Twenty-five years ago, Seattle practitioner Stephen Sulzbacher, PhD, chartered a boat or plane to reach his clients in remote Pacific Northwest communities. Eight years ago, he began using his bicycle instead.

He pedals less than three miles from his home to a videoconferencing studio at the University of Washington Medical Center in Seattle where he uses a two-way audio/video link to connect with patients as far away as Petersburg, Alaska.

"The technology allows me to provide services to more patients because I spend less time traveling," says Sulzbacher, who is on staff at the University of Washington Medical Center and Children's Hospital in Seattle. "Telehealth is a way to take the time and space out of the equation when providing services."

Sulzbacher primarily treats clients ages birth to 21, who have attention-deficit hyperactivity disorder, fetal alcohol effects, autism or other behavioral disorders. Many of them live in remote areas of Washington, Wyoming, Alaska, Montana and Idaho (WWAMI), and he delivers services to them as part of the WWAMI Rural Telemedicine Network.

As is typical with rural patients, he says, they're more willing to access his services when they don't have to come to a city to meet with a specialist.

So far, however, few psychologists have incorporated videoconferencing into their practices. But, experts say, with the technology developing at lighting speed, it won't be long before the quality of videoconferencing improves and the technology becomes more affordable and accessible, allowing practitioners to use telehealth in their everyday practice.

The work of a telepractitioner

Most of the patients Sulzbacher treats with telehealth don't have access to face-to-face services unless Sulzbacher visits their towns. Clinical psychologists rarely practice in these communities, he says. In many cases, behavioral services are delivered by social workers or primary-care physicians.

So, not only does Sulzbacher provide direct services to children and teen-agers with behavioral problems, he also empowers other health-care professionals who work with those youths locally by coaching them via videoconference, e-mail and fax.

Sulzbacher has virtual office hours every Monday afternoon and by appointment. He does an average of one to three video visits per week, or about 30 each year. In the last four years, he has conducted 127 videoconferences.

Although the clinical outcomes of these visits are difficult to assess, WWAMI collects data from the patient, local provider and University of Washington consultant participating in each videoconference. More than 92 percent of all respondents have reported being "very satisfied" with the intervention, says Sulzbacher.

Here's how a typical intervention with a child works: Just as for a face-to-face intervention, Sulzbacher sits at a desk and reviews the patient's file and referral record before the meeting. The only difference is the desk is in the videoconferencing studio, and instead of waiting for a knock at the door, he waits for his clients to appear on a computer screen. Meanwhile, the child, his or her parents and a local provider will sit in front of a computer screen 1,000 miles away at a local clinic or hospital.

"Then the TV will ring, and up will come a picture of the people calling in," Sulzbacher says.

Typically, Sulzbacher has already met the provider, the child and the family in person. To begin the videoconference, he plays a few rounds of computerized tic-tac-toe with the child--an exercise to establish a rapport that he finds is often easier and less time-consuming using videoconferencing than in a face-to-face meeting.

"Kids are fascinated with interacting with someone on a computer monitor because it's like television," he says. "If I'm dealing with a child in my office, usually I have a toy or a game to build rapport. But with videoconferencing, I use the computer as my toy."

After the game, Sulzbacher asks the child why he brought his parents to see a psychologist.

"I like to address the child first," he says.

Sulzbacher then brings the parents and the local provider into the discussion, asking the parents about their family history of behavioral problems and use of alcohol, drugs and medications. When he needs to speak to a family member or local provider alone, he asks the others to leave the room just as he would if they were meeting in his office.

During the videoconference, the patient's image is projected on a 30-inch monitor. Sulzbacher can usually control the remote image by zooming in and out with the camera, focusing on one person or the entire group.

Most videoconferences take about an hour. Although Sulzbacher is only licensed in Washington, WWAMI has limited agreements with the five participating states to conduct consultations by video and on-site. However, the program requires that a local provider--either a physician, nurse or school representative--be present for each videoconference.

"I always end my videoconference saying to the provider and the patient, 'Now let me summarize my advice to your provider so you can decide how to proceed when you meet after we hang up,'" says Sulzbacher.

Sometimes, he says, the case is too complicated to solve in a videoconferencing appointment, and he asks the family to come to Seattle or travels to visit them.


While the technology usually works well, Sulzbacher says some of the most remote areas--such as an Indian reservation in Taholah, Wash.--don't have access to the technology required to support a sophisticated videoconferencing connection and the video picture is often choppy. When that happens, he says, he and his clients often hang up and try to get a better video connection.

If the connection fails at the beginning of a meeting, they often reschedule the appointment. But, he says, this isn't any more disruptive than if the family had come to the hospital for an appointment and there was an emergency that prevented him from seeing them. "And a videoconference is a lot simpler to reschedule than a visit to Children's Hospital," he says.

But, says Sulzbacher, glitches usually don't happen because technicians regularly check the equipment to make sure the connections are good.

Another benefit is videoconferencing has cut in half the number of unnecessary patient trips to Seattle.

"One of our frustrations before videoconferencing was having people being sent to us inappropriately at high costs to the insurance company," he says. "The provider and family ended up being dissatisfied, too."

But, he says, despite these benefits videoconferencing won't completely replace face-to-face visits. Videoconferencing works best when the provider has had an opportunity to evaluate the patient in person prior to the virtual appointment, says Sulzbacher. Nothing can replace a face-to-face clinical interview, he says.

"In a perfect world," he says, "the ideal use for videoconferencing is triage and follow-up."