| by Marlene M. Maheu, Ph.D. | Telehealth: The Furthering of Psychology as a Profession
Technology provides psychology with unprecedented challenges and opportunities. Whether we are computer literate or computer phobic, the march of technology has quickened in the last decade. It is becoming ubiquitous, with advertisements for technology-based goods and services filling our billboards, magazines and TV screens. Technology is quickly re-shaping the delivery of services and products in behavioral healthcare and is forcing our competing professional groups to an all-time race for the healthcare dollar within the next decade. Those psychologists with a keen eye to the future are looking at telehealth to expand psychology as we adapt our practice, education and research methods to the capabilities provided by technology. Telehealth is defined as “the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision, education, and information across distance.” (Nickelson, 1998, p. 527). Other applications for psychologists include administrative, research, teaching, supervision and professional development activities (Administrative Rules of Montana, 1995; McCarthy, Kulakowski, & Kenfield, 1994; Stamm, 1999). Telehealth officially includes the use of all electronic tools for healthcare delivery, ranging from digital telephones to fiber-optic or satellite interactive video. Patient care can involve assessment, psychotherapy, crisis intervention, patient education, case management, and psychopharmocology (DeLeon, Folen, Jennings, & Willis, 1991; DeLeon & Wiggins, 1996). Early research has shown behavioral telehealth to be effective in patient care, and in fact, “Initial evidence indicates that telemedicine works well for group therapy as well as individual consults” (U.S. Department of Commerce, 1997, p. 19). The telehealth term now replaces the more restrictive, previously used, “telemedicine,” adopted by physician groups starting this movement over 35 years ago (Nickelson, 1997). “Behavioral telehealth” refers to the use of technology in behavioral healthcare. Unbeknownst to many psychologists, behavioral healthcare has rapidly become the most frequently used specialty service for telehealth practice (Grigsby, 1997). Behavioral Telehealth Practice Telehealth has been identified as the most significant contribution to healthcare delivery systems of the future (Bashshur, 1997; Council on Competitiveness, 1996; DeLeon, Sammons & Vandenbos, 1998). Telehealth tools and techniques are particularly helpful with patients who need to prematurely terminate therapy due to relocation, post-surgical restrictions, or childcare difficulties. Other patients benefiting from such remote service delivery include those who prefer the convenience of care from their own home, such as those who are homebound, live in rural areas, reside in climates that impede travel or find geographic distance to be prohibitive on a regular basis. Another group of people who can best be served by remote practitioners in the United States are those who speak English as a second language, or do not speak English at all. Services are available for the deaf community (Pollard, 1998) and bi-lingual communities. Meanwhile, the intent of using telehealth technology with these patients is to maintain the essential quality of healthcare interaction while increasing access to direct and indirect services (e.g., Dankins, 1995; Forkner, Reardon, & Carson, 1996; Preston, Brown, & Hartley, 1992; Stamm, 1999; Terry, 1999). Equipment Options. A number of pilot behavioral telehealth programs have begun using systems that include videophones and interactive videoconferencing units that connect via specialized telephone lines (Baer et al., 1995; Burton, 1997; Fetterman, 1996; Glueckauf et al., 1998; Jerome, 1986, 1993; Sampson, Kolodinsky & Greeno, 1997; Troster, Paolo, Glatt, S, Hubble & Koller, 1995). The videophone is a camera unit that is smaller than a VCR, with attachments for a television and a telephone. It permits use of any television and touch-tone telephone for videoconferencing without a computer. With the expected convergence of services through increased bandwidth capacities of the Internet, it is also reasonable to assume that interactive video services will soon be available for psychotherapy through the Net. With any of the above-mentioned low-cost alternatives for convenient videoconferencing services, psychologists may be more prone to enter the current telehealth marketplace and expand the reach of psychology. It is of particular importance to note behavioral telehealth is the largest and fastest growing area of telehealth (D. Puskin, personal communication, April 22, 1999), but that these programs are currently dominated by other professions, including psychiatry, nursing and social work. Psychology can be a leader in behavioral telehealth, but only if it embraces technology as a viable treatment vehicle, and provides the leadership for members to use these tools ethically and legally. Although the expansion of telehealth tools and related services is occurring faster than our ability to integrate or successfully regulate it, the march of technology is steadily quickening. Within the next few years, the following scenarios are likely to become common:
Ethical Issues & Patient Records As would be expected, questions and problems with these changes are beginning to surface. Ethics, credentialing, and licensing boards are being challenged. Several groups including the World Health Organization, various branches of the United States Government (Institute of Medicine [IOM], 1994; Ryboski, 1998; U.S. Congress, 1995) and professional associations such as the American Medical Health Informatics Management Association (Brandt, 1996), the American Medical Informatics Association (Kane & Sands, 1998), the National Council of State Boards of Nursing (1998) and the National Board for Certified Counselors (NBCC, 1998) are providing suggestions and leadership toward the protection of patient records. Among many other issues needing examination, there is a nationwide movement toward developing centralized electronic medical records into a single, multi-user database in the United States. Theoreticians and researchers in both psychology (Maheu, 1998; Maheu, Whitten, & Allen, in press; Maheu, Callan & Nagy, in press; Nickelson, 1998; Stamm, 1998) and medicine (Carroll, Wright & Zakoworotny, 1998; Spielberg, 1998; Waller & Alcantara, 1998) as well as professionals from other countries (Mitka, 1998) are discussing the protection of patient information. Current concerns regarding Internet use in healthcare include the variable quality of patient information, lack of credentialing and accountability and the lack of patient protection alternatives available to consumers (Murry, 1998; Health on the Net, 1998). Patients are already accessing behavioral healthcare from a number of sources on the Internet, ranging from content and community websites, to newsgroups and E-mail discussion lists (Maheu, 1994, 1997). The practical and ethical limitations of using email and chat rooms are beginning to be examined (Koocher, 1999; Maheu, Callan & Nagy, in press; Maheu & Gordon, 1999). It is becoming increasingly clear that videoconferencing capabilities will be needed to diagnose and treat previously unknown patients fully according to the standards outlined in the APA’s current Ethics Code (1992). Given that most graduate students are taught to use auditory and visual cues when diagnosing and treating patients, interactive videoconferencing seems to be the best available alternative to face-to-face practice for comparable diagnosis and treatment by people trained in these traditional methods. Exclusive email and chat room-based psychotherapy currently raises serious legal and ethical questions for the responsible practitioner, especially when low-cost videoconferencing technologies are currently available to both the patient and professional. Other important areas are also being examined by psychologists, such as the proper use of computerized assessment tools (Newman, Consoli & Taylor, 1997). Legislative Issues California has proven itself a leader in legislation related to telehealth. The California Telemedicine Development Act of 1996 (Telemedicine Act, 1996) was signed into Law in September of 1996 by then Governor Wilson. The proposal for this law was submitted in March of 1996 and passed every committee, including the powerful California Insurance Commission, 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 scenarios, and much more. The law took effect in July of 1997. It later was amended to remove inclusion of services delivered via telephones and E-mail (Telemedicine Act, 1997). On the national scene, the Federal Budget for 1999 mandated Medicare reimbursement for telehealth services (Cepelewicz, 1998; Medicare program, 1998; Payment for Teleconsultations, 1998; Nickelson, 1998). Providers of psychological services originally were named as providers of telehealth services in the Federal Budget, but this provision was modified in late 1998, when psychologists were removed from the approved practitioner list by the Health Care Financing Administration after lobbying by psychiatrists (Klein, 1999). The APA Practice Directorate has reported, “The Health Care Financing Administration has denied psychologists the right to reimbursement for telehealth services - despite legislation that specifically directs HCFA to pay psychologists for these services….” (Rabasca, 1999, p. 27). Telehealth in Other Areas It is encouraging to note that professional training related to behavioral telehealth is being offered at graduate and post-graduate levels (J. Albino, personal communication; January 19, 1999; R. Levant, personal communication, January 19, 1999; Sampson et al., 1997). The California School of Professional Psychology will begin offering a Telehealth Training Program for Post-doctoral students in the spring of 2000. Although psychologists have been slow to participate in multi-disciplinary or psychology-based programs using interactive videoconferencing systems, they do appear to be active in some forms of telehealth on the Internet. They have been developing websites, email or chat room services (Frisse, Kelly & Mercalfe, 1994; Maheu, 1997; Practice Strategies, 1999; Rusovick & Warner, 1998; Sleek, 1997). A Call for Action Technology is leaping ahead of our traditional ways of formulating answers and building to a deafening roar. We clearly need to become politically aware and active in shaping technology if psychology is to carve its place in behavioral telehealthcare delivery. It is our task to not only ensure the future of psychology by developing solid research upon which legislation can be crafted, but also from which practice can be developed. We must reverse decisions such as the one above and create, as well as safeguard, a place for psychology in telehealth legislation. Fortunately, APA is taking active steps on several fronts to advance the appropriate use of telehealth. The Board of Directors, the Board of Professional Affairs, and the Committee for the Advancement of Professional Practice all have initiatives under way that it is hoped will provide psychologists with much needed guidance in this area. More information on these efforts is available from the APA Practice Directorate (202-336-5800). On a practice level, we must begin the research to identify delivery systems that can be tailored to individual, specific patients, with specific diagnoses. Similarly, we must identify which telehealth practice will best be integrated into the treatment protocol. For example, we must identify whether treatment for specific disorders is best delivered exclusively face-to-face; or with a combination of face-to-face and remote service, augmented between sessions with email contact, and/or supported by patient self-help groups online. We need to decide and find ways to enforce decisions related to the content of the electronic patient record. We must determine who will have access to that confidential record, and under which circumstances. It will also be helpful to identify which types of practitioners will best be suited to telehealth practice. These and many more questions require answers. Conclusion Psychology has an opportunity to carve a place for itself in the technology-driven marketplace of the future. Medical professionals began their telehealth development 35 years ago, and as a result, have been able to shape state and federal laws to their advantage. As can be seen with the HCFA denial of reimbursement to psychologists, we are already at a disadvantage. It is critical to become active in shaping new technology and legislation supporting psychology’s vital role in behavioral telehealth practice. Telehealth provides practice development opportunities, but psychologists need to create those opportunities. Who among us is ready to help move psychology toward responsible and ethical adoption of telehealth technologies, and thereby further the profession of psychology? References Administrative Rules of Montana. Statutes and Rules Relating to Psychologists. §§ 8.52.606 (2). American Psychological Association. (1992). Ethical principals of psychologists and code of conduct. American Psychologist, 47 (12), 1597-1611. Baer, L., Cukor, P., Jenike, M., Leahy, B., O’Laughlen, J. & Coyle, J. (1995). Pilot studies of telemedicine for patients with obsessive compulsive disorder. American Journal of Psychiatry, 152, 1383-1385. Bashshur, R.L. (1997). Telemedicine and the health care system. In R.L. Bashshur, J.H. Sanders, & G.W. Shannon (Eds.), Telemedicine- theory and practice (pp. 5-35). Springfield, IL: Charles C Thomas. Brandt, M. D. (1996). Practice guidelines for managing health information. American Health Informatics Management Association Practice Brief (Document 406). Burton, D. C. (1997). Report of an active telehealth project: Kentucky advances mental health services through Kentucky Telecare and the state mental health network. TelehealthNews [Online Serial], 1 (2), 1-2. Retrieved January 11, 1999 from the World Wide Web: http://telehealth.net/telehealth/newslettr_2.html Carroll, E. T., Wright, S., & Zakoworotny, C. (1998). Securely implementing remote access within health information management. Journal of American Health Information Management Association, 69(3), 46-49. Cepelewicz, B. (1998, October 8). Telemedicine and strategies to minimize risks of liability. Paper presented at the Telemedicine National Conference on Legal and Policy Developments, Washington, DC. Council on Competitiveness. (1996). Highway to health: Transforming U. S. health care in the information age. Washington, DC: Author. Dankins, D. H. (1995). Plugging into success: Clinical applications from around the globe. Telemedicine and Telehealth Networks, 12, 19-21. DeLeon, P. H., Folen, R. A., Jennings, F. L. & Willis, D. J. (1991). The case for prescription privileges: A logical evolution of professional practice [Special issue: Child psychopharmacology]. Journal of Clinical Child Psychology, 20, 254-267. DeLeon, P., Sammons, M., Frank, R., & Vandenbos, G. (1998). Changing health care environment in the United States: Steadily evolving into the 21st Century. Unpublished manuscript. DeLeon, P. H. & Wiggins, J. G. (1996). Prescription privileges for psychologists. American Psychologist, 51, 225-229. Fetterman, D. (1996). Interactive video online: enhancing communication over the Internet. Educational Researcher, 25 (4), 23-27. Forkner, M. E., Reardon, T. & Carson, G. D. (1996). Experimenting with feasibility of telemedicine in Alaska: Successes and lessons learned. Telemedicine Journal, 2, 233-240. Frisse, M., Kelly, E., & Mercalfe, E. (1994). An Internet primer: resources and responsibilities. Acad Med, 69 (1), 20-24. Glueckauf, R., Whitton, J., Baxter, J., Kain, J., Vogelgesang, S., Hudson, M., Dustin Wright, D., Jared, B., Falco, M. (1998) Videocounseling for Families of Rural Teens with Epilepsy - Project Update. Telehealth News [Online Serial], 1 (4), 1-2. Retrieved January 11, 1999 from the World Wide Web: http://telehealth.net/telehealth/newslettr_4a.html Grigsby, B. (1997). ATSP report on U. S. telemedicine activity. Association of Telemedicine Service Providers. Retrieved August 30, 1998 from the World Wide Web: http://www.atsp.org Health on the Net Foundation Code of Conduct for Medical and Health Web Sites. (1998). [HONcode principles]. Retrieved November 18, 1998 from the World Wide Web: http://www.hon.ch/HONcode/Conduct.html Institute of Medicine (IOM). (1994). Health data in the information age: Use disclosure & privacy. (M. Donaldson. & K. Lohr, Eds.). Washington, DC: National Academy Press. Jerome, L. (1986). Telepsychiatry. Canadian Journal of Psychiatry, 31, 489. Jerome, L. (1993). Assessment by telemedicine. Hospital and Community Psychiatry, 44, 81-83. Kane, B., & Sands, D. (1998) Guidelines for the clinical use of electronic mail with patients. Internet Working Group, Task Force on Guidelines for the use of Clinic-Patient Electronic Mail. Journal of the American Medical Informatics Association. 5, 104-111. Klein, N. (1999). Telehealth becomes new battleground: Psychiatry talks; HCFA listens. AAP Advance. Winter. p. 4. Koocher, G. P., & Morray, E. (1999). Regulation of Tele-Psychology: A survey of State Attorneys General. Manuscript submitted for publication. Maheu, M. (1994). Self-help & Psychology Magazine. Retrieved November 2, 1999 from the World Wide Web: http://shpm.com/ Maheu, M. (1997). Will online services for consumer self-help improve behavioral healthcare? Behavioral Healthcare Tomorrow Journal, 6 (6), San Francisco: Centralink. Maheu, M. (1998). Telehealth - A call to action. American Association of Behavior Therapists. The Behavior Therapist, 21, (6). Maheu, M. & Gordon, B. (1999). Psychotherapy on the Internet: Legal, Ethical and Practice Issues. Manuscript submitted for publication. Maheu, M., Callan, J., & Nagy, T. (in press). Call to Action: Ethical and legal issues for behavioral telehealth including online psychological services. In S. Bucky (Ed.), Comprehensive Textbook of Ethics and Law on the Practice of Psychology. New York: Plenum Publishers. Maheu, M., Whitten, P. & Allen, A. (in press). Telemedicine and telehealth: A comprehensive guide. New York: Jossey-Bass. McCarthy, P., Kulakowski, D. & Kenfield, J. A. (1994). Clinical supervision practices of licensed psychologists. Professional Psychology: Research & Practice, 25, 177-181. Medicare program (1988). Scope of Medicare benefits and application of the outpatient mental health treatment limitation to clinical psychologist and clinical social worker services, 63 Fed. Reg. 21010. Mitka, M. (1998 ). Developing countries find telemedicine forges links to more care and research. Journal of the American Medical Association, 280 (15), 1295-1296. Murry, B. (March 1998). Data smog: Newest culprit in brain drain. APA Monitor, 29. Retrieved January 8, 1999 from the World Wide Web: http://www.apa.org/monitor/mar98/smog.html National Board for Certified Counselors. (1998). Standards for the Ethical Practice of WebCounseling. Retrieved November 18, 1998 from the World Wide Web: http://www.nbcc.org/ethics/wcstandards.htm National Council of State Boards of Nursing. (1998, April). Boards of nursing approve proposed language for an interstate compact for a mutual recognition model for nursing regulation. Communique, 1-4. Newman, M., Consoli, A., & Taylor, C. (1997). Computer assessment and cognitive behavioral treatment of clinical disorders: Anxiety as a case in point. Behavior Therapy, 28, 1-25. Nickelson, D. (1997). Politics & policy. TelehealthNews: [Online Serial], 1 (4), 1-2. Retrieved January 11, 1999 from http://cybertowers.com/ct/telehealth/newslettr_1.html Nickelson, D. (1998). Telehealth and the Evolving Health Care System: Strategic Opportunities for Professional Psychology. Professional Psychology: Research and Practice, 29(6), 527-535. Payment for Teleconsultations in Rural Health Professional Shortage Areas (1998). 63 Fed. Reg. 58879. Pollard, R. (1998). Psychopathology. In M. Marschark & D. Clark (Eds.), Psychological Perspectives on Deafness, Volume 2. Mahwah, NJ: Lawrence Erlbaum. Practice Strategies. (1999, October). Practice fess, incomes and trends report. Practice Strategies, 5(10), 1-10. Preston, J., Brown, F. W. & Hartley, M. (1992). Using telemedicine to improve health care in distant areas. Hospital and Community Psychiatry, 43, 25-32. Rabasca, L. (1999-February). HCFA rejects telehealth payment for psychologists. APA Monitor, p. 27. Rusovick, R. M. & Warner, D. J. (1998). The globalization of interventional informatics through Internet mediated distributed medical intelligence. New Medicine, 2, 155-161. Ryboski, L. (1998, July). National Health Policy Forum: Protecting the Confidentiality of Health Information. George Washington University. Sampson, J., Kolodinsky, R., & Greeno, B. (1997). Counseling on the information highway: Future possibilities and potential problems. Journal of Counseling and Development, 75 (3), 203-212. Sleek, S. (1997, August). Providing therapy from a distance. APA Monitor, p. 1, 38. Spielberg, A. R. (1998). On call and online: Sociohistorical, legal, and ethical implications of email for the patient-physician relationship. Journal of the American Medical Association, 280, 1353-1359. Stamm, B.H. (1999). Creating Virtual Community: Telehealth and Self Care Updated. In B.H. Stamm. (Ed.), Secondary Traumatic Stress: Self-Care Issues for Clinicians, Researchers and Educators 2nd Ed., (pp.179-210). Lutherville, MD: Sidran Press. (new edition) Stamm, B., (1998). Clinical Applications of Telehealth in Mental Health Care. Professional Psychology: Research and Practice, 29(6), 536-542. Telemedicine Act, Cal. Stats. 864 (1996). Retrieved January 25, 1999 from the World Wide Web: http://www.leginfo.ca.gov/pub/95-96/bill/sen/sb_1651-1700/sb_1665_bill_960925_chaptered.html Telemedicine Act, Cal. Stats. 199 (1997). Retrieved January 25, 1999 from the World Wide Web: http://www.leginfo.ca.gov/pub/97-98/bill/sen/sb_0901-0950/sb_922_bill_19970804_chaptered.html Terry, M. (1999). Kelengakutelleghpat: An Arctic community-based approach to trauma. In B. H. Stamm (Ed.), Secondary traumatic stress: Self-care issues for clinicians, researchers and educators 2nd edition. (pp. 149-178), Lutherville, MD: Sidran Press. Troster, A., Paolo, A., Glatt, S., Hubble, J. & Koller, W. (1995). Interactive video conferencing in the provision of neuropsychological services to rural areas. Journal of Community Psychology, 23, 85-88. U.S. Congress, Office of Technology Assessment. (1995, September). Bringing health care on-line: The role of information technologies (OTA Publication No. OTA-ITC-624). Washington, DC: Author. U. S. Department of Commerce (1997, January). Telemedicine report to Congress. (#1997-418-626/42023). Washington, DC: U.S. Government Printing Office. Waller, A., & Alcantara, O. (1998 ). Ownership of health information in the information age. Journal of American Health Information Management Association, 69(3), 28-38. Appendix A Resources American Health Informatics Management Association <http://ahima.org/> American Medical Informatics Association (AMIA) <http://www.amia.org> American Psychological Association <http://www.apa.org> American Telemedicine Association <http://www.atmeda.org/> Association of Telemedicine Service Providers (ATSP) <http://www.atsp.org/> Center for Telemedicine Law <http://www.ctl.org/> The Federal Telemedicine Gateway <http://www.tmgateway.org/> Health Care Finance Administration (HCFA) <http://www.hcfa.gov> Office for the Advancement of Telehealth (OAT) <http://telehealth.hrsa.gov/> Telemedicine Information Exchange <http://tie.telemed.org/>
Dr. Marlene M. Maheu is a licensed psychologist in San Diego, California. She is President of Pioneer Development Resources, Inc., owner of Self-help & Psychology Magazine, the first behavioral healthcare website on the Internet. With an audience of over 4,100 individuals per day, the award-winning SHPM e-zine <http://shpm.com> offers free psychological information to people worldwide. TelehealthNet is a resource center developed to advance psychology as a profession <http://telehealth.net>. She is a noted speaker and consultant in telehealth, and has most recently co-authored a book entitled Telemedicine & Telehealth: A comprehensive guide to be published in 2000 by Jossey-Bass. She can be reached at <drm@telehealth.net> or 858-277-2772. |
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