Psychiatrists typically have limited physical contact with patients, but we often check weight and vital signs when we prescribe certain psychotropic medications. Results from home- and drugstore-based blood pressure monitors may not be accurate enough for treatment purposes. Remote communication also reduces the quality of visual information,20 which can be crucial—for example, when good lighting and visual resolution is needed to decide whether a skin rash might be drug-induced.
Telemedicine raises concerns about licensure and meeting adequate standards of care. Medical care usually is deemed to have occurred in the state where the patient is located. For example, only physicians licensed to practice medicine in California are legally permitted to treat patients in California. As is the case with any treatment, care delivered via telemedicine must include appropriate patient examination and diagnosis.21
Help and guidance
Despite these potential drawbacks, many state agencies recognize the promise of telemedicine, and have developed networks to promote it (Table 2).7-9,22,23 These networks have various goals but share a common pattern of establishing infrastructure, policies, and organized results. In the future, states may adopt laws or regulations that address conflicts in malpractice standards and liability coverage, licensing, accreditation, reimbursement, privacy, and data protection policies that now may impede or inhibit use of telepsychiatric services across jurisdictional boundaries. Last year, Ohio produced regulations to guide psychiatrists in prescribing medication remotely without an in-person examination. The University of Hawaii suggested steps that its state legislature might take to help providers predict the potential legal ramifications of telemedicine.6
Further help for telepsychiatry practitioners may be found in practice standards and guidelines developed by the American Telemedicine Association.24,25 These documents gave guidance and support for the practice of telemedicine and for providing appropriate telepsychiatry health services.
Table 2
Telemedicine services available in different states
| State/Network | Description |
|---|---|
| Arizona www.narbha.org7 | The Northern Arizona Regional Behavioral Health Authority manages a comprehensive telemental health network (NARBHAnet) that uses 2-way videoconferencing to connect mental health experts and patients. It has provided >50,000 clinical psychiatric sessions |
| Kansas www.kumc.edu8 | The University of Kansas Medical Center provides specialty services (including telepsychiatry) through 14 clinical sites in rural Kansas. Cost-sharing helps the telepsychiatric application be successful |
| Montana www.emtn.org9 | Eastern Montana Telemedicine Network is a consortium of not-for-profit facilities that link health care providers and their patients in Montana and Wyoming. This telemental health network includes shared sites for all physicians practicing in the network and has yielded large out-of-pocket savings for patients |
| Oregon www.ortelehealth.org22 | The Telehealth Alliance of Oregon, which began in 2001 as a committee of the Oregon Telecommunications Coordinating Council, was created by the legislature and has served as advisors to the governor and the legislature regarding telecommunications in Oregon |
| Texas www.jsahealthmd.com23 | The Burke Center provides services to people in 12 counties in East Texas. It uses telepsychiatry services to conduct emergency evaluations, therefore keeping people in mental health crises out of emergency rooms |
What should Dr. A do?
In answer to Dr. A’s question, many factors favor including telepsychiatry in her practice. Yet we know little about the accuracy and reliability of psychiatric assessments made solely via Skype or other remote video technology in ordinary practice. Legislation and legal rules about acceptable practices are ambiguous, although in the absence of clear guidance, psychiatrists should assume that all usual professional standards and expectations about adequate care apply to treatment via Skype or other remote communication methods.
Related Resources
- Skype. www.skype.com.
- American Telemedicine Association. www.americantelemed.org.