What is Telehealth?

For instance, telehealth is the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision, education and information to under-served populations, isolated practitioners and individuals separated by distance or barriers. Behavioral telehealth is the application of that telecommunications and information technology to provide behavioral health aspects of these services to the same populations.

Telehealth includes electronic transmission of medical and mental health information between professionals as well as between practitioners and patients.

Telehealth is a blanket term that will include a seemingly endless combination of technology to overcome communication and logistics problems. For example, it will be possible to have desktop videoconferencing (DTVC) between doctors and patients, in real time, allowing complete and immediate assessment of need and severity. Such DTVC assessment could be performed through the patient's personal computer or one in a local clinic.

The Benefits for Professions

One of the benefits of new technologies for professionals is convenience, since many would be able to work from a centralized location. Rather than specialists going out to various clinics at remote locations, a specialist could operate efficiently from an urban hospital, perhaps going on-site on a monthly basis. This plan speaks to all kinds of concerns such as immediate care and cost effectiveness. When a remote clinic may be one or two hundred miles away from the home site, time savings can be more critical than dollars. However, considering that same distance will not have to be traversed on a regular basis, the financial savings become significant as well.

Already, business people are moving back to rural areas because they can still perform with excellence and enjoy the rural lifestyle. Now, a similar move among the medical community is being predicted, with professionals still able to have viable practices that will be intellectually stimulating and rewarding, albeit from rural areas. Professionals who want to stay in a rural area can now be plugged into specialists that can help them with special cases. They can also have continuing education through VC and contact with their colleagues so that they don't feel as isolated. The rural areas can have better hospitals and doctors because the specialists, perhaps in a teaching university such as the University of Kansas, will back up the local doctor.

Current projects are in place in Virginia, Montana, Oregon, southern California, and the University of Kansas has a telemedicine center of significant size. In these situations, a designation is made for hub hospitals with satellite centers in remote communities, some 100 to 300 miles away. The hub hospitals provide specialists 24 hours a day, and in the remote hospitals a nurse practitioner or a crisis counselor can handle most of the presenting cases. For those that need a specialist, perhaps a psychiatrist, the patient can speak directly to the psychiatrist, so a medical evaluation can be done immediately, and proper medication can be given to the patient. As a matter of fact, in the state of Massachusetts, the psychiatrists are able to advise over videoconferencing (VC) lines, so that an angry or out-of-control patient can be put on a mandatory hold from a remote location without waiting for another physician to arrive. The outcome is then beneficial to the patient, doctor and both facilities. The patient in crisis has been treated without added stress of traveling or leaving familiar surroundings; the doctor has consulted with the client as if he were in his own office, leaving the psychiatrist available for other patients without delay of travel. Furthermore, the facilities have staffed only the level of professionals essential for the adequate care of all patients, so their personnel capabilities have increased whereas overhead is tremendously reduced.

Another application of VC technology is already proving to be of significant importance for a variety of reasons. Professionals in hospitals who regularly treat prisoners can forgo the risk of bringing a prisoner to a clinic or having a specialist go into a prison system. Instead, prison officials take the prisoner to the conferencing room where a secure one-to-one connection is set up between the doctor and prisoner. Therefore, the prison does not have to pay guards to transport the prisoner into the community, yet the prisoner still gets the care he/she needs, even a specialist rather than a generalist that might be in the facility. The safety issues for the doctor and the community are solved, without the public relations aspect of allowing a prisoner outside the secured facility ever having to be addressed.

In the mental health profession, we don't need the level of sophistication that a dermatologist would need to diagnose a rash or a surgeon would need to carry on a delicate surgery. We just need to see and hear the person. So a lot of the less expensive equipment is satisfactory. There are a number of programs that are using equipment that costs under $500 per installation. Such equipment is more than adequate for psychotherapy and/or medical consults with psychiatrists, so the kind of equipment we need is much more within reach by the sparest budget than it was even a year ago. The way prices are going now, in another year we can say that it will be even easier to access. A lot of us already have modems, Internet connections and other equipment that make such a program easily accessible to the smallest clinics through private virtual networks (PVN), Internet2 networks with heightened security. These systems should be more commonly available by the year 2000 and will provide increased bandwidth capabilities.

Enhancing the likelihood of another step into technology, the federal government is pumping millions of dollars into advancement. The FCC authorized $400,000,000 a year for the next four years to be spent on reducing phone charges for Internet and VC connections. Microsoft, Intel and Compaq are cooperating to produce equipment that will allow for faster transmission of more data through phone lines. The free-market system is working at its best, creating competition between the telephone and cable systems for rights to VC business.

Healthcare Issues and Decisions

Still to be addressed is the issue of licensure; right now we are licensed to practice in individual states. When we go over state lines there are various sanctions for that. Now that technology is making it so easy to go over state lines, the laws are in a state of flux. The various professional groups are trying to advocate for a driver's license type permit, allowing credentials to cross over state lines.

However, the various states have gotten involved in a kind turf war. For example, the state of California passed a law that went into effect July 1, 1998 called the California Telemedicine Development Act. This act says that practitioners cannot practice out of state, including clinical psychologists. The law also states that we can consult with other professionals out of state, but much more interestingly, it mandates that insurance companies pay for telemedicine services. It also states that insurance companies cannot require face-to-face contact as a condition of reimbursement.

More of the decisions for healthcare are going to be in the patient's own hands. A person could find information on the Internet about what to do for a particular symptom and possibly be able to solve that problem without having to make an appointment with a professional. What this means for professionals is that we are going to be doing a lot less educating while being required to be more specialized in the services that we deliver. So we will no longer simply be the authoritarian professionals that go to conferences a few times a year, who come home and disseminate information to our caseload.

There is a necessity for professions to get involved and decide how and when this equipment is going to be used, and by whom. Right now, patients may come in with journal articles by world-renowned researchers, published and downloaded from the Internet. They will educate us about their illnesses and work with us as a team to get the right type of treatment. In addition, we are going to have to work in a multi-disciplinary world to share VC equipment, and work more often with insurance companies that will triage to us. Insurance companies can refer patients to professionals that have this equipment and even refer patients to a specialist on VC, if there is not one in a particular patient's community.

There are many decisions to make before setting up a telehealth program, such as where to get funding, what type of equipment to buy, how to get referrals from the community, what research models are appropriate and what distance-learning applications are possible. There are still legal and ethical as well as supervision issues that have to be discussed. As a glimpse of what is coming, a psychology training school in Florida just installed VC equipment to allow a supervisor to sit at a desktop and watch an intern doing therapy with a patient, doing away with the one-way mirror. If we don't make necessary decisions now, other healthcare professions will make them for us. Learn as much as you can about behavioral telehealth, and become involved wherever possible. Tomorrow was at the doorstep yesterday, and if you haven't noticed, the future is today.

Marlene M. Maheu is a licensed psychologist in San Diego, California and Director of Telehealth Programs for the California School of Professional Psychology. Dr. Maheu is the president of Pioneer Development Resources, Inc., a company dedicated to the development of electronic delivery systems for healthcare. She is a frequent speaker at professional conferences and is completing a new book with co-authors Pamela Whitten, Ph.D. and Ace Allen, M.D., "Telemedicine and Telehealth Primer and Resource Guide," to be published in the year 2000 by Jossey-Bass. She can be contacted by calling 858/277-2772 or fax 858/294-8181.