We now have four months of experience conducting mental health medical-legal evaluations via telehealth. Since May, we have also been performing live in-person evaluations with mandatory masks and PPE. From my experience the pandemic has created many additional challenges to either form of interaction. However, it is abundantly clear that the telehealth option is better when it is available.
The most obvious reason for this is that there can be no transmission without in-person exposure. Many examinees (not to mention older doctors) have chronic health conditions and vulnerabilities such as metabolic syndrome, limited mobility, obesity, pulmonary illness and Vitamin D deficiency. These factors may place the parties at higher risk of a disastrous outcome if exposed to COVID-19. But there are other reasons that telehealth is better purely from an interactive mental health standpoint:
With a masked examinee, it is harder to read facial expressions and nonverbal nuances. For example, it is more difficult to discern when a comment is expressed ironically.
With a masked examinee, it is more difficult to describe affect.
With a masked examinee or examiner, speech is often muffled and difficult to understand.
N95 masks are uncomfortable if worn for an extended time, and psych evaluations last hours.
Anxiety may be artificially elevated because of contagion worries.
A view of the examinee's home environment may provide clues to mental wellness
Psychological testing can be administered via web services eliminating any risk of transmission from paper and pen.
Our office staff has encountered some resistance to telehealth appointments, but in my opinion, this is based mostly on inertia and privacy concerns. We adhere to strict unrecorded HIPAA compliant encryption even though HIPAA is not technically required in a medical-legal setting. The "newness" should not be off-putting because the technology has been around for over a decade. The platforms keep improving and even in the past few months people are getting better at adapting to it.
There certainly are some practical limitations but this does not apply to most cases. For example, cases involving traumatic brain injury should be seen in person because the psychological tests cannot be performed on-line.
Some examinees lack Wi-Fi or basic smartphone/computer knowledge. Yet I have successfully conducted full three-hour examinations over cellular networks without Wi-Fi. Some examinees have younger computer-savvy relatives who are able to help with connectivity.
I strongly urge insurance carriers, attorneys, examinees and all other parties to consider the telehealth advantage for safer and better examinations.
James O'Brien, M.D.
July 12, 2020