Telehealth: DELIVERING BEHAVORIAL TELEHEALTH VIA THE INTERNET
E-HEALTH

by: Marlene Maheu, Ph. D. 02/01/00

Just as practitioners are familiarizing themselves with the term "telehealth," a new term is emerging: "Ehealth." Similar to the development of the term "eCommerce," as the latest buzzword for the business world, Ehealth is already the preferred term for healthcare services available through the Internet (McLendon, 2000). This article will outline the past, present and future of Ehealth, as well as how psychologists can help psychology grow with these inevitable changes.

Ehealth refers to all forms of electronic healthcare delivered over the Internet, ranging from informational, educational and commercial "products" to direct services offered by professionals, non-professionals, businesses or consumers themselves. Ehealth includes a wide variety of the clinical activities that have traditionally characterized telehealth, but delivered through the Internet. Simply stated, Ehealth is making healthcare more efficient, while allowing patients and professionals to do the previously impossible.

Two types of Ehealth companies have developed since the Internet was deregulated in the early 1990's:

1. Brick-and-mortar companies that are web-enabled.
2. Companies that use the Web as their primary corporate environment.

While over 15,000 healthcare sites already exist online, only a few hundred are exclusively web-based. Numbers in both camps are growing very rapidly, however. They are offering unprecedented services and benefits to their users. Consumer demand is very high. An estimated 60 million adults used the Web to find health related information in 1998 (Kaufman, 1999). In a survey of 3,269 Internet users, Ehealth users reported that finding disease specific information was their number one application of the technology (Intel, 2000). Powered by demand for prescription drugs, consumer spending for online health goods and services is estimated to increase from 1 million in 1999 to .8 billion in 2004 (Intellihealth, 2000).

The medical profession has been developing telehealth technology for over 35 years. The integration of classic telemedicine and telehealth technologies with the Internet was the next logical step. Now that technology is ready for the merger, its sudden growth is staggering. A number of specialty sites already exist for billing, back office functions, marketing, medical records processing, communications, medical supplies and equipment. Some websites offer complete virtual offices for physicians http://www.webmd.com/.

On the consumer side, patients can easily purchase prescriptions http://www.drugstore.com/defaultb.asp , buy products http://www.ablemedical.com and obtain general consumer information http://www.drkoop.com. More advanced websites combine many of these functions. For example, http://www.asterion.com links professionals, insurance carriers, facilities, and patients into an online community, and develops a "smart" database of all activity between community members, with a comprehensive set of data reports on their transactions.

Ehealth Programs of Note. Health Buddy, a portable device developed by Health Hero Network Inc. of Mountain View, Calif., allows physicians to "monitor" hundreds of patients at once by processing patients' daily answers to health questions online, via a telephone hook-up. Physicians may access patient information using a password and are alerted to any signs of trouble, including sudden weight gain or failure to take medications. It also gives immediate results of home tests, such as breathing tests for asthmatics and blood glucose machines for diabetics.

Medtronic.com is developing a new monitoring service that will allow heart patients to use the Internet to relay up-to-date cardiac data from their homes to physicians' offices. The electronic connection would use a home monitor to download information such as heart rate and battery status from an implanted pacemaker, defibrillator or experimental cardiac device, possibly while the patient sleeps. The data would then be automatically transmitted to a cardiologist over a secure Internet link. The physician could call the patient in for an office visit as needed or, eventually, could reprogram the device remotely without the patient leaving home.

PriceWaterhouseCoopers predicts that all homes will be equipped with virtual health agents to screen for disease by 2015 (California Healthline, 2000). Dertouzos describes a more comprehensive healthcare monitoring service as developed in the late 1990's at the Massachusetts Institute of Technology (Dertouzos, 1998). Their "Guardian Angel" program wires insurers, clinics, hospitals and practitioners to offer consumers a seamless healthcare package from the moment of birth through death. Wide scale application of such integrated programs is not far off.

Several vendors are emerging who will supply practice management services to clinicians and clinical organizations over the net for a subscription fee plus nominal transaction fees (T. Trabin, personal communication, January 14, 2000). These Application Software Providers (ASPs) free clinicians and clinical organizations from purchasing software for their individual desktops. The advantages they offer are:

• subscriber does not have substantial up-front investment in software, since its downloaded per transaction from the net;
• subscriber does not have substantial upgrade fees, since each upgrade is handled through the main server and not on each clinician's computer;
• subscriber has lower hardware costs, since only a very basic computer is necessary.

Despite these many advantages, the challenges are many, and include:

• guaranteeing data privacy in transmission and storage of confidential patient information;
• defining who owns the data;
• guaranteeing quick access and transmission power over the Net for user-friendly yet secure transactions.

Psychologists will undoubtedly need to become involved in these developing products and services to protect the patients they serve, as well as the profession of psychology as it makes its way in this new marketplace.

Although Ehealth is an outgrowth of telehealth, it is differentiated in several important ways. telehealth to date has been largely non-Internet based and has been characterized by point-to-point (e.g., T1) and dial-up (e.g., telephone, ISDN) information exchange. Ehealth, on the other hand, is more accessible due to its increasingly affordable ability to communicate through a common set of standards and across operating systems (Allen, 1999). As can be seen in the number of Ehealth websites mentioned above, this increase in access has also led to an increase in the number of uses of the Internet for healthcare. These increases also lead to greater concerns for privacy, confidentiality, security, and data integrity.

The recent amount of financial "buzz" associated with Ehealth has already outstripped the attention paid to telehealth (Allen, 1999, p. 7). Moreover, private industry has taken a keen interest in bringing much of the 77 billion dollar healthcare industry to the Internet, rather than relying on federal telehealth funding. Large technology corporations like Lucent Technologies and Intel have teamed up with medical groups such as Johns Hopkins Medicine and the American Medical Association to provide the infrastructure for Ehealth.

Language is also changing as a result of the Internet and Ehealth. To the dismay of many professionals, those practitioners working for "dot com companies" are referred to as "providers" and patients or clients are called "customers." Ehealth language will most likely be ruled by economics, as has been witnessed by the impact of managed care.

Traditionally, telehealth has followed the classic model of top-down healthcare delivery, from authority to patient. With the Internet, patients increasingly have immediate access to worldwide medical databases, libraries, conference proceedings, and medical records. They can log onto MEDLINE for original journal articles, access textbook collections, drug databases, diagnostic cookbooks, and disease-specific sites. As a result, patients are taking more responsibility for their healthcare decisions and relying less upon individual practitioners (Ferguson, 1997, 1998). Ehealth empowers individuals by allowing them to make their own informed decisions regarding personal healthcare (Spielberg, 1998). Spheres of expertise traditionally held exclusively by professionals are now open to the public at large. Patients are presenting themselves for treatment, often armed with information they found on the Internet, and are seeking answers to questions based upon that information. They are also helping themselves and each other, with or without the help of professionals.

As patients change, so will professionals. Approaching patients with an authoritarian, all-knowing, calling-the-shots attitude will no longer be tenable for professionals as patients gain equal access to information sources online. Professionals will need to become more specialized and learn to accommodate and compliment their newly empowered patients, rather than expecting to be the unquestioned expert.

Problems with Information. Problems are surfacing related to the amount and quality of information available to patients on the Internet as information is no longer screened and delivered to patients by professionals (Hubbs, Rindfleisch, Godin, & Melmon, 1998; Murray, 1998). More specifically, research conducted to analyze the content of medical information on the Internet has found that such information may sometimes not be reliable (Anderson, Allee, Chung, Westra, & Lingle, 1998; Silberg, Lundberg, & Musacchio, 1997). For example, Impicciatore and colleagues used various search engines to systematically study 41 parent-oriented websites that provided advice for the management of childhood fever. Surprisingly, only four adhered closely to published guidelines for home management of childhood fever, and some sites even proposed potentially dangerous remedies (Impicciatore, Pandolfini, Casella, & Bonati, 1997).

On the other hand, another study compared 25 online health databases, focusing on the frequency of updates, response time for email requests, and other features (Anderson, Allee, Chung, Westra, & Lingle, 1998). Sites were compared for design criteria and content quality. Surveys were also sent to each database via email, with an initial response rate of 20%. Repeated requests eventually generated a 76% response rate, with 17 of 25 sites sending complete responses and two sending incomplete responses. Most of the 25 sites checked their links weekly or monthly to ensure the quality of their information.

Other researchers are proposing how the quality of medical information on the Internet might be guaranteed. For example, Silberg and colleagues suggest that health information posted on the Internet should be dated and clearly disclose authorship and credentials, cite and include references and sources for content, and fully disclose site ownership (Silberg, Lundberg, & Musacchio, 1997). Other groups offering criteria for evaluating health information on websites include Miltrek systems and the American Telemedicine Association (ATA, 1999).

Other problems with healthcare information obtained by consumers through the Internet include the complexity of some information, paired with the broad range of reading levels among an international reading community (Graber, Roller, & Kaeble, 1999). The Internet's international community also poses a myriad of multicultural issues and complexities that have yet to be addressed by psychologists (Maheu, Callan, Nagy, in press).

More recently, several consumer Ehealth sites have also started to set up ethical guidelines to protect consumers and govern online advertising, content, sponsorship and privacy. Another serious has been the way some websites use personal data collected from consumers. Companies such as DoubelClick, Inc., have reportedly developed records detailing the Web use of With their purchase of Abacus Direct Group -- a firm that maintains a database of consumer names, addresses and retail habits, DoubleClick is now in a position to have detailed files on over 100 million online surfers represented by anonymous ID numbers, and "to get a detailed picture of who you are, what you do and where you visit on the Web." (California Healthline, 2000, January 31). Researchers have also expressed concerns that some electronic commerce activities may actually be endangering consumers' health (Chin, 1999; "Health on the Net," 1998).

Professional associations are beginning to take a proactive stance to defining appropriate medical content for the Internet. For example, the American Medical Association has joined with six other national physician associations to produce a comprehensive quality health information and communication website called Medical Empowerment http://www.medem.com. The partners in medem.com comprise the American Medical Association, American Academy of Ophthalmology, American Academy of Pediatrics, American College of Allergy, Asthma and Immunology, American College of Obstetricians and Gynecologists, American Psychiatric Association and American Society of Plastic and Reconstructive Surgeons. These societies will own and control the new entity established to create, develop, and maintain the Web site.

The American Medical Association is also working with Intel Corporation to deploy a new form of digital credential that is designed to protect practitioner and patient privacy and confidentiality when they use the Internet to send and receive medical information ("New AMA," 1999). Digital credentials uniquely identify individuals on the Internet and will be issued to all practitioners in order to provide an authentication technique for secure Internet transactions that is more reliable than basic password access security. Practitioners will be able to use the free software to securely access laboratory results, write prescriptions, have their notes transcribed and eventually have their claims processed by insurers. Digital credentials create secure Ehealth communication where privacy and identity are protected, while protecting patients and practitioners from fraud and abuse. The Digital Credential online file includes:

• The complete name and email address of the digital credential holder.
• An encryption key that verifies the signature of the Digital Credential holder.
• The time period during which the Digital Credential is valid.

As will be featured in an upcoming APA Monitor, psychologists are active on the Internet in a variety of capacities. A central focus of Ehealth is the development of low-cost and convenient supportive communities that focus on a wide range of issues (Maheu, 1997; Rheingold, 1993; Turkle, 1995; Wellman & Gulia, 1995). People can anonymously join a sizeable online community to share personal information to a depth that is unprecedented in the face-to-face world. For people with depression or parents of children with ADHD, the friendships they form in these support groups often become pivotal in their social network. Specialized groups offer support for almost every type of mental disorder (e.g. trichotillomania) or life circumstance (such as divorce), as well as support for friends and family. Some email discussion lists and newsgroups, such as alt.support.depression, claim to have tens of thousands of monthly users (Salem, Bogat & Reid, 1997).

Websites such as "iVillage" http://www.ivillage.com and America Online http://www.aol.com, provides virtual communities, chat rooms for personal issues and discussion hours with professionals. Behavioral and lifestyle recommendations are available from a number of public websites such as http://www.realage.com. Developed by this author, a specialty website for behavioral health is SelfhelpMagazine.com, http://www.selfhelpmagazine.com. SHM is frequented by participants from over 70 countries who gather to discuss over 60 topic areas, ranging from Munchausen Syndrome to Depression. Launched in 1994, SHM offers daily behavioral healthcare news, articles, reviews, discussion boards, cartoons, post cards, a meditation center and thousands of links to other healthcare websites. It consists of more than 3,000 pages developed by hundreds of volunteer psychologists, social workers, counselors, designers and artists.

Most leading hospitals have online informational services, http://www.mayoclinic.org. Many managed care organizations offer informational services as well as some types of direct care through privately accessed parts of the Internet, known as "intranets." With an increasing MCO trend toward employing non-licensed "lifestyle managers" to "coach" consumers via telephone for issues related to smoking cessation, weight management and depression, it will be of interest to see how psychologists will find their way to Ehealth in these organizations. To date, it appears that psychologists are employed as program developers rather than direct service providers for online programs.

Traditional telehealth programs are using the internet for some basic functions. For example, in Madison, Wisconsin, patients diagnosed with AIDS, breast cancer, or a number of other conditions are supplied with a PC-based home health workstation called CHESS through their HMO program. The computer supplies 60 to 80 megabytes of high quality information related to the patient's specific condition. It also functions as an electronic support group by linking patients (through a simple modem connection) to their health professionals, local community groups, and with people who share similar diagnoses. Studies have shown that these patients become more responsible for their self-care and require less clinical care (Gustafson et al., 1993).

Some psychologists have taken an active role on the Internet by forming affiliations such as InterPsych http://www.interpsych.org, an interdisciplinary group of professionals who encourage and promote the use of the Internet by both academics and clinical practitioners. Through some of InterPsych's email discussion lists, psychologists can learn of various developments on the Internet. Psychologists and graduate students have also contributed articles and resources to websites that specialize in telehealth, such as http://www.telehealth.net, operated by this author. Another website developed by and for behavioral healthcare professionals is Computers in Mental Health http://www.ex.ac.uk/cimh/.

While the "first generation" of Ehealth primarily offered information and support, the next generation will offer increased access to practitioners and direct service delivery. Psychologists are already beginning to sustain contact with patients through email (Borowitz & Wyatt, 1998; Eysenbach & Diepgen, 1998; Sleek, 1997). Physicians have also been monitoring the repercussions of such email contact with patients (Ferguson, 1998; Spielberg, 1998).

Behavioral healthcare practitioners are also using computers to take histories, fine- tune diagnoses, monitor progress, and maintain therapeutic contact through email (Lamberg, 1997; Maheu, 1997; Rusovick & Warner, 1998; Sleek, 1997). Some psychologists are already using the Internet as a virtual office to provide interactive consultations (Maheu & Gordon, 2000). These new services are not empirically validated and raise more serious legal and ethical concerns (Maheu, Callan & Nagy, in press). Managed care is also making provisions for Ehealth ("E-Commerce: An MCO," 1998; "E-Commerce: Planning," 1998).

Internet-based technologies will soon "converge" with satellite and cable television for full interactive broadcast capabilities delivered through one, seamless technology. Psychologists and patients will be able to interact over the Internet in a secured environment sooner than legal and ethical adaptations can be made. Estimates for the wide-scale deployment of these services range from 24 - 48 months. With continued improvement in security and quality of healthcare websites, consumers and practitioners will be able to increasingly rely upon Ehealth to provide accurate clinical data and support. In the future, Ehealth will include more interactive services and the virtual office will be an integral part of psychology practice.

The Ehealth potential for immediate and international Internet dissemination of patient information and direct service delivery has many legal and ethical repercussions for psychologists. For example, traditional telehealth has relied upon telephone-based technologies for interactive videoconferencing, which has an established history of legal and ethical standards through telephone company regulation. The Internet is challenging these precedents.

Therefore, the protection of patient confidentiality is being discussed by professionals from both psychology (Maheu, 1998; Maheu, Whitten & Allen, in press; Maheu, Callan & Nagy, in press; Nickelson, 1997, 1998; Sleek, 1995; Stamm, 1998) and medicine (Mitka, 1998; Spielberg, 1998; Stein, 1997). Similarly, many professionals are voicing concern due to the lack of credentialing and accountability from unlicensed or unqualified individuals who present themselves as psychologists on the Internet (Maheu & Gordon, 2000; Nickelson, 1997).

Several state and federal laws have been passed to remedy these situations. One of the most significant laws to influence Internet healthcare is the Health Insurance Portability & Accountability Act (HIPAA, 1996). While it requires electronic signature, authentication and audit trails (Gilbert, 1999; Maheu, Whitten & Allen, in press), it leaves several key areas undefined for behavioral healthcare. Psychologists are needed to address these areas. Another area needing attention is that psychologists (Maheu & Gordon, 2000) as well as the regulatory agencies related to psychology (Koocher, in press) have questionable awareness of existing legislation related to the practice of behavioral telehealth. Psychologists can assist with the required shift to technology by becoming educated regarding telehealth and Ehealth, and taking an active role in their local, state, and national professional associations to bring about legislative change.

Ehealth is changing the reality of healthcare for patients, payors and professionals. It is for the betterment of psychology that we become active in Ehealth at this formative stage. Psychology has the opportunity to prosper in this new arena, but only if visionary psychologists hear the call and raise the banner. There are many ways to assist the development of behavioral telehealth and Ehealth. They include learning and teaching as much as possible about technology through seminars and workshops, encouraging the development of ethical guidelines, bringing about change through legislation, and working with software and "dot com" companies to responsibly develop services and products that add value to psychologists and their patients. Psychologists can be of immediate help in working for Ehealth companies as program developers and evaluators. Based in hospital and correctional facilities, they can become active on Internet development teams to insure ethical and legal issues are addressed, including confidentiality, privacy, security and data integrity. They can help develop appropriate content and products being distributed or sold through websites. Frankly, if psychologists don't fill these roles, others will. With vision and leadership, we as psychologists can insure the future of our profession by embracing and taking active steps to promote the growth of psychology through responsible Ehealth.

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