Nonverbal data, including gestures, nods of the head, direction of gaze, smiles, or frowns, are necessary for the evaluation of the patient’s emotional state. The mutual exchange of such nonverbal signals helps ground the doctor-patient relationship and facilitates mutual understanding, clinical task completion, and the development of a positive therapeutic alliance.11,12 These nonverbal cues may have a perceptible transmission delay, even with high bandwidth (384 kilobits/s) VC equipment. In theory, this delay may lead to diagnostic errors. For example, a brief delay in psychomotor movements and a decrease in the cadence of speech may lead an inexperienced practitioner in telepsychiatry to suspect a depressive mood disorder.
In addition to problems arising from bandwidth limitations, a limited field of view may also restrict evaluation. For example, a view confined to the patient’s head and shoulders does not permit evaluation of posture, or movements of the extremities. All these factors may interfere not only with diagnosis but also with development of the therapeutic alliance. This raises the question of whether an established in-person doctor-patient relationship is desirable before telepsychiatry is employed. Periodic face-to-face contact has been found to be helpful for patients treated mainly via VC.13 Clearly, these are issues in need of further controlled study.
Privacy and liability are other important issues to consider when practicing telepsychiatry. When using VC, it is important to place equipment in an area where privacy can be maintained. When using portable applications, visiting case managers at the originating site (usually the patient’s home) can assist in maintaining privacy. Practitioners at the distant site also need to make sure that there is no one else in the office during a teleconference. Use of alternate communication lines (redundancy) and/or emergency protocols should be discussed with patients and instituted in the event of sudden equipment failure.
As telepsychiatry continues to expand and become an alternative in underserved or remote populations, more and more residents are likely to encounter it. There is also increasing acceptance of telepsychiatry for reimbursement purposes. Several states now recognize telemedicine as a legitimate health care delivery modality. States such as Louisiana and California require private insurance plans and Medicaid to reimburse practitioners for telemedicine services and prohibit private plans from excluding telemedicine coverage services.14
Despite the issues described earlier regarding the clinician-patient relationship, a recent court decision could be interpreted as establishing a new standard of care. In United States v Baker, the defendant claimed that the use of videoconferencing equipment during his psychiatric evaluation was, in essence, substandard care. However, the court determined that the use of videoconferencing allows for “patient interview to be conducted in a normal fashion,” and that videoconferencing constitutes treatment comparable to a face-to-face evaluation.15
Our outpatient clinic’s telepsychiatry component has been a successful clinical platform for introducing third-year residents to this treatment modality. Residents learn not only the knowledge base and technical skills applicable to telepsychiatry but also the most compelling reason to use telepsychiatry: improving our patients’ access to good clinical care.