Telepsychiatry is a sub-field of telemedicine that refers to the use of videoconferencing to treat patients in other locations. This used to be an expensive proposition, requiring special videoconferencing equipment, but now anybody with a modern laptop computer and a webcam can videoconference using Skype (www.skype.com), which is free software that takes a couple of minutes to download and is easy to use. Several studies have found that telepsychiatry compares favorably to face-to-face interviews. For example, one study found an excellent correlation between both methods for diagnosis in a sample of 37 patients undergoing initial evaluations (Singh SP et al., BMC Psychiatry 2007; 7:55). And it appears that women and patients aged 20 to 49 are the most accepting of this type of care, according to research at a private telepsychiatry service (Rowe N et al., Telemedicine and e-Health 2008;14(10):1078–1086).
One of the country’s experts on “Skypiatry” (not his term) is Dr. Patrick Barta, a psychiatrist who divides his time between a private practice outside of Baltimore and neuroimaging research at Johns Hopkins Medical School. Dr. Barta’s website, Adventures in Telepsychiatry (adventuresintelepsychiatryblog. patrickbarta.com), is a treasure trove of practical information for anybody interested in adding Skypiatry to his or her practice. I chatted with Dr. Barta recently.
The first concern we all have is whether Skype is secure and is “HIPAA compliant.” HIPAA requires that you take reasonable precautions to keep medical information confidential, and Dr. Barta believes that Skype is secure enough to meet that standard. He points out that Skype uses AES—the Advanced Encryption Standard, approved by the National Security Agency for the transmission of top secret information. According to Barta, “If you’re willing to talk to patients on your cell phone, you should be willing to talk to them on Skype.” (There are others who are more circumspect—see, for example, the website Telehealth.net, on which psychologist and author Marlene Maheu argues that Skype is, in fact, vulnerable to being hacked.)
Regardless of which teleconferencing system you use, there is the crucial matter of insurance reimbursement. Dr. Barta has side-stepped this issue because his practice is fee-for-service. According to the American Telemedicine Association, 12 states have thus far passed legislation forcing private insurance companies to cover telemedicine. These include California, Colorado, Georgia, Hawaii, Kentucky, Louisiana, Maine, New Hampshire, Oklahoma, Oregon, Texas, and Virginia. I called around to some of the major insurance companies in Massachusetts and found that neither Tufts Health Plan nor Harvard Pilgrim cover telemedicine. Both Medicare and Medicaid cover some telemedicine services, but the specifics vary by state, specialty, and specific technology to be used.
If you decide to take the plunge and become a Skypiatrist, Dr. Barta shares a few helpful tips.
1. Your initial session should be in person, to get to know your patient and to ensure you have identified him or her accurately.
2. Check with your state’s medical board to make sure there are no special laws in your state related to telemedicine.
3. Use a telepsychiatry consent form, such as Dr. Barta’s, which you can download at www.patrickbarta.com/practice/ forms, and which you are free to adapt for your own practice.
4. To make sure that your patient has the right technical setup, schedule a one or two minute test call well before the first actual “Skyppointment.”
5. Ask your patient whether there is privacy (ie, whether anyone else can hear the patient’s conversation).
6. Be aware of what your webcam (and therefore your patient) can see behind you, especially if you’re Skyping from home.
7. Buy a webcam that sits on a stand so that you can place it directly in front of the computer monitor, right on the keyboard if you have a laptop. This way, you avoid the appearance of looking below your patient, an artifact of the typical placement of webcams just above most screens. (If you’re confused by this, you’ll understand the issue the first time you Skype.)
8. Assess the technical quality of the videoconferencing and make a note about it in your chart.
9. Ask the patient directly how he or she feels the video session went.