A Day in the Life of...A Virtual Doctor

We spoke with Terry Rabinowitz, MD, FAPA, FAPM, Associate Professor of Psychiatry & Family Medicine, Director of Telepsychiatry, University of Vermont Fletcher Allen Health Care hospital, Burlington, VT, to learn more about the use of telemedicine in modern practice.

How do you decide when to employ telemedicine, and what technology is needed on both ends of the consultation?

The decision to use telemedicine is based on many variables. “Does the patient have access in their local area to the needed services?” and “If they have physical access, are the people who would provide those services available in a timely way?” are two questions that have to be asked about any person before a telemedicine consultation.

Our equipment includes a high-resolution, auto-focus video camera that has pan, tilt, and zoom capabilities; we use a high-resolution monitor, as well. The video is transmitted over telephone or Internet lines, and I use a remote control to operate the camera that is filming the patient. Also, we use picture-in-picture capability, so I can see what I look like to the patient, because the video camera sits just above the monitor; if I were to look into their eyes, it would be as if I weren’t looking into their eyes with respect to the camera. I can monitor if they see me close up or far away, and I will vary the image a little.

Can you describe a typical session?

I first get a briefing from a nurse facilitator without the patient present, and then I invite the patient in for evaluation. Sometimes, they’re accompanied by one or more family members. I’ve found that for the vast majority of patients, when accompanied by family, the interview is much better. I get much more information.

How does telemedicine compare to face-to-face interaction? What do your patients say?

I haven’t had a single patient who hasn’t liked the technology or the modality. One patient said she preferred it to face-to-face interaction, because she felt less nervous without me in the room. Much to my surprise, I also find it may be superior in a lot of ways to face-to-face interviewing, because I have remote control over the patient’s camera, which is very quiet and unobtrusive. I can move that camera and zoom in and out with virtually no disruption of the interview. I can ask an emotionally charged question and zoom in on the patient’s face or hands. Sometimes, people don’t want to tell you everything they feel, but I can see their immediate response to the question before they have an opportunity to cover up that response. I can also ask a question of the patient but focus on a family member and see what their response is to that question.

What benefits does telemedicine offer across all medical specialties?

It enables us to treat patients who would otherwise not have access to the particular medical specialty or sub-specialty they require. It will also likely provide a cost savings function, because the video conference itself is not very expensive. The initial outlay for the equipment may be a little high, but that’s a one-time event, and it doesn’t wear out very quickly. We also know that more timely consultation in any area leads to improvement in healthcare and outcomes. Another benefit is that telemedicine makes it easier to consult with an expert from another specialty. For instance, if in the course of performing a telepsychiatry consultation for a patient in New York I realized that he had a rare medical condition—and it turns out that the world’s expert on that condition is in the Netherlands—through a relatively easy set of steps, we could arrange for a three-way video conference to have this patient evaluated and seen by that expert, enhancing the chances for more optimal treatment.

How much does it cost to set up a telemedicine center?

The initial investment for a high-quality video camera and monitor runs about $7,000, plus the appropriate computer software to interface, and then the phone or Internet line charges.

Are there any issues with reimbursement?

For telepsychiatry, and I believe this is the case for all other telemedicine services, Medicare is willing to reimburse for services at identical rates to face-to-face services. Many private insurers still are not willing to pay for these services, but I think we will be able to get increased buy-in from private insurers as they see that these consultations are likely to save them money in the long run.

Do you archive the video consultations for later review?

Yes we do. We ask for permission when we are interested in video-taping, and we receive permission from all persons who attend the conference. We also tell them the reasons for taping it could be for student, faculty, and resident education; to help in the review of the case; or for help in getting input from colleagues or experts.

Is there anything you’d like to add?

My goal is to try to get as many people as possible at all different levels educated about telemedicine. That’s the best way to enhance the chances that this technology will be accepted. Most people are a bi technophobic, afraid of new technology. Once they see it in operation, I think virtually all of them are impressed and convinced that this can work.

Additional Resources

American Telemedicine Association

Center for Telehealth and eHealth Law

The Association of Telehealth Service Providers

Telemedicine and eHealth

The Telemedicine Information Exchange