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Telehealth -- A Call to Action

by Marlene Maheu, PhD

Joanna sits comfortably at her home computer and dials her modem into her insurance company. Her video monitor shows a smiling intake coordinator, who listens to her complaint, and assigns her a therapist within minutes. The therapist sits in front of a soothing mountain scene, a projected image serving as a backdrop to the virtual office. Joanna has a telehealth therapy session that includes a thorough assessment. She is walked through several online tools that help to assess her current symptoms, situation and coping strategies.

The assessment tools are immediately scored, digitized, and interpreted for the therapist, and the test scores, along with their norms are clearly displayed on the therapist's monitor alongside Joanna's image as they speak. A white board viewed by both parties is used for Joanna to write her assignments for the week. At the end of the interaction, Joanna's therapist determines which portions of the interaction will be saved to the electronic medical record, and sends it off to the national database.

Is this the future of psychotherapy? It's already happening. Before the turn of the century, it will happen with greatly increased frequency.

What?? Where? Who's protecting confidentiality? What training will be required of the therapists? What fee will be charged? What will go into a centralized, electronic database?

Many of those questions have as yet to be answered in detail, but the vehicle for developing such answers is already constructed. Clients/patients are already being serviced by mental health professionals through telemedicine in over 30 pilot projects throughout the US. Laws are being enacted in many states to regulate the how, where, when, and why of such service delivery.

What's Happening? Our world is undergoing another revolution, the Information Revolution. Touted as being as broad sweeping as the Industrial Revolution, the tools for immediate information transfer are being introduced to all major spheres of banking, business and professional information exchange. Medical and banking records will soon be centralized in large computerized data banks, and made available to designated individuals, businesses and government agencies. The health care and banking industries are being greatly assisted by our government. Our legislators are passing laws while allocating large sums of money to building the infrastructure to support these technical advances.


Telemedicine is generally considered to be any form of communication between doctor and patient through electronic equipment from remote locations. It is most likely that the equipment we will be using will include a blend of several technologies, such as audio, video, and text-based interactions for meeting the specific needs of each client, hospital and insurance system. For our specific purposes as psychologists, telemedicine will revolve around videoconferencing. Such equipment enables both parties to view and communicate in real time.

*Telemedicine* is being replaced with the term *Telehealth* in much current legislation, because newer legislation is advocating for the inclusion of allied health professions. For our industry, "behavioral telehealth" is the term being suggested by David Nicholson, a former legislative aid, and current Special Assistant to the Director of the APA's Practice Directorate.

Pilot telemedicine/telehealth projects exist in many states, are typically funded by the federal government, and already use telecommunications equipment for many types of psychiatric interventions. The state of Massachusetts even recently passed a law allowing psychiatrists to order 5150s from remote locations using videoconferencing.

These projects usually involve a hub hospital with satellite hospitals or clinics. The hub hospital typically is staffed with specialists 24 hours a day. The satellite locations are staffed by nurse practitioners or mental health counselors. When a specialist is needed, the professional in the satellite location videoconferences into the hub hospital and accesses the specialist, usually within minutes. Some of the newer behavioral telehealth projects are beginning to offer combinations of technologies: website information, telephone screening, videoconferenced consultation and/or education, home health care, and even continued professional education. The possibilities of this new form of service delivery are just beginning to be discussed.

Why Should We Be Involved Now?

The California Telemedicine Development Act of 1996 was signed into Law in September of 1996 by our Governor. Before I give you details, you might be surprised to know that the proposal for this law was submitted in March of 1996 and passed every committee, including the powerful Insurance Committee without a single oppositional vote. It was signed into law only eight months after its introduction. It mandates insurance payment for scenes like the introductory scenario, and much more in telemedicine. The law takes effect in July of 1997. Do you know what your state is doing with regard to telemedicine or telehealth? For information, see the resource list below.

The California law defines and regulates the practice of telemedicine on a state-wide level. Here are the main provisions:

1. The Telemedicine Development Act of 1996 restricts California telemedicine services to practitioners licensed in California. This means we cannot communicate electronically as primary care providers with clients/patients outside our state.

2. We can serve as consultants connected by telecommunications equipment to professionals in other states.

3. Perhaps even more importantly, insurance carriers (including HMO's and Medi-Cal) are mandated to reimburse providers for the delivery of telemedicine. The new law amends four major state codes to add telemedicine as normal part of healthcare services.

4. The California law also stipulates that third party carriers cannot "require" face-to-face contact as a condition for reimbursement.

How will this last provision impact us? How will it impact our clients and patients? As employees of insurance companies, those of us who are on panels must be wondering about our own future powers to determine how we will interact with patients. What will it mean if we think a patient needs to be seen face-to-face rather than electronically, but our employer, the insurance company, cannot mandate face-to-face treatment as a condition of reimbursement. Do we get to decide how we will meet with our patient?

The Evolution of Mental Health Care into the 21st Century

Healthcare is moving in ways we haven't even begun to contemplate. For example, over 40 states have ongoing "telemedicine" projects, including a number of urban based "Telepsychiatry" centers serving the needs of rural primary care physicians and their patients. Over twenty medical schools have established departments, graduate programs and fellowships in "Medical Informatics." The American Medical Association recently recommended unrestricted licensure for all physicians who wish to practice telemedicine across state lines.

There is a fierce battle waging between states like California and the Federal Government. States do not want to lose their individual power, but the very nature of telecommunication requires some Federal management. A newly introduced federal bill, the "Comprehensive Telehealth Act of 1996" would create a Federal Telehealth Agency, facilitate telehealth services across state lines, and *require Medicare* reimbursement for telehealth services by 1998.

A number of pilot programs have already begun. The Department of Health and Human Services recently awarded $42 million to19 new *physician-run* telemedicine projects, and the Health Care Financing Administration launched a three-year test of telemedicine services at 57 Medicare-certified facilities. The Department of Defense spent over $48 million last year in developing the infrastructure for telemedicine delivery last year.

What Can We Do To Be A Part of This?

If you can see the inevitable change we must undergo as a profession, here are a few places to start:

1. Accept the fact that Telehealth is an important service delivery tool. Our skills can remain the same, but can be re-packaged not only to address current traditional specialty areas, but also those related to new technology and the change required; services delivered to more people, more easily, more economically.

2. Get online.

3.Get information about telemedicine and telehealth. Here's where you can get the facts:

Cybertowers Telehealth Office (for Compilation of Resources)
Professional Email Discussion List: Get online with email and join Telehealth, a free email list that discusses telehealth as an international phenomenon.

To subscribe, send a message to: LISTSERV@MAELSTROM.STJOHNS.EDU
and in the body of the message type:
SUBSCRIBE TELEHEALTH yourfirst yourlastname

so the message will look like

4. Educate others. Let's learn to make telehealth work for us, not against us. Let's be proactive, not reactive. Help someone with the next step. Get them online, show them how to access the professional lists, subscribe them to Telehealth, and teach them about Netiquette so they will know the cultural norms online.

5. Get involved politically. Find ways of being part of the new system of health care delivery being built by our entire government. Lobby, write to your legislative representatives, and use the internet to voice your political opinions about the formation of telehealth federally, in our state, and in our county.

6. Consider computerizing something in your specialty area. If you already have software/hardware developed and ready to market, give it a free listing at this site: where other professionals can learn about it and network with you.

7. Consider starting a pilot project for telehealth in your clinic, hospital or professional group. Begin using videoconferencing tools to facilitate interactions with other professionals and eventually, with patients. If you would like to learn how to participate in pilot projects, please contact me directly

Let's take a proactive approach to telehealth, and not simply become reactive to the decisions made by other professionals.

8. When developing pilot projects, use sound research design to collect data about your project.

9. Publish your results and/or speak about them at local, state and national Psychological Association meetings. Let others benefit from your experiences so our profession can grow strong. We have the potential of providing the mental health world with research-based information. We all need to work together to define psychology's role in behavioral telehealth delivery, as well developing ethical and effective therapeutic use of this new and rapidly changing medium.

10 . And most importantly, we need solid, academic research into how these technologies work, what populations will be best served using these tools, which treatment modalities are best suited to these delivery systems, how medical records need to be kept secure and confidential, and which clinicians will be best suited to deliver services through these technologies. The important truth is that if we do not become active in shaping new technology for our professions, who will?

Marlene Maheu

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