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Skype With Patients: Helpful or Harmful?

September 30, 2013
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In case you didn’t hear, out in far eastern Oklahoma, Thomas Trow, M.D., was disciplined earlier this month for prescribing violations and using Skype—a service that allows users to communicate with peers by voice, using a microphone, video by using a webcam, and instant messaging over the internet—to treat patients under his care.

Trow, of Park Hill, Okla., was using the online service to treat patients with mental health issues. The doctor claimed he thought Skype was a suitable communication system for the practice of telemedicine, according to NewsOK. However, medical board documents showed that Skype is not approved as a telemedicine communication system, NewsOK reported.

Although there are exceptions, most state health laws require an initial in-person visit to establish a patient-physician relationship before a doctor can treat a patient over video conference.  This includes prescribing drugs, rendering diagnoses, and performing other medical services during a virtual visit. 

At the time he drew the attention of board investigators, Trow worked for Hartsell Psychological Services, which provides mental health services to residents of rural communities in southern Oklahoma and northern Texas. As reported by NewsOK, “He said his (registered nurse) traveled to the various satellite clinics and presented the patients to him via Skype,” a board investigator wrote in the complaint against Trow. “He stated that he did not think he had to see patients in person since they were psychiatric patients.” Apparently, Trow did not visit patients himself due to his own failing health.

After board members reviewed his case, Trow was placed on probation for two years and ordered to complete a course on prescribing practices, according to the news report.

It is clear to me that Trow deserved this probation, at the very minimum. If he prescribed his patients medications without ever having physically meeting with them himself—regardless of whether they were psychiatric patients or not—that is simply unacceptable.

So the obvious question that gets raised from this story is, “Should doctors be allowed to use Skype to treat their patients?”

The answer isn’t clear-cut. On the positive side, the Sioux Falls, S.D.-based Avera Health Network is supporting doctors to care for emergency room (ER) patients by attending to them virtually, via Skype. According to a story from The Atlantic, Avera is the only long distance ER care center in the U.S., and their "telemedical" services use high definition video conferencing software from Skype to connect their critical care experts with the doctors on the ground in rural locations.

The fact is that some small-town hospitals in the Midwest might only have 25 beds, at most. In South Dakota, there are people who live in small, geographically-isolated communities who often make the trek to Sioux Falls, the state’s largest city, for hospital services. But during emergencies, the up-to 200 miles to Sioux Falls becomes even further away.

And as the rural population ages—the proportion of people over the age of 65 is about 72 percent higher in South Dakota than the rest of the U.S., and is expected to double by 2020—the need for easy access to high-quality care will only increase.

Avera has experts available 24/7 in locations throughout South Dakota, North Dakota, Minnesota, Iowa, Wyoming, and Nebraska. Their four main services—eConsult, eICU Care, eEmergency, and ePharm—are set up to provide resources and support to the 10 percent of America's doctors currently serving the 25 percent of the country's population that resides in rural areas. And as of last October, they reported an 18 percent decrease in ambulance and helicopter transfers to major hospitals, equating to $6.6 million saved.

Those are the kinds of telehealth initiatives that give you confidence in the promise of technology. Then there are stories like Trow’s that make you think twice about how these video virtual visits are really being used. And gray areas will only continue to emerge—it’s not unreasonable, for instance, to argue that for mental health patients, it could be stressful and perhaps even unnecessary to constantly travel to the doctor’s office. So is using Skype suitable for some forms of healthcare delivery, but not others?

It’s also necessary to consider the privacy risks associated with software such as Skype. Under its privacy policy, Skype says:

Skype will take appropriate organizational and technical measures to protect the personal data and traffic data provided to it or collected by it with due observance of the applicable obligations and exceptions under the relevant legislation. Your personal and traffic data can only be accessed by authorized employees of Microsoft or its affiliates, subsidiaries or service providers who need to have access to this data in order to be able to fulfill their given duties.

To me, that sounds broad and general with potential loopholes scattered throughout, and I’m sure the lack of privacy features in terms of clinical workflow remains a concern to many telehealth practitioners. It is also unclear whether or not Skype is completely HIPAA-compliant; HIPAA says that protected health information must be encrypted if it is sent over the internet, and Skype does use 256 bit AES encryption (whatever that means). But seemingly, there is more to it, and the logistics of the debate can get quite granular. I’d put it this way—if I were a provider, I’d do my homework before using Skype to treat patients.

So while there are certainly fair arguments on each side of the coin, at the end of the day, common sense and medical ethics should prevail. If a doctor is simply providing routine follow-up visits after seeing the patient in person, then the use of software such as Skype seems to be warranted in certain circumstances.  

However, Skype should not be used if we’re talking about making serious clinical judgments and prescribing medicine to patients you have never seen before. I do believe in the promise of telemedicine, and hope that a few bad seeds (assuming the Trow allegations are valid) won’t ruin something that can truly change the way healthcare is delivered for the better.

Questions or comments? Feel free to respond below or on Twitter by following me at @HCI_RLeventhal

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