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Trends in Telehealth
by Morgan T. Sammons, Ph.D.
Learning Objectives
- Understand different forms of Telehealth, and their advantages and disadvantages.
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Learn the different ways Telehealth can be utilized.
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Understand ethical and liability concerns surrounding Telehealth.
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Learn about concerns with regulation of services and databases, especially drug prescriptions via Telehealth.
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Learn the impressions Telehealth will have on the cost of mental health services and care.
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Learn how Telehealth affects clients, professionals, providers, and third-parties.
The Internet provides a powerful yet
largely untested mechanism for improving mental health service provision.
Most of the potential advantages have yet to be realized--indeed, most
remain unknown. In considering the future role that telehealth will
play in the provision of psychological services, a focus on the sociopolitics
of telehealth, as Lehoux and Blume (2000) suggest, rather than on technological
factors (which change rapidly and unpredictably) may provide a more
compelling organizing heuristic. Lehoux and Blume (2000) recommend that
the potential effects of telehealth be measured via their influence
on four key elements: the actors involved (i.e., providers, patients,
families, manufacturers, administrators, and third party payers); the
flow of resources (reimbursement strategies for providers; funding for
development, placement, and maintenance of networks); knowledge (who
establishes the rules for desirable telehealth interventions, and how),
and power (who controls this new technology–patients, providers, third
party payers, or others--and to what end) . In analyzing the data presented
in this brief, I suggest that attention to these four factors, rather
than technological or economic details, may help us develop a better
picture of the future of distance provision of mental health services.
ACTORS
Satisfaction: Patients, Providers, and
Third Party Payers. Studies report generally good levels of patient
satisfaction with telehealth services, though this finding is not universal.
Provider satisfaction is also variable. A recent Canadian survey indicated
high patient satisfaction with teleprovision of psychiatric services,
but when a smaller group was queried directly, approximately one half
the patients stated they would have preferred face-to-face consultation
(Simpson, Doze, Urness, Hailey, & Jacobs, 2001). Another Canadian study
specifically addressing the growing shortage of medical providers in
rural settings found that most providers believed enhanced telehealth
capabilities would significantly improve provider satisfaction and morale
(Watanabe, Jennett, & Watson, 1999). In a study of child psychiatric
service provision in Newfoundland, (Elford, et al., 2000), high levels
of satisfaction among parents were noted, with somewhat lower satisfaction
levels for child and adolescent patients. Service providers were
found to prefer face-to-face consultation. An Australian study of a
small number (32) of patients using videoconferencing for mental health
consultation found that the majority believed this form of service helped,
though almost all patients stated a preference to have both face-to-face
and videoconferencing available (Kennedy and Yellowlees, 2000). A study
comparing face-to-face and telehealth evaluations in a jail population
found no significant differences in patient satisfaction using either
modality (Brodey, Claypoole, Motto, Arias, & Goss, 2000).
Outcomes: Few good outcomes studies yet
exist for telehealth mental health service provision. Most published
reports are in the form of case studies (e.g. Hilty, Sison, Nesbitt,
& Hales, 2000), and while these generally report positive outcomes and
good patient acceptance, it is difficult to generalize.
Of the few controlled outcomes studies
available, an investigation of reliability of distance neuropsychological
evaluation of patients with alcohol abuse suggested comparable outcomes
to face-to-face consultation (Kirkwood, Peck, & Bennie, 2000). Though
the number of participants was small (27), reliability was high between
distance and face-to-face administration, and patient satisfaction was
rated as good. A recent retrospective analysis of 49 patients found
similar reductions in Global Assessment of Functioning scale scores
between those treated with interactive television and those treated
face to face. It was noted that those treated with distance methods
had a higher attendance rate and that follow-up visits were shorter
than in face-to-face encounters (Zaylor, 1999). Uncontrolled studies
(e.g., Ermer, 1999) suggest similar outcomes for teleconferenced as
opposed to face-to-face interviews, but methodology and small subject
size hamper generalizability. Thus, given the dearth of controlled studies
regarding comparative outcomes (Capner, 2000), reliability of telehealth
assessments is likely to remain an unanswered question for some time
to come.
FLOW OF RESOURCES
Cost: As in other applications of the
Internet, any cost benefits accruing through the use of distance mental
health service provision have yet to be realized. Most programs are
small in scope, and thus economies of scale are not yet in force. A
significant increase in patients will be required to achieve savings,
which may largely be through reduced transportation costs and paperwork
(Lamminen, Lamminen, Ruohonen, & Uusitalo, 2001). Savings to patients
can be significant in terms of both dollars and time, particularly if
the patient has to travel. Nevertheless, the balance between potential
savings and the cost of such services remains largely unknown. At this
point, therefore, cost savings are questionable. An Irish study conducted
over two years found that costs for teledermatology were higher than
for standard care, largely due to fixed equipment costs, but when other
factors (travel time, etc.) were factored in, telehealth, at least in
the rural setting, represented some savings over conventional care (Loane,
Bloomer, Corbett, Eedy, Hicks, Jacklin, Lotery, Matthews, Paisley, Steele,
& Wootton, 2000).
Most cost efficacy studies have been
carried out in European Union countries and generally do not address
mental health care. Few cost comparison studies are available for mental
health services. An Alberta study has found the breakeven point for
teleprovision of psychiatric services to be over 300 patients per year;
however, the number was considerably lower when distance media were
used for administrative functions (Simpson, Doze, Urness, Hailey, &
Jacobs, 2001). Elford, et al.’s study of child psychiatric service provision
in Newfoundland (2000) revealed that even with significant travel costs
factored in for patients (over $400 per consultation), telehealth service
was only marginally less expensive.
Positive regulatory action (e.g., expansion
of telehealth service provision under Medicare) and reimbursement by
non-governmental third party payers will be necessary before distance
mental health service provision is fully utilized (Charles, 2000). In
a survey of 29 Canadian university-based telehealth programs, Aires
and Finley (2000) reported that 70% of respondents listed funding as
a major factor negatively affecting growth of their programs.
Liability: Practitioners’ liability is
another issue that practitioners and regulators must address. As the
federal government and other third party payers become involved in reimbursement
for telehealth, accountability to payers must be considered. Although
recent federal regulations concerning the practice of telehealth have
been interpreted favorably to practitioners (e.g., the fact that a telehealth
network was owned by a consultant was not found to be a violation of
anti-kickback statutes; Stewart, 2000), regulation in this area is in
its infancy. HCFA regulations pertaining to the reimbursement of telehealth
services in authorized rural areas are developmental (Stewart, 2000).
The ability of psychologists to submit for telehealth reimbursement
in rural areas via Medicare is as yet unsettled.
Other liability issues that continue
to be unresolved relate to the particularities of providing care in
two locations: if a breach in the standard of care occurs, under which
community’s standards is that breach judged and in which jurisdiction
will it be adjudicated? Additional unresolved legal issues pertain to
informed consent, licensure and credentialing, confidentiality of information
stored on systems that may not be owned by a practitioner, ownership
of intellectual property rights on such systems, and, conceivably, antitrust
issues, in that telehealth might allow a single practice to establish
dominance over a large geographic area (Edelstein, 1999).
Placement and Ownership of Networks.
Telehealth networks for mental health services exist predominantly in
rural areas, as might be expected, particularly in large geographic
areas with provider shortages. A telepsychiatry service in Victoria,
Australia, conducted approximately 137 sessions per month among 27 rural
sites (i.e., 5.1 consultations per site per month; Buist, Coman,
Silvas, & Burrows, 2000), perhaps indicating that telehealth plays a
still minor but growing role in rural service provision. Regardless
of location, ownership of networks is a significant issue. Since many
such networks are likely to be operated by private information technology
firms under contract, ownership of intellectual property and safeguard
of patient data are paramount concerns.
POWER AND KNOWLEDGE
Regulatory and Ownership Concerns. The
use of telemedicine technology to enter and purchase prescriptions is
growing rapidly. Palm-held digital devices with wireless Internet connections
are being promoted to physicians as mechanisms for entering prescriptions.
Drug compendiums noting interactions, dose forms, contraindications,
and price structures are made available to providers with the suggestion
that this information, combined with the ability to cross-check prescriptions
in a central data bank, will enhance safety. Critics of such devices
note, however, that their use not only makes patient information available
to unknown parties but also provides drug distributors with valuable
information regarding the prescribing habits of the provider.
Patient use of the Internet to purchase
drugs is also growing significantly, and associated legal issues (e.g.,
purchase of cheaper drugs abroad that are then illegally imported into
the US, or purchase of drugs without adequate medical examination) are
increasingly a concern. The proposed 2001 budget for HHS includes $10
million to the FDA to prosecute illegal purchase of prescription drugs
on the Internet. Specifically mentioned are illegitimate pharmacies
that process prescriptions and the sale of
counterfeit or contaminated drugs. Distance technologies are also being
used to link hospital data systems more closely and to provide for hub
and spoke “virtual hospitals” where providers in one central site are
linked to patients and providers in outlying sites. Such projects are
already underway; a Georgia medical system, for example, is now implementing
this technology.
Organization changes resulting from telehealth
services are likely to be significant, though their exact direction
is uncertain at present. A small focus group found that greater physician
openness was a desired consequence of telemedicine service provision
(Tachackra, 2000). Another small qualitative survey of individuals working
in teledermatology, telepsychiatry, telepathology, and teleotolaryngology
noted that participants experienced not only expected benefits of distance
technology (reduced travel time, etc.), but also changes in organizational
structure (new job titles, different patient flow through the system,
enhanced coordination of care; Aas, 2001).
Regarding psychological services in particular,
much remains unknown. The development of specific regulatory models
and implementation of adequate practice standards for mental health,
as well as for other disciplines involved in telehealth, remains embryonic
at this point (Picot, 2000). This is particularly the case for the international
provision of telehealth services. Salient issues that must be addressed
before effective international telehealth service provision can take
place include compatibility of technology employed, the effect of varying
or competing legal and regulatory mechanisms, the establishment of global
quality assurance mechanisms, the effects of telehealth on healthcare
management practices, and mechanisms for evaluating cost efficacy and
outcomes (Lacroix, 1999).
CONCLUSION
Clearly, the future of telehealth service
provision depends not only on the ability of the profession to solve
issues particular to dispensing psychological services over the Internet,
but also on the way the Internet affects multiple political, economic,
and cultural factors around the globe (Kun, 2001). For mental health
services in particular, it is essential that better outcomes data and
analyses of cost effectiveness be developed (Frueh, et al., 2001). Patient
acceptance and provider satisfaction are two additional key variables
that must be positively answered for telehealth to become an established
technology that administrators and third party payers are willing to
endorse. Answers to these questions depend largely on resolution of
the more general economic, legal,
and ethical concerns surrounding use of the Internet for health care.
In the final analysis, safety, in the
form of adequate protection of patient rights and confidentiality, and
efficacy, in the form of optimum distance service provision, remain,
as in traditional mental health service provision, the benchmarks for
quality. To meet such goals, the National Academy of Science has recently
suggested focus on the following key areas: enhanced security, stronger
forms of authentication, effective tools for protecting anonymity, and
the use of deferral agencies as models for demonstration
projects (National Academy of Science, 2000). Likewise, Lehoux, Battista,
and Lance (2000) suggested four primary goals Internet service provision
would have to meet to be effective: reducing transportation needs of
patients and providers, improving service to underserved populations,
enhancing knowledge of both providers and patients, and reducing rural
isolation.
Much remains to be settled. It seems
likely, however, that telehealth will never completely replace traditional
face-to-face provision of services (viz. Jenkins & White, 2001) save
perhaps in extremely remote areas, but that it has great potential to
augment currently available services and possibly to improve access
and reduce the cost of traditional mental health care.
REFERENCES:
Aas, I. H. M. (2001). A qualitative study
of the organizational consequences of telemedicine. Journal of Telemedicine
and Telecare, 7, 18-26.
Aires, L. M., & Finley, J. P. (2000).
Telemedicine activity at a Canadian university medical school and its
teaching hospitals. Journal of Telemedicine and Telecare, 6, 31-35.
Buist, A., Coman, G., Silvas, A., & Burrows,
G. (2000). An evaluation of the telepsychiatry programme in Victoria,
Australia. Journal of Telemedicine and Telecare, 6, 216-221.
Brodey, B. B., Claypoole, K. H., Motto,
J., Arias, R. G., & Goss, R. (2000). Satisfaction of forensic psychiatric
patients with remote telepsychiatric evaluation. Psychiatric Services,
51, 1305-1307.
Capner, M. (2000). Videoconferencing
in the provision of psychological services at a distance. Journal of
Telemedicine and Telecare, 6, 311-319.
Charles, B. L. (2000). Telemedicine can
lower costs and improve access. Healthcare Financial Management, 54(4),
66-69.
Edelstein, S. A. (1999). Careful telemedicine
planning limits costly liability exposure. Healthcare Financial Management,
December, 1999, 63-69.
Elford, R., White, H., Bowering, R.,
Ghandi, A., Maddiggan, B., St John, K., House, M., Harnett, J., West,
R. & Battcock, A. (2000). A randomized, controlled trial of child psychiatric
assessments conducted using videoconferencing. Journal of Telemedicine
and Telecare, 6(2), 73-82.
Ermer, D. J. (1999). Experience with
a rural telepsychiatry clinic for children and adolescents. Psychiatric
Services, 50, 260-261.
Frueh, B. C., Deitsch, S. E., Santos,
A. B., Gold, P. B., Johnson, M. R., Meisler, N., Magruder, K. M., &
Ballenger, J. C. (2000). Procedural and methodological issues in telepsychiatry
research and program development. Psychiatric Services, 51, 1522- 1527.
Hilty, D. M., Sison. J. I., Nesbitt,
T. S., & Hales, R. E. (2000). Telepsychiatric consultation for ADHD
in the primary care setting. Journal of the American Academy of Child
and Adolescent Psychiatry, 39, 15-16.
Jenkins, R.L., & White, P. (2001). Telehealth
advancing nursing practice. Nursing Outlook, 49(2), 100-105.
Kennedy, C., & Yellowlees, P. (2000).
A community-based approach to evaluation of health outcomes and costs
for telepsychiatry in a rural population: preliminary results. Journal
of Telemedicine and Telecare, 6, Suppl 1, S155-157.
Kirkwood, K. T., Peck, D. F., & Bennie,
L. (2000). The consistency of neuropsychological assessments performed
via telecommunication and face to face. Journal of Telemedicine and
Telecare, 6, 147-151.
Kun, L. G. (2001). Telehealth and the
global health network in the 21(st) century. From homecare to public
health informatics.
Computerized Methods and Programs in Biomedicine, 64, 155- 167.
Lacroix, A. (1999). International concerted
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Health Technology and Informatics, 64, 12-19.
Lamminen, H., Lamminen, J., Ruohonen,
K., & Uusitalo, H. A cost study of teleconsultation for primary-care
ophthalmology and dermatology. Journal of Telemedicine and Telecare,
7(3), 167-173.
Lehoux, P., Battista, R. N., & Lance,
J. M. (2000). Telehealth: passing fad or lasting benefits? Canadian
Journal of Public Health, 91, 277- 280.
Lehoux, P., & Blume, S. (2000). Technology
assessment and the sociopolitics of health technologies. Journal of
Health Politics,
Policy, and Law, 25, 1083-1120.
Loane, M. A., Bloomer, S. E., Corbett,
R., Eedy, D. J., Evans, C., Hicks, N., Jacklin, P., Lotery, H. E., Mathews,
C., Paisley, J., Reid, P., Steele, K., & Wootton, R. (2001). A randomized
controlled trial assessing the health economics of realtime teledermatology
compared with conventional care: an urban versus rural perspective.
Journal of Telemedicine and Telecare, 7, 108-118.
Picot, J. (2000). Meeting the need for
educational standards in the practice of telemedicine and telehealth.
Journal of Telemedicine and Telecare, 6, Suppl 2, S59-62.
Simpson, J., Doze, S., Urness, D., Hailey.
D., & Jacobs, P. (2001). Telepsychiatry as a routine service--the perspective
of the
patient. Journal of Telemedicine and Telecare, 7, 155-160.
Stewart, E. E. (2000). OIG offers guidance
on the legality of telemedicine arrangements. Healthcare Financial Management,
June, 2000, 71-72.
Tachakra, S. (2000). The changes patients
expect to result from telemedicine. Journal of Telemedicine and Telecare,
6, 295–300.
Watanabe, M., Jennett, P., & Watson,
M. (1999). The effect of information technology on the physician workforce
and health care in isolated communities: The Canadian picture. Journal
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Zaylor, C. (1999). Clinical outcomes
in Telepsychiatry. Journal of Telemedicine and Telecare, 5, Suppl 1,
S59-60.
AUTHOR
Mental Health Department Chair, Naval
Medical Clinic, Annapolis, MD., Pres., Maryland Psychological Assoc.,
NR Board of Directors
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