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Telemedicine Update

Dear Colleagues,

Recent events are pressing me to share some important new developments which may be upsetting for some, and exhilarating for others. I trust most of you are seated.... I want to alert you to changes that already are taking place in healthcare delivery in California. Before I start, please allow me to state that I am not speaking for the APA or any other organization. I am simply a psychologist who has done a lot of reading on the topic of telehealth care delivery. I strongly encourage you to do the same.

Let's begin with definitions. Various pieces of legislature and medical journal articles refer to telemedicine as communication between doctor and patient through electronic equipment in different or remote locations. The equipment can range in sophistication from telephones to fiber optic and satellite video conferencing. When referring to telemedicine and telehealth in the mental health arena, most professionals are referring to some sort of video conferencing equipment that enables both parties to view the other in real time.

There are a number of nationwide trends in telehealth that have been developing rapidly, and without our participation. The legal race among states wanting to pass telemedicine acts has already been won by California. Its *Telemedicine Development Act of 1996* was signed into law last September, and will be enacted this July (1997). The majority of psychologists seem to be unaware of the law, despite Barry Gordon's posting about this law last November in NetPsy, the email list for Internet Psychology. The California law defines and regulates the practice of telemedicine on a state-wide level for the first time. Remarkably, it was unopposed throughout the entire legislative process, including the powerful Insurance Committee, and was passed unanimously only eight months after its introduction.

Why is this Law Important?

Even if you've heard of this law, you should still re-read it very carefully. It not only restricts California telemedicine services to practitioners licensed in California, but also requires insurance carriers to reimburse providers for its delivery, including HMO's and Medi-Cal. It amends 4 major state codes to add telemedicine as normal part of healthcare services.

Did you catch that? Please re-read this last statement slowly. Telemedicine will be a part of *normal healthcare delivery* within five months in California. How could this happen so quickly? Many more things than we imagine are already in place for telemedicine to be enacted.... Aren't we already seeing patients go to insurance companies first when they want mental health services? Don't those companies do some form of assessment and screening before we get the patient as a referral by telephone? Don't we already get case consultations (with managed care case workers) by telephone? Haven't we been doing this for a few years now?

There is more...the law stipulates that third party carriers cannot *require* face-to-face contact as a condition for reimbursement. How will that impact us? How will it impact our clients and patients? Those of us on panels are official employees of the insurance companies. What will happen if we decide a patient requires face-to-face treatment? Do we get to decide? "Impossible!", you say? The law goes fully into effect in July, so we'll soon see what the wording means. How strong can opposing voices be, given the fact that the majority of nationwide telemedicine pilot projects are saving millions of dollars in insurance healthcare costs?

Healthcare is moving in ways we haven't even begun to contemplate. The lack of attention paid to telecommunications by most psychologists has put us far behind our medical and psychiatric colleagues in other arenas as well. For over three decades, physicians have successfully developed programs to experiment and research numerous telehealth delivery models. 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.

Federal Legislation

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 to 19 new *physician-run* telemedicine projects, and the Health Care Financing Administration launched a three-year test of telemedicine services at 57 Medicare-certified facilities.

What Can We Do?

Well, if we approach this situation as we did managed care, our path is clearly delineated:

But wait -- maybe the coming of telehealth has benefits to be mined by skillful hands....

Here's What You Can Do

Get informed. Educate others. Let's learn to make telehealth work for us, not against us. Let's be proactive, not reactive.

Here's Where You Can Get The Facts

You may access official text versions of the California Telemedicine Act of 1996 and the proposed Federal Telehealth Act (1996) on the World Wide Web, by clicking the "Telemedicine and Telehealth Links" hypertext on CyberTowers Distance Learning Center located at URL address:

You can also read over 90 comments from therapists with first-hand experience with online therapy at my Online Ethics Survey Project at:

I urge all list members to carefully review the above websites. Ethics principles are heavy reading, but now is the time to read those identified by the APA as being relevant to online work. These issues will surely change with telehealth technology, but our understanding of the issues will help all of us understand and participate in formulating the new research, practices, and teaching models immediately required by telehealth. We all need to work together to define psychology's role in telemedicine and telehealth delivery, as well developing ethical and effective therapeutic use of this new and rapidly changing medium. And the Internet gives us the needed tool to spread the word, mobilize energies, and strengthen our stumbling profession.

Do any of you have media connections to help us spread all the information we can find about telehealth? Send this post to those people. Can you post this message to other lists? Will you start your own investigations and keep people up to date in your state? Will you help create a new future for us all?

Marlene Maheu

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