Patient confidentiality in remote consultations

During the lockdown last year, I was asked by the International Psychoanalytic Association (IPA) to help them update their guidance on remote consultations. I spoke to a range of GPs, surgeons, psychologists and psychoanalysts about what they’d learned during the first lockdown about working over the phone, or over Skype or Zoom. The IPA has now published my report, on a web page that also has their guidance to members both before and after the exercise.

Before the pandemic, remote consultation did happen, but not all therapists offered it; and confidentiality concerns tended to focus on technical security measures such as whether the call was encrypted end-to-end. After everyone was forced online in March and April 2020, clinicians learned rapidly to focus on the endpoints. Patients often have problems finding a private space to talk; there may be a family member in earshot, whether by accident, or because they’re cooped up in a tiny apartment, or because they have a controlling partner or parent. A clinician may return a patient’s call and catch them in a supermarket queue. And the clinic too can be interrupted, if the clinician is practicing from home.

Technical endpoint compromise is occasionally an issue; a controlling family member could inspect a patient’s device and discover a therapeutic relationship that had not been disclosed. By far the worst endpoint compromise that happened during the study period was when the Vastaamo chain of clinics in Finland was hit by ransomware; 45,000 patients’ records were stolen, and some were put online by extortionists demanding bitcoin payments. (And now we face an even larger-scale issue in the UK as the government plans to hoover up all our GP records for sale to drug companies unless we opt out by June 25; see here for how to do that.)

Such horrors aside, the core problem is to establish a therapeutic space where both patient and clinician can interact effectively, which means being able to concentrate and also to relax. There’s more to this than just being comfortable trusting the endpoint environments, the devices, the communications medium and any record-keeping mechanism. Interaction matters too. Many clinician communities discovered independently that the plain old telephone system often works better than new-fangled stuff such as skype and zoom. Video calls add maybe half a second of latency for buffering, which destroys conversational turn-taking. A further advantage of the phone is that you’re not staring at someone’s face at an unnatural distance. You can walk around the room, or even walk around the park.

Since doing this work I’ve started to avoid zoom and teams in favour of phone calls when I can, and use end-to-end encrypted voice calls on WhatsApp or Signal where call costs or client confidentiality make it sensible.

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