Jake changes the channel on his television, picks up the telephone, and calls his psychologist using a videophone, all from the comfort of his living room. The videophone is a camera unit that is smaller than a VCR, with attachments for a television and a telephone. It permits the user to use any television and touch-tone telephone for videoconferencing to anyone else with the same equipment. Jake simply speaks into the telephone and uses his TV screen to see his therapist - without a computer.

Within minutes, his call is answered by Dr. Johnson, seated at her desktop videophone in the urban mental health clinic, 200 miles away. She sits in front of a soothing mountain scene, a projected image backdrop to her virtual office. She has chose this scenery specifically for Jake's session, due to his family's preferences for mountain scenes, and the need to sooth the six-year-old, who has been distressed since her parent's divorce two months ago.

Jake's dog is at his feet, and Shannon, his problematic six-year old is on his knee. Shannon is intrigued by the "television doctor" and contributes to the therapy session with the enthusiasm of a typical 6-year-old. Jake appreciates the convenience of receiving much needed psychotherapy at home, where he has his greatest struggles with his daughter, and at bedtime, when she proves to be most problematic.

He also appreciates that the videophone was easy to install, and was inexpensively rented from Dr. Johnson for the duration of treatment. His telephone charges are the same as any outgoing telephone call. Dr. Johnson rents several of these units to clients who originally were face-to-face clients, but needed to relocate for one reason or another.

To practice within the bounds of her licensure, she is careful not to deliver services over state lines; has participated in several of the California Psychological Association's Telehealth workshops; and has sought private consultation with an expert in Telehealth. As with Jake and Shannon, satisfaction ratings from other clients are very high, given the continuity of care provided by the equipment. She purchased the equipment from her local electronics store (such as CompUSA or Frye's Electronics) for less than $500 per unit.

Is this the future of psychotherapy?

At the dawn of this new millennium, "Telehealth" is identified as the most significant contribution to healthcare delivery systems of the future (Bashur, 1997; Council on Competitiveness, 1996; DeLeon, Sammons & Vandenbos, 1998). 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). The term now replaces the more restrictive, previously used, "telemedicine," adopted by physician groups starting this movement over 35 years ago (Nickelson, 1997).

Telehealth officially includes the use of all electronic tools for healthcare delivery, ranging from digital telephones used for literature reviews and patient contacts, to fiber-optic or satellite interactive video. The intent of using this technology is to maintain the essential qualities of the healthcare interaction while increasing access by overcoming impediments such as economics, culture, climate, and geography (e.g., Dankins, 1995; Forkner, Reardon, & Carson, 1996; Preston, Brown, & Hartley, 1992 ; Stamm, 1995; Terry, 1995).

Behavioral Telehealth

"Behavioral Telehealth" refers to the use of such tools in behavioral healthcare, a practice that has rapidly become the single most frequent used specialty service for Telehealth practice (Grigsby, 1997). Initial evidence indicates that telemedicine works well for group therapy as well as individual consults" (U.S. Department of Commerce, 1997, p. 19.)

Patient care can involve assessment, psychotherapy, crisis intervention, patient education, case management, and psychologist's rapidly expanding interest in medication support (DeLeon et al. 1991; DeLeon & Wiggins, 1996 ). Other applications for psychologists include administrative, research, teaching, supervision and professional development activities (Administrative Rules of Montana, 1995; McCarthy, Kulakowski, & Kenfield, 1994; Stamm, 1995).

Mental health practitioners are experimenting with technology to deliver psychology in new and effective ways, including the Internet (Frisse, Kelly & Mercalfe, 1994; Maheu, 1997; Rusovick & Warner, 1998; Sleek, 1997). 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). A number of pilot behavioral Telehealth or telepsychology programs have already begun (Baer et al., 1995; Burton, 1997; Fetterman, 1996; Glueckauf et al., 1998; Jerome, 1986, 1993; Sampson, Kolodinsky & Greeno, 1997; Troster et al., 1995). Professional training via Telehealth technology is already being offered at graduate and post-graduate levels in some of our graduate institutions (Judith Albino, personal communication; January 19, 1999; Ron Levant, personal communication, January 19, 1999; Sampson, Kolodinsky & Greeno,1997).

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 (DHHSa, DHHSb, 1997; 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. Yet, a critical question remains: who among psychologists is attending to these critical issues?

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, in preparation; Maheu, Callan & Nagy, in press; Nickelson, 1998b; 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. 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 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 scenario, 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). The California law defines and regulates the practice of Telehealth a state-wide level. Psychologists are considered providers for Telehealth reimbursement through all third party carriers, including Medi-Cal. Here are the main provisions:

1. The Telemedicine Development Act of 1996 restricts California telemedicine services to practitioners licensed in California. This means we cannot communicate electronically as primary care providers with clients/patients outside our state.
2. We can serve as consultants connected by telecommunications equipment to professionals in other states.
3. Perhaps even more importantly, insurance carriers (including HMO's and Medi-Cal) are mandated to reimburse providers for the delivery of telemedicine. The new law amends four major state codes to add telemedicine as normal part of healthcare services.

We must also be aware that patients also have rights and responsibilities as information becomes increasingly available to them through technology (Maheu, 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, 1998a). 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 that "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?." (Rabasca, 1999, p. 27).

We clearly need to become politically aware and actively involved if we are to survive as practitioners in the psychology marketplace of the future. 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. We must identify which delivery system will suit which patient with which diagnosis at which point in the treatment process? What information will go into the patient record? Who will have access to that record? These answers must be found within our lifetimes as psychologists. Ultimately, if we do not become active in shaping new technology for our professions, who will? Other professionals in the mental healthcare marketplace won't wait for us to realize and respond to what is happening worldwide in the re-tooling of global economy.

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Appendix A

Free Professional Email Information Sources

NetPsy. Email discussion list for professionals interested in Internet psychology, ethics, distance learning, and general online behavior. This list also sponsors training opportunities for learning about interpersonal email dynamics. To subscribe, go to: http://www.telehealth.net/subscribe/netpsy/index.html

Telehealth. Email discussion list for professionals - discusses all aspects of Telehealth, including legal, ethical, government funding, international opportunities. http://www.telehealth.net/netpsy/netiquette.html

TelehealthNews. Email newsletter discusses the best of discussions on the Telehealth listserv (above), and invites articles, URLs, job announcements, funding sources, and other resource listings from professionals actively delivering services in Telehealth projects. http://www.telehealth.net/subscribe_telenews.html

PsyFORUM: Email discussion list for psychologists, psychological assistants, and graduate students working toward a doctorate in psychology. For details and subscription information, go to: http://www.telehealth.net/subscribe/psyforum.html

Search the following locations on the World Wide Web:

American Psychological Association at http://www.apa.org
American Psychological Society http://psych.hanover.edu:80/APS/
American Medical Association http://www.ama-assn.org/
American Medical Informatics Association http://www.rsna.org/about/orgs/amia.shtml
American Health Informatics Management Association http://ahima.org/