Prescribing without Physical Proximity

The holy grail for the process of home-based telepsychiatry would be the wide-based acceptance of the prescribing of medicines without an in-person evaluation. Even many avid supporters of telemedicine run for cover at the thought of prescribing without the physician having been in the same room with the patient - at least once. But why must this be so when physical examination is not part of the standard of care in traditional outpatient psychiatry?

Skype telepsychiatry allows for a routine medical evaluation which meets standard of care, and therefore prescribing without physical proximity should be considered appropriate. Skype telepsychiatry allows for a review of the patient identification and chief complaint, present illness, psychiatric and medical history, family and social history, cognitive screening, and visual inspection of the patient for documentation of the all-important mental status examination. If there are medical concerns then the patient may be referred to primary care for physical examination and/or basic labs.

The various state BME's approach this concept very differently; some have addressed it directly and have signified broad-based approval; others have not. For example, New York has offered its approval for prescribing without physical proximity in the following quote taken from the New York State Department of Health Statement on Telemedicine:

The fact that an electronic medium is utilized for contact between parties or as
a substitute for face-to-face consultation does not change the standards of care.

California has offered its approval in the following quote

There are prohibitions relating to prescribing over the Internet, which can
result in license discipline, and carries hefty fines for prescribing without an
appropriate prior examination. This examination, however, need not be in-person,
if the technology is sufficient to provide the same information to the physician
if the exam had been performed face-to-face

from the Medical Board of California's document on Practicing Medicine through Telemedicine Technology. Texas also implies its approval of this process in its State Board of Medical Examiner's statement on Telemedicine, and Maryland Board of Physicians does so in its analogous statement.

Conversely, Florida and New Jersey are examples of states who do not formally sanction prescribing without physical proximity, based on the requirement for a "physical examination" for the prescribing of medicines in their statements on Telemedicine Prescribing Practice and BME Regulations, respectively.

The Federation of State Medical Boards was keeping track of the emergence of legislation governing Internet Prescribing, but this document seems somewhat out of date and it does not address the question of whether Skype telepsychiatry qualifies as "internet prescribing" or whether Internet Prescribing refers only to the illegitimate dispensing of medications through so-called Online Pharmacies. I will address the Ryan Haight Online Consumer Protection Act of 2008 in an upcoming entry.

In the meantime I'd like to reference two particularly relevant and current documents from the American Telemedicine Assocation: the Challenge of Regulating Internet Prescribing and Practice Guidelines for Videoconference-Based Telemental Health, both of which address the issues with realism and practicality, and both of which appear to support the prescribing of medicines without physical proximity.