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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マーキュリアル 新作オークリー ジュリエットニューバランス m996 グレーWesley Valdesmedicalquack Recent comment authors
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マーキュリアル 新作
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オークリー ジュリエット
Guest

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ニューバランス m996 グレー
Guest

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medicalquack
Guest

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… Read more »

Martin
Guest

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… Read more »

David Harlow
Guest

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… Read more »

Rob
Guest

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… Read more »

Rashad
Guest

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,… Read more »

Michele
Guest
Michele

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… Read more »

Wayne Roffer, Psy.D.
Guest

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.

Joe Kvedar
Guest

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.

Wayne Roffer, Psy.D.
Guest

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… Read more »

Wesley Valdes
Guest
Wesley Valdes

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… Read more »

userlogin
Editor

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… Read more »

Joe Kvedar
Guest

Well stated.