Cover Story

The telehealth scene seems quiet these days compared with the frenetic activity of a few years ago, when a spate of new companies emerged and competed to provide psychological services over the Internet. Almost all of those companies have gone under, and no others have risen to take their place.

But telehealth is far from dead, say psychologists who have followed the field since the early 1990s. It is simply going through a retrenchment, focusing on the populations that need it most--those who otherwise lack access to health care--and developing technologies that will have a major impact on health care when the appropriate infrastructure is in place.

"The pressure has sort of gone away," says David Nickelson, PsyD, JD, assistant executive director of technology policy and projects in APA's Practice Directorate. With private companies largely absent, state and federal agencies, hospitals and other major health-care providers are taking the lead. "They're responding to need, not investor dollars," says Nickelson. "It's been pushed back to rural communities, to those who have a real need for it."

Convergence

Whether one uses the term "telemental health" or just "telehealth" to refer to psychological services provided remotely, almost all such services involve collaborations between psychologists and specialists in other disciplines.

In fact, many of the situations in which telemental health is most appropriate--such as providing counseling to people with disabilities in rural areas (see Access)--depend on partnerships between psychologists and physicians, nurses, social workers and other health-care professionals.

In rural communities, where health professionals are scarce, collaboration becomes even more important. That's certainly been the experience of Beth Hudnall Stamm, PhD, a psychologist at Idaho State University who directs Telehealth Idaho, a project to increase access to health care by working through health-care professionals.

According to an APA analysis conducted in the late 1990s, Idaho has fewer than 12 psychologists for every 100,000 people--less than half the national average. The situation for other health-care professions, including psychiatry and nursing, is even worse. Rural areas across the country face similar situations.

In Idaho, the shortage is amplified by low population density and difficult terrain, which force some residents to drive for hours to reach the nearest specialist. As a result, there is a dire need for alternative pathways for all types of health care, says Stamm.

Though directed by a psychologist, Telehealth Idaho isn't psychology-specific. Dental, physical and behavioral health are all included in the project's research, educational, consulting and infrastructure-building efforts.

Indeed, a major trend in telehealth today is the convergence of different kinds of telehealth, says psychologist Leigh Jerome, PhD, research director of the Pacific Telehealth and Technology Hui at the Tripler Army Medical Center in Hawaii.

Technological convergence is one part of that development. At the Pacific Hui, as elsewhere, there are ongoing efforts to ensure that the computer systems of different health-care providers--such as Veterans Affairs and the Department of Defense--can speak to each other, says Jerome.

Hurdles

Still, a number of challenges remain. One of the most critical is the question of efficacy: How do providers, patients and insurers know that the technologies they are using and paying for have the intended effects?

Unfortunately, there's no simple answer, says psychologist Robert Glueckauf, PhD, director of the Center for Research on Telehealth and Healthcare Communications at the University of Florida.

"What works may vary with the population," explains Glueckauf. The issue is not really whether a particular technology--videophone, telephone, e-mail, etc.--is effective, he notes, but rather "which technology works best for which population for which types of problems. Even if you segregate the rural issue from other concerns in telehealth, you still have that 'fit question' to address."

A good example is a study that Glueckauf and his colleagues are conducting, which examines different methods of providing counseling to rural children with epilepsy.

Preliminary results--published last year in Rehabilitation Psychology (Vol. 47, No. 1)--suggest that videophone and speakerphone interventions are just as effective for dealing with family problems as in-person counseling. But they also suggest that more advanced technologies don't necessarily bring better results.

A second challenge is training health-care professionals to use the new technologies. "What's happened with telehealth globally is that people have just bought new systems and have to make it up as the they go along," says Jerome. "There aren't a lot of tools for training." Finding the tools that do exist can be hard for rural professionals who are far from the urban centers and universities where technologies and expertise are concentrated.

Some individual instructors, such as Stamm and Glueckauf, have been offering university courses on telehealth for years. Psychology graduate programs on the whole, however, have been slow to include telehealth training in their curricula. There have been some opportunities to learn about the new technologies at psychology conventions, but even there the offerings have been limited, says Marlene Maheu, PhD, co-author of "E-health, Telehealth and Telemedicine" (Jossey-Bass, 2001).

The slow growth in educational opportunities might be due, in part, to another major challenge: resolving the new ethical and professional issues that telehealth raises. So far, says Maheu, there's little consensus within the psychological community on how telehealth should be used.

In a new book, scheduled for publication by Lawrence Erlbaum later this year, Maheu and her co-authors suggest that psychologists should follow "community standards of care": an initial in-person assessment that provides an opportunity for informed consent, followed by an agreed-upon treatment plan that incorporates telehealth.

In some situations, says Maheu, intensive techniques like videoconferencing might be best. In others, self-directed use of an automated Web site might be more appropriate.

Maheu is as enthusiastic about the possibilities of telehealth as anyone, but she also sounds a note of caution. Along with their promise, the new technologies carry some significant risks, she says. Unlike dermatologists, radiologists and other specialists who have embraced telehealth, psychologists are in the business of helping people who, because of the nature of their health problems, may pose a serious threat to themselves or others.

That's one reason, Maheu says, that most psychologists are unlikely to follow the model that doomed the dot-com startups--psychological consultation done solely over the Internet.

"Most of us are trained for worst-case scenarios," she says. "If you imagine yourself in front of a licensing board having to say that you only communicated with your patient over e-mail...I think most of us would not want to be in that position."



ON THE WEB

Further Reading

  • Glueckauf, Robert L. (2002). Telehealth and chronic disabilities: New frontier for research and development. Rehabilitation Psychology, 47(1).

  • Maheu, M. (2001). E-health, telehealth and telemedicine. San Francisco: Jossey-Bass.

  • Stamm, B.H., & Perednia, D.A. (2000). Evaluating psychosocial aspects of telemedicine and telehealth systems. Professional Psychology: Research and Practice, 31(2).