connected health


Tele-Coach: How An Eating Therapist Learned To Love Skype

By Jean Fain
Guest contributor

“How’d you do with your eating since last we met?” I recently asked members of my group on food issues.

“I’m really struggling,” said Heidi, a 27-year-old entrepreneur from Boston. “When I get overly full, that self-critical voice takes over. All I can think is ‘Screw it! I’ll start fresh tomorrow.’ I don’t know how not to let my eating spiral into overeating.”

Author Jean Fain while Skyping (courtesy).

Author Jean Fain while Skyping (courtesy).

Lydia, a 45 year-old minister from Akron, jumped in: “Instead of believing that self-critical voice, I’ve been telling myself: ‘That’s not what I believe.'”

“Did you hear that?” I asked Heidi. “Next time you start thinking ‘Screw it,’ you might try ‘That’s not what I believe’ or another of Lydia’s inspired responses.”

Heidi and Lydia (not their real names) are talking face to face, but not in person. Thanks to recent telecommunications advances, the 650 miles between the two are no barrier to participating in my eight-week group on using self-compassion for eating issues. Nor is a six-hour time difference. Last week, one participant Skyped in from her Lisbon hotel room.

Yes, I’ve jumped on the telemedicine bandwagon. I’m just discovering what hospitals, home health agencies and other major health organizations have been touting as the most cost-effective alternative to traditional face-to-face medicine since castor oil.

Clients with food and body image issues generally feel a lot less self-conscious attending a group remotely than up close and personal.

I knew about the telemedicine or “telehealth” trend, using technology to remotely deliver health-care services and information. But I’d never seriously considered joining the high-tech trendsetters. For decades, I’ve been happily providing individual and group therapy the old-fashioned way, and there are major legal questions about virtual psychotherapy, particularly across state lines.

According to Marlene M. Maheu, Ph.D., Executive Director of the Telemental Health Institute, “It’s the wild west. Clinicians are making up their own rules and disregarding those they agreed to follow when they got their licenses, and the consumers are at risk. They really don’t know who’s the right person to go to.”

Then, three things converged:

• Sixty-five members of The Center for Mindful Eating from around the world enthusiastically participated in my teleconference on The Self-Compassion Diet.
• My clients started complaining about sitting in traffic during the interminable reconstruction of Route 2 in Concord, Mass.
• One client couldn’t say enough about her Skype sessions with Los Angeles nutritionist and mindful eating author, Evelyn Tribole.

So I asked myself: “Why not Skype with clients?” Well, because telemedicine has real downsides. Besides the fuzzy legal regulations, I had at least three other concerns: Continue reading

Doc Punished For Treating Patients Via Skype: What To Make Of It?

(Wikimedia Commons)

(Wikimedia Commons)

Last week, the Oklahoman news Website reported that Dr. Thomas Trow, a doctor living in “far Eastern” Oklahoma (read: towns few and far-between), had been disciplined for treating patients over Skype for mental health issues.

He was accused of prescribing them medications without ever having physically met with them; his response was that his nurse traveled to satellite clinics to meet the patients and present them via Skype. Also, NewsOK reported, “He stated that he did not think he had to see patients in person since they were psychiatric patients.”

According to the complaint against him, one patient overdosed three times in six months, NewsOK reports. “The patient known as R.C. died while under Trow’s care — as did two other patients during the same time — but investigators said Thursday that those deaths were not attributable to Trow.” The penalty:  “Trow was placed on probation for two years and ordered to complete a course on prescribing practices,” NewsOK says.

Telemedicine run amok? Or a reasonable rural strategy that went awry? We asked Dr. Joseph C. Kvedar, founder and director of the Center for Connected Health at Partners HealthCare, to comment.

Dr. Joseph C. Kvedar
Guest contributor

The medical board of the state of Oklahoma recently sanctioned a physician for using Skype to conduct patient visits. A number of other factors add color to the board’s action, including that the physician was prescribing controlled substances as a result of these visits and that one of his patients died. This situation brings up several challenges of telehealth — that is, using technology to care for patients when doctor and patient are not face-to-face.

• Legal/regulatory: On the legal side, physicians are bound by medical regulations set by each state. It appears that the use of Skype is not permitted for patient care in Oklahoma.

• Privacy/security:  Skype says its technology is encrypted, which means that you should not be able to eavesdrop on a Skype call. That would seem to protect patient privacy. At Partners HealthCare, we ask patients to sign consent before participating in a ‘virtual video’ visit. Because this is a new way of providing care, we feel it’s best to inform our patients of the very small risk that their video-based call could be intercepted. I don’t know if the Oklahoma physician was using informed consent or not.

But the most interesting aspects of this case involve the question of quality of care. Can a Skype call substitute for an in-person visit? Under what circumstances?

Video virtual visits are a new mode of care delivery. Whenever anything new comes up in medicine, it is subject to rigorous analysis before entering mainstream care. That same rigor applies to video virtual visits. Although some studies suggest virtual visits can be useful, the evidence is not yet overwhelming. I can’t say with 100% certainty how virtual visits will best be used, but based on several pilot programs under way at Partners, I have a hunch or two.

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. Continue reading

How Payment Reform Can Be Like Dieting In a Locked Room

I love this analogy. Actually, I love any analogy that can add juiciness to the eye-glazing dryness of health policy, but this one in particular, because the image of locking yourself in a room to avoid food temptation (or health-spending temptation) is so vivid.

Here’s the actual quote, from Dr. Timothy Ferris of Massachusetts General Hospital, a big experimenter on alternative models of care and payment. He’s speaking at the Center for Connected Health symposium now under way in Boston. At about one minute in to the above video, as he talks about how shifting health care payment to global budgets and Accountable Care Organizations is doable but hard, he says that “Maybe we should be trying harder.”

“If you go on a diet, there’s a whole different strategy of going on a diet between saying ‘I’m not going to eat more’ and locking yourself in a room with only a limited amount of food. That’s a fundamentally different way to diet, right? I think there’s a role for locking ourselves in rooms that we carefully think about and plan on, and saying, ‘We’re going to live on what’s in this room for the next three years,’ and use that as a mechanism.”

Wonkish readers, please take this analogy and run with it! My own initial thought is that as the rooms start getting locked, it’s a concern that some of them hold far better-stocked cupboards than others. I’d hate to live for three years on Ramen alone.

Watch the video a bit further to see the response from Dr. Jeff Goldsmith, a prominent skeptic of the ACO model.