Dr. Avrim Fishkind, a psychiatrist in Houston, rarely sees any of his patients in person, and that's the way they like it.
Fishkind is part of a fast growing movement in the mental healthcare field where therapists counsel patients via inexpensive, Web-based video conferencing technology.
"We've had just over 60,000 patient encounters. To my knowledge, only six have refused to be seen via teleconferencing," he said. "When it comes to mental health issues and the difficult things you need to talk about in a crisis, a lot of patients feel it's less threatening and easier to be open and communicate via telemedicine."
Fishkind said telepsychiatry is limited only by insurance reimbursements. As more insurance companies start to reimburse for telepsychiatry treatments at the same rate as they do for in-person visits, the emerging medical field will grow exponentially.
In many instances, telepsychiatry is a necessity, not just a convenience for doctors and patients. Patients are often located in regions with no private psychiatric practices or where hospitals don't employ staff psychiatrists.
Telepsychiatry is also often used to treat prison inmates and nursing home patients.
"We're tailor made for telemedicine because we don't check people's livers. We just talk. Besides radiology, you can't imagine a medical discipline better adapted to telemedicine," Fishkind said. "It's so easy to implement, replicate and expand. That's why it's exploding so quickly."
Telepsychiatry is also a perfect platform for expanding the use of electronic medical records to document patient information through physician notes.
Fishkind noted that as he counsels patients via video conferences, he simulataeously types notes on his laptop, which are added to the patient's electronic records.
Dr. Dilip Chandran, a psychiatrist who works for Youth Health Services Inc. in Elkin, West Virginia, has been treating patients in remote locations via telemedicine for the past five months.
Chandran spends three days a week in Morgantown, where his home and this employer University of West Virginia is located, and two days in Elkin. Chandran is works for Youth Health Services under a contract the agency has with the university.
"[Patients] feel great about seeing me on television and they actually become more animated when they see me that way, especially kids with anxiety issues. They do very well with telemedicine," said Chandran, who treats adolescents, including teenagers.
Chandran uses a webcam from Logitech and secure video conferencing software from Secure TeleHealth to communicate with patients, who sit in a fully equipped satellite office near their homes. The whole setup costs less than $1,000 for each side.
While Chandran uses a television for the video conference, a laptop or desktop screen would work just a well.
Chandran's web conferencing system has full high-definition capabilities -- 1080P resolution running at 30 frames per second -- which allows Chandran to see even subtle ticks or other visual signs that may reveal problems.
The software ensures that the video stream is encrypted using the 128-bit AES algorithm and digital certificates.
"The average laptop is not what it used to be. If our customers bought a $600 laptop and connected a Logitech webcam to it, they'd be trilled," said Eric Kintz, general manager of Logitech for Business.
"It is as good as a face-to-face consultation, but you're doing it on your $80 a month Internet connection, a $600 computer and a $90 webcam," said Jim Mountain, president of Secure TeleHealth. "This is one of most promising areas available to cut Medicaid costs. The avail of a psychiatrist to a patient can help avoid hospitalization. Once you're admitted [to a hospital], costs climb into the $50,000 to $100,000 range."
As government grants for network and electronic healthcare systems - particularly for rural areas - grow, telemedicine will continue to expand across the nation, said Fishkind, CEO and chief medical officer for JSA Health Telepsychiatry, a health care firm that with 24 part-time or full-time psychiatrists who treat emergency patients in Texas and Louisiana.
The company provides on-demand telepsychiatrists for patients in schools, jails, community health centers, and hospital emergency departments.
Telemedicine and telepyschiatry began in the 1990s with the maturation of the World Wide Web and the ability to communicate online with patients using email and instant messaging.
The fledgling industry targeted people living in rural areas, and were unable to make the trek to clinics and private practices. Early on, video conferencing was difficult due to the lack of Internet bandwidth.
In 1999, a group emergency psychiatrists, including Fishkind, who specialized in crisis situations met to discuss the potential of telepsychiatry. The group concluded that most psychiatric crises occur in jails, shelters, schools, homes and hospital ICU units.
"Most of us were practicing in tertiary care - medical school-based hospitals where the emergency room had a separate psychiatric care unit," Fishkind said. "When you looked at the numbers, this is where probably 1 percent of all psychiatric emergencies took place.
"It became obvious even then that eventually, the only way to bring emergency psychiatry where it was needed would be through telemedicine," he said.
But early on, high-definition video conferencing technology cost tens of thousands of dollars. Additionally, security was an even greater concern than today.
Most doctors or healthcare regulators wouldn't embrace having psychiatric sessions over the public Internet. One more secure option, virtual private networks, required strong technical expertise and significant network bandwidth.
In recent years, technologies like the voice-over-Internet protocol service Skype have emerged, and prices for complex software and high-resolution video cameras have dropped dramatically, making it possible for psychiatrists to connect securely - and relatively cheaply - with remote patients.
Fishkind also noted that younger, more tech-savvy patients are far more comfortable being treated via Web-based video conferencing.
"Thirteen to 25-year-olds are the most comfortable with it because they commonly use Skype and other technologies to communicate. That's the way they've communicated their whole lives, so they may see as completely adequate," Fishkind said.
Skyping your patients
Voyager Telepsychiatry LLC administers a national Skype network for 80 clinicians and clinics that it claims is used to treat millions of patients.
Besides administering the network, the company runs a scheduling and billing system for the clinicians.
CEO Douglas Ikelheimer said sophisticated 256-bit AES encryption makes Skype as secure as proprietary technology, but without the added software costs.
"It should revolutionise telepsychiatry and eventually the practice of mental health itself," he said in an email to Computerworld.
Ikelheimer said that telepsychiatry has long been limited by cost and more recently by the advent of "HIPAA fear-mongerers," who he said spread fear about security issues often for financial gain.
"This group is largely comprised of people from the videoconferencing industry ... and HIPAA education people that provide training courses, books, and manuals on the subject," he said.
Ikelheimer argued that even though Skype is peer-to-peer technology - which is less secure than dedicated server networks -- the encryption algorithm means it can only be accessed by the most dedicated cyber-criminals.
"Whereas you can easily buy sophisticated listening and phone tapping equipment to spy on traditional appointments," he wrote. "And when it comes to checking on the latest changes to your Prozac dose, who is going to go to those lengths and for what gain?"
Secure or not, some psychiatrists still feel Skype exudes insecurity.
"I wouldn't feel that it was safe," Chandran said. "I don't know about it in terms of encryption. I'd assume most computers are safe enough."
Others feel laptops don't offer a large enough screen to provide a feeling of intimacy with a physician.
Fishkind the screen size issue depends on the patient. "The younger the patient, the more comfortable they are [with a computer screen]. As patients get older - 45, 55 or 65 - then the comfort of a computer screen diminishes as opposed to a television screen."
Smartphones become therapists
Northwestern University's Feinberg School of Medicine is currently field-testing a mobile application that is said to enable a smartphone to determine when patients are at risk for depression.
Dr. David Mohr runs the program, called "Mobilyze!, which has completed an initial pilot. The app is now being tweaked and prepared for a second pilot program.
"We're trying to use context sensing," Mohr said. "We're using the in-dwelling sensors in the smart phone to identify specific patient states that may be relevant to depression and the treatment of it."
Mobile phones today have myriad sensors, such as GPS, gyroscopes, accelerometers, light sensors and microphones.
Mobilyze!, under development in Feinberg's newly opened Center for Behavioral Intervention Technologies, harnesses cell phone sensor data on a near continuous basis, and uses computer algorithms to detect specific patient states.
"The states we're trying to detect are location, activity, social context and mood," Mohr said. "We're using a machine-learning paradigm that initially requires some user input."
For example, the application can use sensor data to determine a person's location, activity level, and level of social interaction.
If a patient inputs that one of their positive activities may be calling a friend or meeting someone for coffee, the phone can determine if the patient has performed that activity of a period of time, and if they've haven't, it will remind them.
"When people are depressed they tend not to engage in activities that are rewarding or enjoyable. If you increase those activities, it will improve your mood," Mohr said. "If you're at home on Saturday for four hours or more, for example, then you're at greater risk for depression."
But don't expect smartphone consultations anytime soon. JSA Health Telepsychiatry's Fishkind said size still matters.
"We believe, and not everyone does, that very high quality equipment on the other end makes patients more comfortable faster," he said. "If they were looking at a small picture on a cell phone, you can imagine there would be a very different sense of connectedness to the psychiatrist then if they're doing a 1080P transmission on a 42-inch television."