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.