Using Skype for patient visits: A doctor is sanctioned

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 is director, Center for Connected Health, Partners HealthCare. He blogs at The cHealth Blog. This article originally appeared in WBUR’s CommonHealth.

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  • Kathy J. Shattler

    I agree with using virtual visits in cases such as you suggest. Just the other day I saw my dr. and he walked in told me I had inflammatory bowel disease and food allergies with no physical exam, normal labs and no food allergy testing. Compare care.

    • http://truthexposed123.blogspot.com/ jimi

      what do you mean? he diagnosed you without doing any labs?

  • John C. Key MD

    Regulatory agencies as a rule erect barriers to improvement and progress in better patient care. In this case I’m not clear as to whether the sanction was due to use of Skype or rather from inappropriate prescribing. If it is the former, the Board should “butt out”–whether Skype or another digital technology is used should be between the doctor and his established patients–the negligible risk of confidentiality breaches should be one that the patient is allowed to take.

  • NPPCP

    I am inclined to make a snap judgment, but won’t. Let’s hope it was for inappropriate prescribing. The board has no business nosing into a physician utilization of technologies such as Skype. They are just trying to do what the overseers are demanding – use digital technology. If this did have anything to do with Skype – this is yet another reason (going to raise some hackles, I know) to have more non-physicians (citizens) on the state medical board.

    • Michael Rack

      I am all for adding non-physicians to the Medical Board, but how would adding a few more ministers or golfing buddies of the state governor help?

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Regarding privacy and security, Skype which is owned by Microsoft now, is one of the specifically named suppliers of bulk data to the NSA. The fact that something is “encrypted” means very little these days.

    Using something like this, particularly for mental health, is probably not a good idea, unless that informed consent clearly states that your consultation may be recorded and accessed by government agencies, and their private contractors, at will.

    • NPPCP

      It’s kind of a catch-22. Who ISN’T monitored by the NSA? We can only do the best we can with what we have. We can’t afford the $25,000 “special telemedicine” equipment so if the bosses want this to take off and save dollars by virtual visits, something will have to give. I like the informed consent route and go ahead with it.

    • May Wright

      I agree with you in principle, but the same holds true for a patient-physician phone call if either the physician or the patient is using AT&T or Verizon phone service.

      We need to reign in the government somehow. As long as they feel that they can do anything they want and are accountable to no one, there’s going to be no patient-physician interaction that’s guaranteed safe from them.

      We need to repeal Bush’s “PATRIOT Act”, and put at least as much time and effort into enforcing the Fourth Amendment as we do the First and Second. In my dreams there would be a bipartisan lobby group as powerful as the NRA, but instead of protecting peoples’ Second Amendment rights they’d be protecting their Fourth:

      “The right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures, shall not be violated, and no Warrants shall issue, but upon probable cause, supported by Oath or affirmation, and particularly describing the place to be searched, and the persons or things to be seized.”

      • NPPCP

        Speaking the obvious. Great post. Forgot all about the fact that we use telephones which are monitored more than anything!

  • KJK

    This is very interesting to see that more of healthcare is moving this way. In the not to distant past telepharmacy became a big feature, where the pharmacist is not actually within the store in some locations and instead the main individual that the patients see is a technician. For a lot of patients and pharmacists a like this came as a surprise and not a very well taken advance. It leads to some of the same questions, with the pharmacist not within the walls of the pharmacy how can they really double check what the technician does, how can they smell the medications or look at the markings or see whats in that opaque bottle? how can they talk the patients and see their reactions and understand the patient as a whole when they are some 50 to 500 miles away? but in some places this works. I guess this is just an advance that we will all have to tweak until it is perfect and learn to accept it because it is a way for us as healthcare providers to provide care to the masses that may not be close to anyone or anything else.