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Telemental Health for Follow-Up Visits Only?

Telemental Health

If you read our recent post, “Oklahoma Doctor Disciplined For Using Skype To Treat Patients?” you will recall that an Oklahoma psychiatrist was disciplined for a range of questionable medical practices last month. The circumstances of Dr. Thomas Trow’s discipline are noteworthy, but not just because three of his patients died while under his care, nor because he used Skype to treat one of those patients.

Rather, he was sanctioned because he was prescribing controlled substances without a required in-person assessment prior to using telehealth. While the viability of videoconferencing does not seem to have been the pivotal issue in this case, the Oklahoma board’s actions have led to a vigorous discussion by telehealth researchers and practitioners about the appropriate role of video teleconferencing (VTC) in mental health care. 

In an article recently published by WBUR’s CommonHealth, Dr. Joseph Kvedar made the following comment about using telehealth for follow-up only:

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.

A point that is rarely mentioned in many of these discussions is that the vast majority of U.S. states have similar prohibitions against prescribing medication online without an in-person assessment (See CTel’s, “50 State Survey–Internet and Telemedicine Prescribing: Survey of Individual State Policies and Regulations“).

Even more of relevance to allied mental health professionals is that fact that, unlike their medical colleagues, many allied mental health regulatory boards have not yet clearly stated their positions with regard to treating clients online using email, chat rooms or video teleconferening.

Both the recently published American Telemedicine Association (Practice Guidelines for Video-Based Online Mental Health Services) and the American Psychological Association  (Guidelines for the Practice of Telepsychology) suggest that practitioners consider an in-person assessment but they have not taken a stand against conducting intakes online.

What are your thoughts about treating clients or patients online without an in-person assessment or intake?

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5 comments on “Telemental Health for Follow-Up Visits Only?

  1. If assessment cannot be completed effectively online, does telehealth really improve access to care? Is access to care the most salient point about telemental health?

  2. How effective a virtual house call could be with respect to a medication adjustment would depend on how accurate and clear the video image so that the patient can be observed well, not just talked to. Patient report is one thing, but actually clinically observing makes all the difference.

  3. The VA has an active Tele-health and Tele-Mental health practice for patients once they have been seen in person by their provider. There are situations that really do need an in person visit, and there are situations where a virtual visit will accomplish the same results. This particular provider was said to have prescribed meds without an in person assessment “before using tele health”. Does that mean he has never seen the patient in person, or saw the patient in person initially and just does everything by tele health now? There are devices that can be hooked up to the tele health device in the patient’s home, such as for vital signs, if it is a visit just to check in, but I have concerns about something like medications, especially controlled substances, without actually eyeballing the patient. My experience with tele health is that it is used mainly for followup visits of a routine nature, and that anything outside of that should be done in person, at least initially if there is a new treatment or adjustment being prescribed. IF the patient is too sick to come to the office, tele health can be helpful so that they don’t miss their appt because they cannot travel; however, I would hope that there could be someone there, like a home health nurse or caretaker who can provide some on site assessment during the call.

  4. I agree with you that it is best to have some other health care provider eyeballing the patient during a telemental health visit. However, given the problems with access, rather it be the health status of the patient, transportation, communicable disease, or any other issue that prevents the patient being seen in person, telemental health has the potential to be lifesaving. What if there were a pool of professionals available when a suicide hotline is called and the patient has a clear plan they can execute? Of course, universal technology has to catch up with our ideas!

    • In-person assessemnt makes it safer for everyone, but I don’t think it is necessary in all cases. That precise line between acceptable and unacceptable intake without in-person assessment might very well be determined by a combination of the skills of the therapist, the circumstance of the client/patient and the validity/reliability of the assessment tools or procedures being used.

      Licensing boards are the ultimate rulers in these cases, though. If you listen to the January 2014 webinar about the physician who was disciplined by the Oklahoma Medical Board for several telemedicine infractions, you will see that licensing boards will not sit strill for what’s happening now. Wewill see much more regulation in the very near future.

      See: “Skype and Related Practices Found Unacceptable by Oklahoma Medical Board” https://store.telehealth.org/index.php/webinars

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