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Doc Punished For Treating Patients Via Skype: What To Make Of It?

September 20, 2013


This post first appeared on WBUR’s CommonHealth blog

Last week, the Oklahoman news Website NewsOK.com reported that Dr. Thomas Trow, a doctor living in “far Eastern” Oklahoma (read: towns few and far-between), had been disciplined for treating patients over Skype for mental health issues.

He was accused of prescribing them medications without ever having physically met with them; his response was that his nurse traveled to satellite clinics to meet the patients and present them via Skype.  Also, NewsOK reported, “He stated that he did not think he had to see patients in person since they were psychiatric patients.”

According to the complaint against him, one patient overdosed three times in six months, NewsOK reports.  “The patient known as R.C. died while under Trow’s care — as did two other patients during the same time — but investigators said Thursday that those deaths were not attributable to Trow.”  The penalty: “Trow was placed on probation for two years and ordered to complete a course on prescribing practices,” NewsOK says.

Telemedicine run amok?  Or a reasonable rural strategy that went awry?  We asked Dr. Joseph C. Kvedar, founder and director of the Center for Connected Health at Partners HealthCare, to comment.

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.

29 Comments leave one →
  1. September 20, 2013 2:31 pm

    Seems to me that Skype could be a red herring in this case. All doctors are not created equal and we don’t know much at all about the quality of care delivered whether it be via remote video consults or face to face. Having an established relationship with at least one in person visit annually is the model used in Texas for patients with diabetes and it seems to work very well.

    • September 20, 2013 5:18 pm

      I agree, the preexisting relationship is important, at least at this point in history

  2. JLNDewitt permalink
    September 20, 2013 3:19 pm

    I hate to hear about the sad result of an overdose, as my own son perished the same way. However, I also hate to hear that Skyping is being considered a part of why that death occurred. As with any medication, I’m sure that the doses were very clear on the label, and if this patient had visited with the doctor in the office, he/she would have walked out with the same prescription. I hope that Skyping becomes nation wide, and accepted by all insurance carriers. I recently moved across country, and I am not able to keep the psychologist that I have seen for the last 3 years because Aetna won’t cover Skype visits. I didn’t even pursue checking out whether Skype visits are legal in the state I left and in my new residence, since it wasn’t covered. My doctor and I both felt that this would have been a workable way for us to continue my visits. Thankfully, he has already helped me a lot and I probably was on my way to switching to a once a month model, but now I can’t talk to him at all. I don’t want to start all over with a new therapist… it took two years to just get through all the grief issues I was dealing with. I don’t want to have to retell all of the events concerning my son’s death. I would also like to have the Skype option for visits with my internist. He’s been my doctor for 9 years and I would like to keep my patient relationship with him because of the trust level I have with him. Obviously, I would have to return to his office for physicals, but yearly physicals are now being considered not necessary for everyone. I do have one medical issue that needs to be overseen, but all of that can be done 3 or 4 times a year via phone, patient portal, or Skype. I do need to find someone here in case of any acute problem that might come up, but I would like to be able to consult with him as well. Skyping is going to work, but it’s important not to jump to conclusions by blaming the medium for patient problems, and in this case… a tragic ending.

    • September 20, 2013 5:19 pm

      great testimonial. well stated

    • September 26, 2013 2:47 pm

      I use Skype for business everyday and also use it to stay in touch (voice and video) with a sibling that lives overseas.

      I see great value in using this technology with my medical providers, especially when traveling to their office doesn’t make sense. On Skype, our doc see us and hear the tone and or concern in our voice. Skype is great tool for communication and I hope healthcare and insurance companies get on board with its value.

  3. September 21, 2013 12:36 pm

    Daily we conduct therapeutic interventions via our own secure Skype like platform; as well as via a professionally managed peer community and guided learning programmes. It would be tragic if one case deterred the potential for hundreds of thousands of people experiencing mental distress (of whom 75% receive no treatment whatsoever) to access support and recovery services. Our LiveTherapy platform achieves 12% better recovery rates, as defined by the British Department of Health, than offline services under the Government Improving Access to Psychological Therapies programmes. Yet governance is critical including risk screening, regular monitoring through clinical tests, clinical supervision and clear protocols to escalate when someone appears to be in crisis.

    When medication is involved, best practice as this time would suggest that, it is better to have an in person consultation but that follow up and monitoring can be performed well remotely.

    More research is needed but it is clear that traditional service models fail dismally to address the nature and volume of mental disorder globally. One has only to look at the continuing epidemic of suicide amongst veterans in the USA to realise that new models are needed to reach people that will never access traditional services. Over 85% of the Serving Personnel using our services have never presented their poor mental health to their doctor.

    We know from our research that enabling 24/7 access to digital support and treatment results in saved lives and less demand on services, such as emergency rooms, that are ill-equipped to deal with mental illness. In the coming year we are going to track this through an integrated intervention at population level to look at how services that have little or no barrier to engagement truly impact at societal level on, for example, presentation in A&E and the incidence of violent crime as well as suicides.

    For now, let us remember that people are using all kinds of technology for self-treatment every day. Apart from improving clinician’s informed utilisation of digital, we need also to look at enhancing people’s ability to keep themselves safe online.

  4. Paul Dattoli permalink
    September 26, 2013 12:59 pm

    Very interesting article and I agree with your conclusions. Personally I am an advocate for using Skype in this manner to touch base with my primary care physician. If I am traveling and require medical assisatnce I would prefer to see my doctor before I step into any foreign place for treatment. I would prefer that he could see my face in this case rather than only hear my voice. I would have no problem signing an agreement to confer with my primary care physician in this manner.

    • September 26, 2013 1:58 pm

      Thanks Paul for this and all of your thoughtful comments.

  5. m conley permalink
    September 26, 2013 1:04 pm

    I think there are subsets of patients who are treating for mental illness. Some patients are treated for minor to moderate anxiety or depression.These patients may have good insight into their medications and treatment plan and may well benefit from a skype follow up. Other mental health patients belong to a high risk population, that include other co-morbidities. These patients often need a face to face medication reconciliation to help them stay on track, and prevent medication errors. The future of any of these technologies will depend on the competency and discretion of the providers who utilize them.

    • September 26, 2013 1:58 pm

      yes, of course, ‘mental health’ is not a monolithic group. Our experience is that targeting those healthcare interactions that are of low emotional exchange and highly algorithmic works best. Your first group would seem to fit in this category.

  6. Ron Pion MD permalink
    September 26, 2013 1:08 pm

    Please take time to review Zoom.us website. I believe it could become a de-facto standard for virtual visits.

  7. September 26, 2013 1:13 pm

    I agree with you Jen. Novel communication platforms are tools that can be used to improve patient outcomes by enhancing physician availability. However, the right system structure for the right patient or group of patients, needs to be determined.

    Nice article. Thanks.

  8. September 26, 2013 1:21 pm

    I encourage you to read Volume 173 (No.1) of Jama Internal Medicine which looks at a direct comparison of the quality of patient care from physician e-visits and in-person doctors visits. Researchers looked at some 8,000 patients with sinus infections and urinary tract infections between 1.2010 and 5.2011.
    The study found that for both patient groups 7% or less returned for another consultation withing three weeks, suggesting that those treated through a telehealth platform did not have higher rates of misdiagnosis or treatment failure.
    Furthermore, the MAMA researchers found that patients treated through an e-visit pait 21% less than those treated during an office visit.

    Interesting, factual information with statistical relevance for the future of telehealth.

  9. Mike Mazzola permalink
    September 26, 2013 1:34 pm

    I found this article and the comments well done. There is not a one size fits all for remote care so investigation and guidance on proper application is required. But what I find sad is the resistance by tradition care to apply these innovative services in a more timely way. Yes it takes time to get it right but we are losing many more people everyday because of this painfully slow process. It does not have to be this way. Patients want this and will increasingly demand it. Let’s clear the smoke and make it happen.

    • September 26, 2013 1:54 pm

      Well stated. Juan Enriquez, who spoke at last year’s connected health symposium has a phrase for this phenomenon. he calls it “medicine’s missing measure’ – the idea that we don’t measure lives lost because of inaction as much as we measure the cost of mistakes.

      here’s one example of his talk http://www.youtube.com/watch?v=jXHqG2sf8S4

  10. Kenneth Drude, Ph.D. permalink
    September 26, 2013 4:25 pm

    It is interesting that the Oklahoma Medical Board does not mention the use of Skype or videoconferencing in disciplinary actions against Dr. Trow. The minutes of the medical board at http://www.okmedicalboard.org/meetings/rs201309.pdf only states the following “Disciplinary hearing alleging dishonorable/immoral conduct, prescribing violations, narcotic law violations, medical records violations, and dishonorable or immoral conduct likely to deceive/defraud/harm the public”

    • September 26, 2013 4:43 pm

      I did not source verify the original article in the Oklahoma newspaper.

  11. September 26, 2013 5:45 pm

    Don’t think of Skype as a convenience for the Doc; think of it as helping the patient, eliminating travel, and offering easier or more frequent access when needed.

    Think of the elderly who can’t drive and must rely on a friend or caretaker to bring them, and the need for taking time off from work to do that, or the impact to health when the appointment is delayed until it’s more convenient to travel.

    Think of the anxiety that many patients face when visiting a doctor office compared to that of a Skype call.

    Think of how multiple parties can be included in the call so all are on the same page with the care plan, including Doc, patient, specialist, family advocate, paid caretaker, etc.

    Think about the economic implications and the effect on workplace productivity (their’s not yours), as well as the relief from traffic congestion, demands for fuel, environmental pollution, etc.

    Think about the advantages of remote and real-time sensor monitoring, including placing simplified medical equipment in the hands of patients themselves.

    Then think about future regulatory issues, such as how to allow telehealth across state lines, or international borders. Who will or should provide the regulatory oversight and licensing?

    And think of the implications of supercomputer analytics and knowledge systems like IBM’s Watson. What functions will move from specialist to PA, NP, RN, LVN, aide, or the patient themselves and what it will take to support that?

    Will the profit incentives of a powerful medical industry get in the way of progress, or potentially push it too quickly? Are we using technology for medical efficiency to increase profit, or medical efficacy to improve patient care? And is the risk of using new technologies greater than the benefit they provide?

    I look at these issues not from the perspective of a physician but from that of a technologist, futurist and consumer advocate.

    • September 26, 2013 8:12 pm

      Wayne, You totally nailed this! Thank you for bringing the patients’ needs to the forefront. Isn’t patient care what we’re trying to improve today – provide best-in-class medical care that is cost effective and meets the needs of the patients? I know that there is push back from medical professionals when patients are identified as their customers, but heh, we are their customers!

    • September 26, 2013 8:14 pm

      well stated. thanks!!

  12. September 26, 2013 11:02 pm

    Reblogged this on healthcare software solutions lava kafle kathmandu nepal.

  13. September 27, 2013 3:29 am

    To get trained during medical carrier is essential to avoid malpractice. Please join the demand to update University medical training.

  14. September 27, 2013 9:19 am

    As medical director of a company providing telestroke services to Oklahoma for years, I can attest that in that state for a physician to have an interaction via teleconferencing equipment(and security/encryption is a must in this system), there must be another physician on the other end of the call. This is state board policy. We adhere to this policy in every state we practice, as it is common sense as well.

  15. September 27, 2013 3:05 pm

    The official CMS policy reads as follows:

    “The use of a telecommunications system may substitute for a face-to-face , “handson” encounter for consultation, office visits, individual psychotherapy and pharmacological management”
    I don’t think Skype is the issue in this case. It must be a doc him self. Also physician should use Telemedicine service with HIPPA and encryption. Skype is very open source.

    Also Medicare pay for Telehealth in following

    1-Real-time telehealth: Remote patient face-to-face services seen via live video conferencing.

    2-Store and Forward :digital images, video, audio, and clinical data are captured and “stored” on the client computer or mobile device; then at a convenient time they are transmitted securely (“forwarded”) to a clinic at another location where they are studied by relevant specialists.

    3-Telehealth services : remote monitoring, the patient has a central system that feeds information from sensors and monitoring equipment, e.g. blood pressure monitors and blood glucose meters, to an external monitoring center. This could be done in either real time or the data could be stored and then forwarded.

  16. September 29, 2013 7:17 pm

    thanks. was not aware of widespread reimbursement for store and forward (only Alaska and Hawaii) nor any for remote monitoring. do you have examples?

  17. December 4, 2013 1:33 am

    What’s up, I log on to your blog on a regular basis.
    Your story-telling style is witty, keep doing what you’re doing!

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