I have obtained and hereby make available for review and comment DEA Form 82: Notice of Inspection of Controlled Premises. I understand, but cannot be sure, that DEA agents will require OBOT physicians to sign a copy of this agreement before initiating audit of records. OBOT physicians may want to ask an attorney to review the form now so as to be prepared when audited.
I was glad to see the form includes a statement of rights. I notice, too, that the form includes no reference whatsoever to questioning or interrogation. There is a stipulation that the agent will be allowed to inventory stock of controlled substances.
DEA should make a copy of this form available on the agency Web site. Until it does you can make do with this copy.
Saturday, December 5, 2009
Thursday, December 3, 2009
DEA Suboxone Audit Update V
The Government Relations Department of the American Psychiatric Association has issued a helpful document providing more details regarding the OBOT audits. My local DEA office still has not provided me with a copy of the “Notice of Inspection” (DEA form 82?) I was promised. Not surprisingly they also refused my offer of an appointment for my audit. In fact there was no response to my letter at all.
The document states that DEA sent each physician to be audited a letter. I do not recall receiving such a letter, but according to APA this may yet come from the local office, but audits have already started in my area.
According to the document agents will "verify" that the physician treats no more than the 30/100 limit. It would seem that agents cannot verify this without some independent source, such as pharmacy records. They must simply take the physician's word.
The only suggestion APA could offer as to why the audits cannot be scheduled is that this is standard practice. Well, that does sound like the federal government: standard practice prevails even if it involves waste.
The document states that DEA sent each physician to be audited a letter. I do not recall receiving such a letter, but according to APA this may yet come from the local office, but audits have already started in my area.
According to the document agents will "verify" that the physician treats no more than the 30/100 limit. It would seem that agents cannot verify this without some independent source, such as pharmacy records. They must simply take the physician's word.
The only suggestion APA could offer as to why the audits cannot be scheduled is that this is standard practice. Well, that does sound like the federal government: standard practice prevails even if it involves waste.
Tuesday, December 1, 2009
Telepsychiatry and Liability
These actual questions posed to me when I asked my professional liability (malpractice) carrier to cover me for conducting medication management sessions via audio/video connection using the Web, serve to illustrate some of the misconceptions about telemedicine and the extent to which state law and the courts irrationally interfere with progress, in some cases likely increasing risk.
· [In] Which states will you practice telemedicine? If multiple states, do you have licenses to practice in each state?
Most states apparently regulate medical activity where the patient is rather than where the physician is or where either resides. If my patient travels there, California law may govern treatment I provide from my home state. Unless I am licensed in CA I risk running afoul of the law there. Patients and physicians should not have to worry about care provided during travel by either party or both. A national license could solve this problem, but don't hold your breath.
For now I plan to only treat patients who normally reside in my state. If I or the patient travel to other states, I plan to contact the licensing board of the other state before (temporarily) managing the patient's care there. I already do this before contacts using the telephone only.
· Number of Patients/hours per week devoted to telemedicine?
The word "hours" in this context implies psychotherapy to me. I plan to do neither psychotherapy nor initial evaluation via telemedicine. I intend to examine every patient at least once in the office before considering telemedicine visits.
I want to use this technology for as many patients as want to use it.
· Ages & types of conditions/treatment for telemedicine?
I only treat adults and have opted out of Medicare, but I see no justification for discriminating on the basis of age. I treat patients with most psychiatric diagnoses. I see no reason why diagnosis should determine whether to apply this technology. I hope someone will comment on whether there might be certain types of cases that should not be managed via Skype.
· Previous telemedicine experience?
Lots of experience on the phone, which emphasizes the fact that insurers, and maybe the courts, see this as a limiting technology when in fact it is less limiting than the telephone if only because you can see the patient. The differences of course are not addressed in the question: I have never charged a fee for telephone contacts, and telemedicine contacts would replace at least some in person contacts.
· Equipment used? Who supplies the telemedicine equipment?
Another vague question. Both physician and patient need a computer, a video camera, and an Internet connection. Funny that they never ask this question if you propose telephone contact. Who supplies that cell phone? Who supplies that battery? Who supplies those telephone poles? Let me propose an office visit: Wait, who supplies the car? the furniture? the roof? the light bulbs?
· Is informed consent signed?
How does one sign consent? OK, this refers to yet another form. Actually, I am putting together an agreement which will include informed consent. But should I not have a separate consent form or agreement for telephone contact or office visit as well?
Phone: "I understand that doctor and patient may not be able to see each other when talking on the phone and that this leads to risk of misidentification or that each party may be unable to see the other party making rude gestures during conversation."
"I understand that if I talk to my psychiatrist on the telephone she may not be able to see holding a knife to my wrist."
Office: "I understand that meeting the physician in the office entails risk of unwanted touching that cannot happen via telephone or Skype. I understand that by traveling to the doctor's office I expose myself to risk of traffic accident, being mugged or murdered, or having my boss, who is also a patient there, see me walking into the waiting room."
Can patients decline treatment?
No! Absolutely not! All patients must submit to treatment on penalty of death!
Seriously, maybe they mean to ask whether the patient can choose to conduct visits in person. Of course they can. By telephone? Not with me.
· Will a psychiatrist or mental health professional be available if immediate attention is needed by the patient?
This is my favorite. Where do I start?
I try to picture a patient in my office for an appointment scheduled two weeks ago needing "immediate attention." I'm a doctor. It is not my job to give people attention. I diagnose and treat mental disorders. What are they talking about here? I would be available. If a patient seems at risk of suicide or some emergent medical problem we call 911 or send them to an emergency room. Doesn't matter whether the patient is in my office, at home, or on vacation in San Francisco.
This question seems to suggest that this mythical patient with this mythical need for immediate attention should have a psychiatrist or "mental health professional" (whatever that is) assigned to be present with the patient when the telemedicine contact is initiated. Why? And what exactly is this person supposed to do? Emergency psychotherapy? Hand them a tissue? Most patients probably wait weeks for an appointment with a psychiatrist. One local ER here has probably not enjoyed a visit from an on-call psychiatrist in 20 years. And if the patient is at risk of violence they need immediate attention from a SWAT team, not a mental health professional.
· Will you be obtaining the patients medical history?
What perplexes me about this question is that it could refer to almost any element in the initial evaluation, assuming that is what they refer to here. Why not ask about the psychiatric history, family history, developmental history?
If so, how will you obtain the medical history?
I like to start with general anesthesia. Then I make a 3 inch incision over the right supra-numerary fossa and dissect through the soft tissue to the hard tissue. If it's even there.
Seriously -- but not very seriously -- I ask.
· Is there a backup plan in the event of an equipment failure?
Absolutely. If the furnace goes out, I put on warm clothes. If the car breaks down, they take a cab. Or reschedule for later in the week. Hay, that just happened today. With no telemedicine involved. If the cell phone battery goes dead, we recharge it.
Oh, you mean if the computer, or the video cam, or the Internet connection fails. This really is not rocket science. You use a different computer, make do with the telephone, reschedule, or play Neanderthal and schedule an office visit. Does this really need a plan? (Maybe if you left your common sense under the pillow.)
That's all for the underwriter's questions, but here are a few more thoughts.
Using telemedicine a patient cannot physically assault a physician, office staff or another patient. Neither can they transmit infectious diseases to other patients over the Web, like they can in a waiting room.
Telemedicine markedly increases privacy for obvious reasons, some of which I hint at above. Vulnerability to hacking is a real risk, but we must weigh it against risks associated with office visits.
Skype is arguably superior to telephone but does not require waiting for business hours or availability of an office. It can also increase continuity since better-than-telephone contacts can occur when either or both parties are traveling or unable to reach the office due to illness, disaster, transportation or weather problems.
True, I will not be able to smell alcohol on the breath of an intoxicated patient, but neither will that patient kill someone while driving to my office under the influence.
Nothing in medicine is perfect, but, used sensibly, this technology offers clear advantages and deserves a place in the armamentarium of some if not all physicians, that is despite one undeniable disadvantage: My patients won't be able to enjoy petting my dog, which is why I think most pay to see me anyway.
· [In] Which states will you practice telemedicine? If multiple states, do you have licenses to practice in each state?
Most states apparently regulate medical activity where the patient is rather than where the physician is or where either resides. If my patient travels there, California law may govern treatment I provide from my home state. Unless I am licensed in CA I risk running afoul of the law there. Patients and physicians should not have to worry about care provided during travel by either party or both. A national license could solve this problem, but don't hold your breath.
For now I plan to only treat patients who normally reside in my state. If I or the patient travel to other states, I plan to contact the licensing board of the other state before (temporarily) managing the patient's care there. I already do this before contacts using the telephone only.
· Number of Patients/hours per week devoted to telemedicine?
The word "hours" in this context implies psychotherapy to me. I plan to do neither psychotherapy nor initial evaluation via telemedicine. I intend to examine every patient at least once in the office before considering telemedicine visits.
I want to use this technology for as many patients as want to use it.
· Ages & types of conditions/treatment for telemedicine?
I only treat adults and have opted out of Medicare, but I see no justification for discriminating on the basis of age. I treat patients with most psychiatric diagnoses. I see no reason why diagnosis should determine whether to apply this technology. I hope someone will comment on whether there might be certain types of cases that should not be managed via Skype.
· Previous telemedicine experience?
Lots of experience on the phone, which emphasizes the fact that insurers, and maybe the courts, see this as a limiting technology when in fact it is less limiting than the telephone if only because you can see the patient. The differences of course are not addressed in the question: I have never charged a fee for telephone contacts, and telemedicine contacts would replace at least some in person contacts.
· Equipment used? Who supplies the telemedicine equipment?
Another vague question. Both physician and patient need a computer, a video camera, and an Internet connection. Funny that they never ask this question if you propose telephone contact. Who supplies that cell phone? Who supplies that battery? Who supplies those telephone poles? Let me propose an office visit: Wait, who supplies the car? the furniture? the roof? the light bulbs?
· Is informed consent signed?
How does one sign consent? OK, this refers to yet another form. Actually, I am putting together an agreement which will include informed consent. But should I not have a separate consent form or agreement for telephone contact or office visit as well?
Phone: "I understand that doctor and patient may not be able to see each other when talking on the phone and that this leads to risk of misidentification or that each party may be unable to see the other party making rude gestures during conversation."
"I understand that if I talk to my psychiatrist on the telephone she may not be able to see holding a knife to my wrist."
Office: "I understand that meeting the physician in the office entails risk of unwanted touching that cannot happen via telephone or Skype. I understand that by traveling to the doctor's office I expose myself to risk of traffic accident, being mugged or murdered, or having my boss, who is also a patient there, see me walking into the waiting room."
Can patients decline treatment?
No! Absolutely not! All patients must submit to treatment on penalty of death!
Seriously, maybe they mean to ask whether the patient can choose to conduct visits in person. Of course they can. By telephone? Not with me.
· Will a psychiatrist or mental health professional be available if immediate attention is needed by the patient?
This is my favorite. Where do I start?
I try to picture a patient in my office for an appointment scheduled two weeks ago needing "immediate attention." I'm a doctor. It is not my job to give people attention. I diagnose and treat mental disorders. What are they talking about here? I would be available. If a patient seems at risk of suicide or some emergent medical problem we call 911 or send them to an emergency room. Doesn't matter whether the patient is in my office, at home, or on vacation in San Francisco.
This question seems to suggest that this mythical patient with this mythical need for immediate attention should have a psychiatrist or "mental health professional" (whatever that is) assigned to be present with the patient when the telemedicine contact is initiated. Why? And what exactly is this person supposed to do? Emergency psychotherapy? Hand them a tissue? Most patients probably wait weeks for an appointment with a psychiatrist. One local ER here has probably not enjoyed a visit from an on-call psychiatrist in 20 years. And if the patient is at risk of violence they need immediate attention from a SWAT team, not a mental health professional.
· Will you be obtaining the patients medical history?
What perplexes me about this question is that it could refer to almost any element in the initial evaluation, assuming that is what they refer to here. Why not ask about the psychiatric history, family history, developmental history?
If so, how will you obtain the medical history?
I like to start with general anesthesia. Then I make a 3 inch incision over the right supra-numerary fossa and dissect through the soft tissue to the hard tissue. If it's even there.
Seriously -- but not very seriously -- I ask.
· Is there a backup plan in the event of an equipment failure?
Absolutely. If the furnace goes out, I put on warm clothes. If the car breaks down, they take a cab. Or reschedule for later in the week. Hay, that just happened today. With no telemedicine involved. If the cell phone battery goes dead, we recharge it.
Oh, you mean if the computer, or the video cam, or the Internet connection fails. This really is not rocket science. You use a different computer, make do with the telephone, reschedule, or play Neanderthal and schedule an office visit. Does this really need a plan? (Maybe if you left your common sense under the pillow.)
That's all for the underwriter's questions, but here are a few more thoughts.
Using telemedicine a patient cannot physically assault a physician, office staff or another patient. Neither can they transmit infectious diseases to other patients over the Web, like they can in a waiting room.
Telemedicine markedly increases privacy for obvious reasons, some of which I hint at above. Vulnerability to hacking is a real risk, but we must weigh it against risks associated with office visits.
Skype is arguably superior to telephone but does not require waiting for business hours or availability of an office. It can also increase continuity since better-than-telephone contacts can occur when either or both parties are traveling or unable to reach the office due to illness, disaster, transportation or weather problems.
True, I will not be able to smell alcohol on the breath of an intoxicated patient, but neither will that patient kill someone while driving to my office under the influence.
Nothing in medicine is perfect, but, used sensibly, this technology offers clear advantages and deserves a place in the armamentarium of some if not all physicians, that is despite one undeniable disadvantage: My patients won't be able to enjoy petting my dog, which is why I think most pay to see me anyway.
Monday, November 30, 2009
Iscribe Down, Up Again
All you throwbacks still writing prescriptions on paper can stop laughing now.
Iscribe (iscribe.com) has announced that it's running correctly again. I hope it really is. Prescription renewals I authorized days ago failed to go through when ordered, but according to a recent email Iscribe should have transmitted them to pharmacies (via surescripts.com) by now.
Patients keep ignoring me when I tell them to call the pharmacy before trying to pick up prescriptions, one thing no one had to worry about when I wrote them on paper. With all the advantages and disadvantages eprescribing I plan to stick with Iscribe for the time being.
Iscribe (iscribe.com) has announced that it's running correctly again. I hope it really is. Prescription renewals I authorized days ago failed to go through when ordered, but according to a recent email Iscribe should have transmitted them to pharmacies (via surescripts.com) by now.
Patients keep ignoring me when I tell them to call the pharmacy before trying to pick up prescriptions, one thing no one had to worry about when I wrote them on paper. With all the advantages and disadvantages eprescribing I plan to stick with Iscribe for the time being.
Sunday, November 29, 2009
How We Should Treat the Homeless Mentally Ill
On this week's Vinyl Cafe Stuart McLean's Morley tells us how to treat the homeless mentally ill Emil.
Podcast
Podcast
Friday, November 27, 2009
Does the American Psychiatric Association Need a New Ethics Compass?
When you think of ethics and psychiatry what comes to mind? Probably physicians' financial relationships with drug companies and sexual relationships with patients. While I do not deny the importance of either I believe APA's handling of many other ethical matters warrants improvement, and I hope to address these in more detail in subsequent posts. A list of planned topics follows:
Last time I looked APA had not revised its online Opinions of the Ethics Committee on The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry since 2001. I know the ethics committee has issued opinions since then. Only those members who can access them can benefit from those opinions.
Psychiatrists have published online or in print case histories sufficiently detailed that the patient or those who know the patient could identify them. In many of these cases if they are fiction this fact was not mentioned. It is possible that patients consented to publication, but the patient may have felt pressure to consent, and there is little likelihood that the patient might benefit from the publication. APA has not dealt adequately with this problem.
APA published Questions & Answers About Procedures for Handling Complaints of Unethical Conduct as an addendum to the Code, but the most recent answer I could find was published in 2003.
Section 9 of the Code states: "A physician shall support access to medical care for all people." There is no associated "Annotation Especially Applicable to Psychiatry" except this: "New section recently adopted by the AMA." As far as I can determine recently means 2001. This feel good "principle" has clear political implications but only questionable applicability in the context of the physician patient relationship. Do we need a test case?
APA has addressed ethical considerations related to availability for patient emergencies, but the opinion (at least the only one with which I have been provided) seems to ignore realities and refers to factors which seem extraneous or indeterminable.
Third parties regularly exploit treating psychiatrists for cheap or free opinions related to obtaining benefits for patients or to return to work. APA seems unwilling to take a firm stance regarding the ethical implications.
For many years psychiatry and psychodynamic psychotherapy have been inseparable. Ethics opinions still occasionally refer to dynamic/analytic concepts like transference. Today many psychiatrists either provide psychotherapy using other methods such as CBT or provide no psychotherapy at all. Published psychiatric ethics principles and determinations should refer only to principles related to all psychiatrists and should scrupulously avoid imposition of psychoanalytic principles to psychiatrists outside the context of that method of treatment.
I will devote an extended series of posts to an ethical question I posed over three years ago which has never been addressed definitively despite referral to a number of district branches and state associations. Even when initiated at the local level APA should ultimately address ethics questions with national applicability at the national level. What is unethical in Nebraska is unethical in Florida.
Last time I looked APA had not revised its online Opinions of the Ethics Committee on The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry since 2001. I know the ethics committee has issued opinions since then. Only those members who can access them can benefit from those opinions.
Psychiatrists have published online or in print case histories sufficiently detailed that the patient or those who know the patient could identify them. In many of these cases if they are fiction this fact was not mentioned. It is possible that patients consented to publication, but the patient may have felt pressure to consent, and there is little likelihood that the patient might benefit from the publication. APA has not dealt adequately with this problem.
APA published Questions & Answers About Procedures for Handling Complaints of Unethical Conduct as an addendum to the Code, but the most recent answer I could find was published in 2003.
Section 9 of the Code states: "A physician shall support access to medical care for all people." There is no associated "Annotation Especially Applicable to Psychiatry" except this: "New section recently adopted by the AMA." As far as I can determine recently means 2001. This feel good "principle" has clear political implications but only questionable applicability in the context of the physician patient relationship. Do we need a test case?
APA has addressed ethical considerations related to availability for patient emergencies, but the opinion (at least the only one with which I have been provided) seems to ignore realities and refers to factors which seem extraneous or indeterminable.
Third parties regularly exploit treating psychiatrists for cheap or free opinions related to obtaining benefits for patients or to return to work. APA seems unwilling to take a firm stance regarding the ethical implications.
For many years psychiatry and psychodynamic psychotherapy have been inseparable. Ethics opinions still occasionally refer to dynamic/analytic concepts like transference. Today many psychiatrists either provide psychotherapy using other methods such as CBT or provide no psychotherapy at all. Published psychiatric ethics principles and determinations should refer only to principles related to all psychiatrists and should scrupulously avoid imposition of psychoanalytic principles to psychiatrists outside the context of that method of treatment.
I will devote an extended series of posts to an ethical question I posed over three years ago which has never been addressed definitively despite referral to a number of district branches and state associations. Even when initiated at the local level APA should ultimately address ethics questions with national applicability at the national level. What is unethical in Nebraska is unethical in Florida.
Thursday, November 26, 2009
Remote Referral: Serendipity and Anonymity on the Web
I harbor no illusion that a reader could not discover my true identity with sufficient effort, but I prefer not to use BehaveNet to promote my practice, and I don't want my patients to have "in their face" everything I write.
(Names have been changed to protect the innocent.)
I need to refer a patient to a psychiatrist or psychotherapist in a distant part of the country where I know none personally. I put the word out to some friends and family, but I don't expect much. So I resorted to the directories on the Web. When I looked at the brief profile of one professional a piece of information, along with prior suspicions about the geographical location of this individual, made me suspect I had read some of his work and liked what I read. Furthermore I thought this might make for a good match between patient and provider. I emailed the provider, dropped a few hints, and believe there has been confirmation of my suspicion.
Here's my dilemma:
I firmly believe in the Golden Rule. I don't want to reveal the professional's identity to the patient, and hope he won't tell the patient about my own presence on the Web. On the other hand I certainly will not deceive the patient by claiming more knowledge than I possess about this professional.
My idea of a solution:
I tell the patient only that my knowledge of this professional is limited to what I have read on the Web. I leave it to the professional to decide whether to reveal his Web identity to the patient. And I send a link to this post to the professional.
Happy Thanksgiving
(Names have been changed to protect the innocent.)
I need to refer a patient to a psychiatrist or psychotherapist in a distant part of the country where I know none personally. I put the word out to some friends and family, but I don't expect much. So I resorted to the directories on the Web. When I looked at the brief profile of one professional a piece of information, along with prior suspicions about the geographical location of this individual, made me suspect I had read some of his work and liked what I read. Furthermore I thought this might make for a good match between patient and provider. I emailed the provider, dropped a few hints, and believe there has been confirmation of my suspicion.
Here's my dilemma:
I firmly believe in the Golden Rule. I don't want to reveal the professional's identity to the patient, and hope he won't tell the patient about my own presence on the Web. On the other hand I certainly will not deceive the patient by claiming more knowledge than I possess about this professional.
My idea of a solution:
I tell the patient only that my knowledge of this professional is limited to what I have read on the Web. I leave it to the professional to decide whether to reveal his Web identity to the patient. And I send a link to this post to the professional.
Happy Thanksgiving
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