Technology provides psychology with unprecedented challenges and opportunities. Whether we are computer literate or 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 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, 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:

Dr. LaFleur's patient was scheduled for a hysterectomy. With a dread of the potential post-surgical re-occurrence of depression, Martha was overwrought with the anxiety of not being able to visit Dr. LaFleur for 3-5 weeks after her surgery. Dr. LaFleur loaned Martha a videophone, to use from the comfort of her home. Using the videophone she has at her office, Dr. Lafluer practiced connecting with Martha via the videophone before the surgery. Martha was relieved to know that she could access her psychologist from her home after the surgery.

Dr. Allen's patient received a job transfer to a city 100 miles upstate. Rather than terminating treatment, Dr. Allen arranged for Mark to work with him through an Internet website catering to professionals who develop a virtual office with video capabilities to access their patients. Mark was particularly enthusiastic about using this system because it would allow him to easily include his two children in their discussions of his parenting skills without the mid-winter struggle of transporting them to Dr. Allen's office. Mark was also able to gain support for his efforts with his children through the website's parent education distance learning class. Similarly, Dr. Allen participated in the videoconferencing skills development distance learning workshop offered by the website. He also took advantage of several professional continuing education programs provided by his professional community through state and national conventions.

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 email 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 email (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&133:." (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 are 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, the 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?

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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/
Health Care Finance Administration (HCFA) http://www.hcfa.gov
Telemedicine Information Exchange http://tie.telemed.org/