Tech

A Physician Faces Disciplinary Action For Seeing Patients on Skype — Early Guidelines For Patient Video Visits

The medical board of the state of Oklahoma recently sanctioned a physician for using Skype to conduct patient visits.  A number of other factors add color to the board’s action, including that the physician was prescribing controlled substances as a result of these visits and that one of his patients died.  This situation brings up several challenges of telehealth — that is, using technology to care for patients when doctor and patient are not face-to-face.

• Legal/regulatory: On the legal side, physicians are bound by medical regulations set by each state.  It appears that the use of Skype is not permitted for patient care in Oklahoma.

• Privacy/security: Skype says its technology is encrypted, which means that you should not be able to eavesdrop on a Skype call.  That would seem to protect patient privacy.  At Partners HealthCare, we ask patients to sign consent before participating in a ‘virtual video’ visit.  Because this is a new way of providing care, we feel it’s best to inform our patients of the very small risk that their video-based call could be intercepted.  I don’t know if the Oklahoma physician was using informed consent or not.

But the most interesting aspects of this case involve the question of quality of care.  Can a Skype call substitute for an in-person visit?  Under what circumstances?

Video virtual visits are a new mode of care delivery.  Whenever anything new comes up in medicine, it is subject to rigorous analysis before entering mainstream care.  That same rigor applies to video virtual visits.  Although some studies suggest virtual visits can be useful, the evidence is not yet overwhelming.  I can’t say with 100% certainty how virtual visits will best be used, but based on several pilot programs under way at Partners, I have a hunch or two.

We have believed for some time that this technology should be limited to follow up visits, where the patient and physician already have a well-established relationship.  Technologies such as Skype and Facetime allow for a robust conversation, but most doctors’ visits require much more than just conversation.  For example, any time a physical exam is required, this technology will not work well.  That’s why one of our first pilot studies was to implement video technology for mental health follow up visits (as did the doctor in Oklahoma).

Our early results are promising.  It seems that virtual video visits for mental health offer both the provider and the patient important benefits.  For many mental health patients, it can be stressful to travel to the doctor’s office.  When a patient is being evaluated for a medication adjustment, for example, they are not at their best.  The convenience of having a follow-up visit from their own home can be a big lift for these patients.  On the other hand, doctors often feel that the home environment is particularly relevant in sorting out mental health problems.  A virtual visit allows them to, in effect, conduct a virtual house call.

I’ve been working in telehealth for almost 20 years and the most successful use of technology fills a void in care delivery.  It’s not just about conducting an office visit virtually, but improving on the traditional care model.  It looks like virtual visits for mental health may do that, and that’s exciting.

So where does that leave us with the situation in Oklahoma?  It leaves us in an unclear place.  If the doctor was providing virtual follow-up visits to patients that he has a good relationship with, I’d stick my neck out and maybe disagree with the state board.  If, on the other hand, he truly was giving advice and prescribing sedatives to patients he’d not met before, that could legitimately be cast as an error in judgment.

Of course, it’s not my place to decide.  But the story does provide a nice backdrop to think about how technology is changing the way care is delivered and what your follow-up visit might look like in the near future.  We have to do the studies, so don’t ask your doctor to Skype you just yet, but I’m optimistic that this technology will change health-care delivery for the better — and soon.

Joseph Kvedar, MD is the Director of the Center for Connected Health at Partners Healthcare. This post originally appeared at cHealth Blog and WBUR’s CommonHealth blog.

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15 replies »

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  4. HIPAA final rule page 8342, lower right hand corner, last paragraph: because “paper-to-paper” faxes, person-to-person telephone calls, video teleconferencing, or messages left on voice-mail were not in electronic form before the transmission, those activities are not covered by this rule”. Not that there aren’t a number of other laws and security best practices that should be followed for telemedicine and video-conferencing but HIPAA – at least for the video conferencing piece is pretty clear on the issue. It needs to be noted that many, if not most, of the consumer video conferencing solutions also incorporate instant messaging, the ability to record, and chat – all of which would create data in electronic form – and may be subject to HIPAA if they are considered a BA. The new rules also clarify what entities need to have BA agreements in place vs what entities don’t. See http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/businessassociates.html for examples. The third bullet point on “other examples” should answer this issue as well as video conferencing companies and telephone companies are conduits for information as an act of normal business processes.

  5. Back in 2011, I called it “Redneck Telehealth” and yes we need more details here but when you need help, use the resources you have available. Couple years ago had client who had a foot issue and was overseas, told him to get on Skype with his MD, put that foot up there for the doctor to see…as he would not go to a foreign doctor for help. This is just logic..

    http://ducknetweb.blogspot.com/2011/05/and-now-word-about-redneck-telehealth.html

    It’s been a couple years since that post and there’s been a lot of technology developed and in use since that time, but who has it available for use and how many can afford it is perhaps another question…sounds like this is one of those “context” issues..your context, my context, or who knows who else s context is in here:)

  6. I think this is a very slippery slope because there are circumstances where virtual video calls allow doctors to regularly ‘see’ patients that otherwise won’t or can’t be able to get to the clinic but there are a number of instances where it isn’t as effective as a personal visit to the clinic.

    Being a part caretaker of my dad who suffers kidney disease and needs to regularly visit the doctor, the presence of mobile phones and skype are a God send. They allow us to quickly get in touch with the doctor when things happen. Many times, the questions are trivial but because you don’t know what do to or if you should worry about a new symptom or not it takes one 5 second answer from the doctor via skype or call not having to drive a couple of hours to the clinic for a 10 second chat.

    On the other hand, when you need to be physically checked or seen by the doctor, it isn’t always the best to get things done this way. Doctors listen to your lungs, take your BP and do their other physical checks to get a better understanding before making a diagnosis. These things can be blurred or problematic if don’t over the line. I think in that particular issue, the prescription and issues that came up including the deaths really put light into the practice, but care has to be given with this liberty not to abuse it but also not to shut the door to letting physicians reach patients quicker, better and more regularly.

  7. HIPAA sets very stringent encryption requirements for data that is stored, as well as “data in motion” (ie transmitted).

    For “data in motion”, such as that transmitted via a clinical video system, the cryptographic algorithms have to be validated by the National Institute of Standards and Technology (NIST) Computer Security Resource Center under what is known as Federal Information Processing Standard 140-2 (FIPS 140-2).

    FIPS 140-2 defines the requirements for encrypting sensitive data, such as protected health information (PHI). In order for covered entities to be compliant with HIPAA when transmitting PHI, the program they are using must use a FIPS 140-2 validated cryptographic module.

    Skype is not FIPS 140-2 validated, nor do they use a cryptographic module that is. In this case, Skype cannot be considered an “approved telemedicine system”.

    States may further define the type of system that is appropriate for delivering telemedicine (telephone but not email, audio/video but not phone, etc), but you can be sure that any such clinical video system will have a FIPS 140-2 validated cryptographic module.

    Just because a program uses encryption doesn’t mean it meets the requirements set forth by HIPAA.

  8. I’m writing to echo Joe’s and Michele’s thoughts — The best use of a new technology is to extend care rather than to replicate care provided through other channels. Unfortunately, here as in other arenas, the regulatory system is always a step or two behind the state of affairs “in the wild.” Some more-enlightened state medical boards and third party payors have already recognized the legitimacy of telemedicine; some of those boards have also adopted lightweight licensure requirements for out-of-state docs who wish to provide telemedicine services in-state, and those payors have approved payment for these services. As we edge further away from FFS medicine, the payor side of the story will matter less. The licensure issue remains, and it will remain, because of a mix of turf issues and quality of care issues. Is an in-person visit really necessary? For what kinds of services? As the quality of sounds and images transmitted over the internet improves, can we reach a state of affairs where no in-person visits should be required? In an effort to stay ahead of the curve, I would like to see state medical boards addressing these issues in a proactive, rather than a reactive, manner, so that they can be better prepared to deal intelligently with the current and future rush of telemedicine issues.

  9. Not sure what an ‘approved telemedicine system’ is. I asked our technical experts and the encryption that Skype publishes is better than most commercial videoconferencing software. I am not aware of anything definitive on Skype and HIPAA, so would not be so quick to condemn.

  10. Isn’t it crazy to squash a convenient form of communication like this? I understand this doctor was trying to cheat, but the discipline for using a communication modality that is “not approved” seems as bit regressive. It seems that most office visits have very little hands-on exam done, with the majority of time (aside from that dedicated to patient waiting and doctor documenting) spent getting a history. What is the real difference of seeing the patient in person? What is the real advantage? If the person then needs to get their chest listened to, they can come in, get that done, and then leave – a task that can take a few minutes.
    Good care is about good communication, and using tools that will make that communication happen better should be encouraged, not subjected to draconian judgments like this one. Again, the real problem was the doctor’s drug mill, not the use of telemedicine. If these tools can be used to improve care and to make it more convenient, why not encourage it?
    Unfortunately, the answer is this: not enough paperwork can be filled out for privacy, informed consent, agreement to pay, release of information, etc. The rules are more important than the ones they are meant to serve. We subject patients to horrible customer service in the name of obeying rules.
    Are we not smarter than this?

  11. The only impediment that’s truly holding back telemedicine is that there are no established CPT codes among Big Payers to bill for virtual visits.

    In my experience researching my company happyhealth.me, physicians value a virtual visit at the same rate as an office visit reimbursement: $100, $200 whatever; patients value a virtual visit at the co-pay amount: $20, $30, etc.

    Unfortunately, only insurance can come in and bridge that gap, because most patients won’t pay the doctor’s expected amount, and most physicians won’t accept patient expected amount.

    The liability risk is just a function of creating well-documented informed consent verbiage, and setting up the proper process workflows.

  12. I had the same thoughts as the previous poster. I too would like to know more about this story…What if this provider was giving care to patients that had no other option? What if they lived so far away from a doc that getting there was prohibitive? People who live close to care have no idea how far most of rural America lives from a provider. Many rural folks never even see an MD/DO but only see a mid-level provider or nurse or even just an MA.

    At clinics I’ve worked at, when a child comes in for a well visit, they’re given up to 8 immunizations because depending on the circumstances, the provider’s worried that they may not see that child again and better to give them all the shots and know that the child will have some protection — is THAT good medicine? Depends.

    All I know is that most providers I meet are genuinely concerned with the patients they treat. Providers are overworked (you MUST see 18 patients a day now) — get all their charting done, read and assess all the labs, oversee staff. We expect them to do it all and when someone comes up with a creative way of doing it we punish them.

    How “healthy” is healthcare — for patient? for provider?

  13. According to NewsOK, the disciplinary action was for two violations: 1) use of Skype which is not approved for telemedicine in Oklahoma (and really should not be used at all anywhere since it does not meet HIPAA encryption requirements), and 2) prescribing medications without ever seeing the patient.

    Most states require that physicians see patients in-person prior to prescribing medications over telemedicine communication systems.

    It is alleged that this physician never saw the patient (who eventually died under the physician’s care) in-person for an initial evaluation prior to prescribing medications.

  14. This is the kind of smart, out of the box use of technology that should be encouraged. It’s cheap. It’s effective. And it goes a long way to eliminating a problem we’ve been struggling to deal with for years — getting doctors into places where we don’t have any doctors.

    If nothing unfortunate had happened, the physician involved would be being praised as a hero. Instead he’s being punished. Without knowing the details involved, I’m hesitant to comment further on the case, but …

    State medical societies everywhere should be taking this issue up and thinking about developing reasonable guidelines and policy. International guidelines are probably a good idea too, for that matter …

    This can make a huge difference ..

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