometimes, bad weather makes travel difficult. I am considering providing remote treatment via Skype. Is this a reasonable idea? What are the risks of using this technology in my practice? — Submitted by “Dr. A”
Diagnosing and treating patients without a face-to-face encounter is not new. Doctors have provided “remote treatment” since shortly after telephones were invented.1 Until recently, however, forensic psychiatrists advised colleagues not to diagnose patients or start treatment based on phone contact alone.2
The Internet has revolutionized our attitudes about many things. Communication technologies that seemed miraculous a generation ago have become commonplace and have transformed standards for ordinary and “acceptable” human contact. A quick Internet search of “telephone psychotherapy” turns up hundreds of mental health professionals who offer remote treatment services to patients via computers and Web cams.
Physicians in many specialties practice telemedicine, often with the support and encouragement of state governments and third-party payers. To decide whether to include telepsychiatry in your psychiatric practice, you should know:
- what “telemedicine” means and includes
- the possible advantages of offering remote health care
- potential risks and ambiguity about legal matters.
Defining telemedicine
Studies of remote, closed-circuit “telediagnosis” extend back more than 4 decades, closely following mid-20th century advancements in audio and video relay technologies that made space broadcasts possible.3 Then as now, “telemedicine” simply means conveying health-related information from 1 site to another for diagnostic or treatment purposes.4 It’s an adaptation of available technology to deliver care more easily, with the goal of improving patients’ access to care and health status.
Telemedicine usage accelerated as the Internet and related technologies developed. Telemedicine programs in the United States increased by 1,500% from 1993 to 1998.4 Telemedicine use has grown 10% annually in recent years and has become a $4 billion per year industry in the United States.5 Recently enacted federal legislation is likely to extend health care coverage to 36 million Americans and require coverage of pre-existing conditions. To make these changes affordable, health care delivery will need to exploit new, efficiency-enhancing technologies.6
Advantages of telemedicine
State governments and some third-party payers have recognized that telemedicine can overcome geographic and cost barriers to health services and patient education.5,7-9 Although closed-circuit video transmission has served this purpose for some time, Skype—free software that allows individuals to make video phone calls over the Internet using their computers—is an option that doctors are using to treat patients.10-12
Research suggests that telepsychiatry may provide huge benefits to medically underserved areas while reducing health care costs.4 Telepsychiatry can reduce travel time and expenses for professionals and patients, and it also may lower wait times and “no-show” rates (Table 1).4 Telepsychiatry lets patients see caregivers when winter weather makes roads unsafe. It may allow geriatric patients who can no longer drive to access psychiatric care and it lowers health care’s “carbon footprint,” making it “eco-friendly.”13
Social media strategies are playing an expanding role in medical education,14,15 and this probably will help practitioners feel more at ease about incorporating the underlying technologies into work with patients. Increased use of laptops and mobile phones lends itself well to telepsychiatry applications,13 and studies have examined the feasibility of psychotherapies delivered via remote communication devices.16 Smartphone apps are being designed to assist mental health professionals17 and consumers.18
Table 1
Potential benefits of telemedicine
| Category | Benefit(s) |
|---|---|
| Access | Patients can see specialists more readily Addresses regional doctor shortages Reduces health care disparities between urban and rural areas |
| Urgent care | Facilitates information transfer for rapid interventions |
| Productivity | Provides a conduit for clinicians to share skills and expertise Facilitates remote monitoring and home care |
| Cost | No travel costs Alternative revenue stream for health care organizations that offer more broadly delivered medical services |
| Patient-centric care | Care is taken to the patient Translator services are more readily available |
| Source: Reference 4 | |
Potential pitfalls and drawbacks
Although convenience, access, cost, and fossil fuel savings may favor video-chat doctor visits, telemedicine has downsides, some of which apply specifically to psychiatry. First, no current technology provides psychiatrists with “the rich multidimensional aspects of a person-to-person encounter,”19 and remote communication may change what patients tell us, how they feel when they tell us things, and how they feel when we respond. Often, an inherent awkwardness affects many forms of Internet communication.20
Also uncertain is whether Skype is compliant with the Health Insurance Portability and Accountability Act and protects doctor-patient privacy well enough to satisfy ethical standards—although it probably is far better than e-mail in this regard. Third-party payers often will not reimburse for telephone calls and may balk at paying for Skype-based therapy, even in states that require insurers to reimburse for telemedicine.