Ah, Vacation

I feel a little sheepish about this, but yes, I'm writing a post while on vacation. That wasn't my intention. I went off to an indulgent, overpriced spa to be indulged and not think about anything but being indulged. But part of the pleasure of vacation for me is that I get to catch up on back-issues of magazines that have been lying around, beckoning to me, for months.

Well. I was working my way through the October 2012 issue of Metropolis, the theme of which is "Brave new City: Seven Visionary Teams Re-imagine the Urban Experience". And I found this:

It's the HomeWerk table and chairs by LUNAR, a system designed for working from home. Those are not cardboard figures sitting in the chairs. The chairs, themselves, are dynamic screens.

These digitally sophisticated furnishings fit easily into most homes and apartments by replacing the traditional dining set with display backs that allow for life-size, face-to-face meetings with coworkers, customers and clients.

You sit in your chair at home, and participate in a meeting at work. When you move, your 2D persona moves. When you speak, it speaks. Oh, and it doesn't matter if you're in your underwear.

"The real-time video allows [users] to wear whatever they want, as their screen double displays appropriate business attire."

(Not sure why "glasses" isn't lifting his left hand in the photo)

You can change the appearance of the furniture, too, so when you're finished working in your modern "office", you can go home to your Victorian, or country cottage, or beach house, or groovy pad.

Think of the applications outside of an office meeting! You can have Thanksgiving dinner with your daughter in Chicago and your son in Hong Kong!

Aaaaaaand...You can have therapy sessions with patients. This is SO much better than Skype. And it brings up all sorts of interesting therapeutic issues.

For instance, you learn a lot from the way a patient chooses to dress to a session. What are you missing if you have no idea what the patient is really wearing? What do you learn from the clothes the patient chooses to display? What about what you're wearing?

Would you and your patient need to own the same piece of furniture? What would that be like? Is it different from both of you owning computers?

There's also something called, "impactful time-shifted video messages", which allows users to join meetings even if they have schedule conflicts. I don't understand how that would work. Sounds like time travel. What would that mean for missed sessions? Gives me a headache to think about it.

Of course, even with the coolness factor, there's still a lot missing. Odors, room temperature, everything that goes with physical presence. And I don't believe HomeWerk is in production. But that just means there's more time to work out the details.

Skype-chiatry Link

Thanks to Dinah, from Shrink Rap, for her comment on Tele Me More. The podcast includes an interesting discussion of the more technical aspects of Skype-chiatry (In the future, will people practice Skypoanalysis?). Check it out, episode #49.

Tele Me More

I want to pick up where I left off with the telepsychiatry post by looking at evidence in the literature.

One study, The Effectiveness of Telemental Health Applications: A Review  
Canadian Journal of Psychiatry | Nov 2008, reviewed 72 papers. There was evidence of success with "Telemental health" (TMH) in the areas of child psychiatry, depression, dementia, schizophrenia, suicide prevention, posttraumatic stress, panic disorders, substance abuse, eating disorders, and smoking prevention. Evidence of success for general TMH programs and in the management of obsessive–compulsive disorder were less convincing.

Another study, Outcomes of 98,609 U.S. Department of Veterans Affairs Patients Enrolled in Telemental Health Services, 2006–2010, Psychiatric Services, 2012, compared number of inpatient psychiatric admissions and days of psychiatric hospitalization among patients who participated in remote clinical videoconferencing during an average period of six months before and after their enrollment in the TMH services. Psychiatric admissions of TMH patients decreased by an average of 24.2%, and days of hospitalization decreased by an average of 26.6%.

Yet another study of 494 subjects, Is Telepsychiatry Equivalent to Face-to-Face Psychiatry? Results From a Randomized Controlled Equivalence Trial, Psychiatric Services, June 2007, compared interactive videoconferencing with face to face treatment in psychiatric consultation with brief follow-up (monthly, up to 4 months), and found equivalent improvements in function in both groups, with similar levels of satisfaction with service. And TMH cost 10% less than face-to-face treatment.

A study of 297 individuals, published in The Lancet in 2009, Therapist-delivered internet psychotherapy for depression in primary care: a randomised controlled trial, found that 38% of patients treated with online CBT recovered from depression (BDI<10), vs. only 24% of patients treated as usual by their GP. Since this study was done in the UK, I'm not sure what the usual function of a GP is there, and whether some do psychotherapy.

The China American Psychoanalytic Alliance (CAPA) has offered Skype or Oovoo training in psychoanalysis and psychotherapy to clinicians in China since 2006. It also offers low fee Skype psychoanalysis and Psychotherapy. There seems to be a lot of satisfaction with the program, with waiting lists for treatment, but there is no data that directly compares the results with face-to-face treatment.

So what do we know?

• TMH seems to be helpful in treating some conditions, such as depression and PTSD.
• In veterans, TMH has decreased admissions and length of stay by roughly 25%. 98,000 veterans-you can't ignore that number.
• TMH was equivalent to face-to-face treatment for consultation with brief follow-up, and cost less.
• Online CBT looked better than treatment by a GP in the UK.
• Many Chinese who otherwise wouldn't have access to psychotherapy or psychoanalysis are eager to have TMH treatment.

Based on this information I'd like to see a more formal study of face-to-face vs. Skype treatment for  a more general population, and for, say, psychodynamic psychotherapy, before drawing any conclusions. But I certainly wouldn't dismiss the idea of TMH entirely. 

Please note, my DSM-V survey will close on the 28th, so if you haven't responded yet, you still have time. Just click HERE.

Dr. Tele-Love, or, How I learned to Stop Worrying and Love Skype

In the process of learning all about the new CPT coding, I also learned that phone and Skype sessions are not covered by insurance. The reasoning seems to be that they are considered substandard care. And apparently you can't cut a deal with your patient in which he will pay you for a phone or Skype session, regardless of his coverage, because a patient cannot legally agree to substandard care. Well, I guess you CAN make that agreement with your patient, but if he ever decides to sue you, you're buggered.

Furthermore, the point was made by the lawyer who gave the talk I attended that if you call your doctor to ask about something, say, at night, you don't get a bill for it. So, by extension, you can't bill for a full session that takes place on the phone.

True. Only lawyers can bill for phone exchanges. By the minute.

Personally, I don't like phone sessions. Maybe because I don't like talking on the phone, in general. I find it difficult to lose that sense you get of a patient who's in the room with you, not to mention the facial expressions and other visual cues (admittedly, these are lacking in analysis, as well).

That said, sometimes, it's necessary. A patient who needs to move suddenly, but hasn't transitioned to another psychiatrist yet. Or maybe doesn't want to. A patient who's laid up at home because of illness. Or maybe because of maternity or paternity leave. A patient who has to fly to a distant city due to a family emergency or a death.

It seems to me there are a lot of good reasons to rely on phone or Skype sessions, especially when the patient would suffer without any session at all. Are we, as psychiatrists, really supposed to spend 45 minutes on the phone with a patient, making the same comments and interpretations we would make in person, working just as hard as we would in person, and then not charge for the session?

This is a topic for another time, but why do people think it's immoral, or somehow distasteful, for doctors to want to make a living? Are we really supposed to work for free?

So what's the deal, here? Why is tele-medicine considered substandard? Is it just an excuse to limit coverage, or is it based on some factual data?

As it turns out, prison systems routinely use tele-psychiatry. I hope it isn't the case that prisoners are getting substandard care.

And you can use telepsychiatry in some states, but not others. Additionally, the use of telepsychiatry varies based on type of insurance.

For instance, medicaid covers telepsychiatry in NY.

Private insurance varies by insurer. My guess is, if there's any excuse not to cover, they won't cover.

Medicare covers telepsychiatry with some provisos. First, the consumer must be located in a "non-metropolitan statistical area", which may or may not be the same thing as a Health Professional Shortage Areas (HPSA) .

From what I can tell the consumer also has to have the session in a qualified facility, which I guess means that he or she needs to show up at a clinic or hospital, and have a qualified staff person with him or her. During the actual session? I can't figure that out.

The clinician, on the other hand, can be anywhere, even at home, but has to be licensed in the appropriate state. I assume that's the state where the patient is located.

Now, back to that "substandard care" business. If it's good enough for prisoners and people in rural, underserved areas, it should be good enough for anyone. Alternatively, it's not really good enough for anyone, but it's the best anyone can do under certain circumstances.

The next question is, "What does the literature say about how telepsychiatry compares to in-person treatment?"

Stay tuned.