American Psychological Association

109th Convention
San Francisco, August 24-28, 2001

[Behavioral Telehealth Panel]
Photo: (Left to Right) John Grohol, David Nickelson, Gerald Koocher
1102 Psychology Online: Current Issues in Behavioral Telehealth

This report posted to the Current Topics and TherapyOnline list-servs, August 24, 2001

Friday, August 24, 2001

Asynchronously "live from San Francisco"-

Hi, here is the first news out of APA's 2001 Convention, here in the beautiful, sunny and refreshingly cool city of San Francisco, California. I can hear the clanging of the trolleys as I type.... (Keyboards are much quieter these days.)

Even before this afternoon's opening keynote speech, the day began for this intrepid reporter by attending a very interesting panel symposium. There were quite a few good presentations happening at the same time, unfortunately, and I would have loved to also attend those on psychology and secondary schools, on data sharing, IQ, bullying, research issues, and a host of other topics of great interest to me, all at the same exact time, unfortunately. I wound up going to a very informed and crisply engaging symposium on a topic near and dear to me (and quite "in sync" with the presentation which yours truly will be doing on Monday). These are people who really know their topic! Nice to see familiar names and faces, too.

"Psychology Online-- Current Issues in Behavioral Telehealth"

Chaired by Dr. Abraham Wolf, participants included several experts on the legal and practical issues being experienced today, by individual practitioners as well as the general public.

David Nickelson, Psy.D., J.D. (APA's Director of Technology and Special Projects) began with an inside look at "Psychological Services and the Internet: Regulated Practice in an Unregulated Environment?"

Dr. Nickelson began by highlighting some of the many grey areas which are presented both legally and ethically in the practice of regulated professions (such as psychology) in an environment such as the Internet, which defies traditional notions of jurisdictional boundaries. He noted that the Internet and it's various uses can promote unique interpersonal relationships which really need to be better understood. Such well-known phenomena as the "disinhibition effect" were cited, and Dr. Nickelson also noted that online mental health offerings run along a continuum, from things like psychological information to self-help materials to assessment, diagnosis, and treatment . I could elaborate more on this, but won't, since what he said is very similar to what I'll be presenting in a few days, myself. Needless to say, we think quite alike in terms of seeing a need for change in licensing and regulatory thinking, with a positive outcome being something like the nurse's concept of a "driver's license" model, where it is conceded that if one has a skill (whether driving, nursing, or practicing psychology), one is equally skilled even if only briefly "driving through" the state (or Cyberspace).

Dr. Nickelson went on to present a framework which he suggested would be useful in thinking about how to approach online treatment, from both a practice and legal perspective. He invoked a fundamental grounding in basic ethics, being conscientious about such things as informed consent, practicing within one's scope, and having enough information to make "a defensible clinical decision". He also noted that incoming HIPAA regulations "will have a significant impact" on how online work may be legally done, as this will "have a huge impact" in terms of compliance with many new complex requirements. Dr. Nickelson noted also that "at least 13 states reimburse through Medicaid" already, for "telehealth" services, mostly through video. (He noted an informative Medicaid website for more information... don't have the url, though.) One of the cutting-edge changes described there is that some providers will now pay for clients accessing specific *information*, e.g., on a specific disease, and billing for it. (Which sounds to me like bibliotherapy may be one of the first codified online therapies to be considered cost-effective by the HMO's.)

In re-stating the common sense of the nurses' "drivers' license model" for resolving interstate licensing disputes, Dr. Nickelson noted that "69% of states' regulatory boards have not yet received [any] complaints about online therapy". 17 percent have. The rest?

Finally, Dr. Nickelson addressed the status across various states in terms of law suits, and how "scope is a slippery term" because "it seems like a post-test analysis" often, forcing examination of "scope" only after a party is injured. He noted that there are several sets of existing guidelines which address both the ethical and practical concerns regarding online work by mental health practitioners, including the guidelines of
ISMHO ( and the ACA. [There's NBCC too.] Meanwhile, Dr. Nickelson is working within APA to promote consumer information and self-help with projects such as his "DotComSense" brochure, available in hard copy or at He promises that very soon, there will be "lots more coming on the APA website."

Gerald Koocher, Ph.D.,, of Harvard Medical School (and trustee of the APAIT insurance organization) followed with a presentation about the "Challenges to Professional Integrity in Telehealth Practice".

Dr. Koocher began by asking the audience how many had ever sent an e-mail response to the wrong person? Following some nervous laughs of recognition, Dr. Koocher talked about issues of workplace access and organizational dynmics, punctuating his discussion with the admonition, "Never underestimate the power of stupid people in large groups". He also used some visual presentations to highlight other ways in which "misunderstanding the medium" can be so easy. He also noted the simple facts about text being qualitatively different than f2f communication: "E-therapy is not subject to the extended process of the integration of visual cues". [Ahh, Integration!] He commented also that a quick proof of the value of visual cues was available the night before, on national television, as millions of people watched Congressman Gary Condit smirk and exhibit a particular body language that all the experts analyzing his presentation this morning (8-24-01)

Dr. Koocher mentioned other experiential factors which need to be acknowledged also, such as the "spontaneity factor" and the risk of losing valuable information in not being able to consider tone of voice, etc. And he noted that even with the technology of cell phones, interceptions have been made which serve as reminders that our security may not be as great as we think. Dr. Koocher also addressed the licensing issue, and how in fact there are a few "loopholes" which do allow occasional practice under rare circumstances, in a state one is not licensed in, sparing the need to hold multiple licenses. For example, even in California, which explicitly forbids practicing psychology "in California" unless licensed there, a law states that one can practice "for less than 10 days". Converting that to 240 hours would yield a lot of wiggle room under that law, for occasional online work. The issue of "where does treatment take place", despite California's unilateral decision that it takes place in their residents' computers, is clearly unresolved.

Dr. Koocher knows of only one case where someone pursued a therapist for legal remedy, across state borders. In this instance it was against a California therapist who moved out of state but continued *telephone* treatment from his/her new location. It was only because this therapist was in fact licensed in California that the California resident who initiated action was able to take action. Like Dr. Nickelson, he issued "an appeal to clinicians' integrity" and noted the need to be especially cautious now, "as in any new practice area". As an APA task force member for the new ethics guidelines, he sees the movement within organized psychology as being *away* from the separate ethical guidelines some are calling for to govern specifically online work. While the arguments about the uniqueness of such work are duly noted, the thinking is that if one is competent to practice law or medicine or psychology, whatever, it should be "generic" competency as a professional, and not only in some specific niche. This way it is more likely "to stand up over time". He emphasized that with online work, just as offline, therapists need to be knowledgeable about such questions as "Does it work?", "What limitations apply?", confidentiality, and "What would I do in an emergency".

John Grohol, Psy.D., a co-founder of ISMHO, online community leader, and pioneering webmaster/researcher for numerous mental health websites since the mid 1990's, presented " State of the Internet Behavioral Health Care Industry."

Dr. Grohol presented a rather sober look at how many of last year's upstart dotcoms are no longer with us*, though he noted some strong survivors amidst the "significant number of consolidations and mergers" in the face of the current economy. In contrast with the boom of only a year ago, the landscape now looks very different suddenly. He summed it up in one word: Change.

He noted that the successful companies will continue to thrive if they offer something useful. HelpHorizons, with which Dr. Grohol is affiliated, sees one of its marketable strengths as providing its clients with a useful "tool set" for practice management. As for the companies that faded away despite tons of promotion, he noted that "you had to ask yourself: where was the business? In some cases the demand was there. In other cases...." He noted that some of the larger dot coms which ceased operating are "gone but nobody knows it", as in the case of at least, where the company is no longer functioning but the website is still there. [This was confirmed the next day by the director of R&D for Here2Listen. It was also noted that at this year's APA convention, gone are all the dot.coms with only one exception: a company which utilizes the net to provide referrals to local, f2f therapists.]

So, "What happened?" to the boom in online mental health startups? Some of the problems, as he sees it, include:

"What's Happening Now?" The industry is "housekeeping with mergers", amidst a general suspicion now about new Internet-based services and businesses, and a drying up of venture capital in reaction to a feeling that "they've been burned".

So what's in the future? In the immediate future Dr. Grohol sees a rather conservative environment, where realistic, proven business plans are what is being sought. He sees a trend towards partnering with larger, well-known brick-and-morar businesses while at the same time there will be an emergence of small operations with "technology driven by need".


* Though he didn't mention it, this week another casualty was announced: The Industry Standard announced it is halting publication immediately and will be declaring bankruptcy. In addition, Excite announced this week that it is not profitable and its parent, AT&T Broadband, is unlikely to bale it out.

Leigh Jerome, Ph.D., of the Tripler Army Medical Center rounded out the presentation with a presentation titled "Hot Links to a Digital Future"

Dr. Jerome began by taking a look at how "telehealth" is defined, and proceeded to make the argument that "it is not a distinct profession" but rather a service delivery model which can be accessed readily by large numbers of people who apparently turn to the Net for help of every variety. In terms of utilization, "more than 100 million adults in the U.S. turn to the Internet for health information", especially anxiety and depression. The information is easy to find, as there are now over 15,000 health information sites, plus in addition there are chat rooms, support groups, etc.

Dr. Jerome rightly noted that there is a wide spectrum of "responses to emerging technologies", ranging from "knee jerk objections" to any possible use of the Internet for online work, to "informed concern", "proactive involvement", and then "unbridled optimism". She stated something I've often found myself saying: "Technology is a tool". (In fact, one definition of technology is "anything wo/man made which improves the ease and/or quality of life".)

Dr. Jerome believes that in general the Internet is still under-utilized, with the exception of *informational* services. In some areas of health, such as general medical practice, "the medical record is becoming dynamic". Yet, as Dr. Koocher had also noted, most regulations are still based on paper records. This is so even in an age where digital MRI scans can be instantly shared and stored. Other medical applications are beginning to include such things as pre-surgical simulation, though this has some unique challenges, such as providing realistic feedback and training in hand pressure, etc. Data transfer is another area easily facilitated by online communication-- things like blood glucose readings, etc, and clearly could be used readily by some patients and their healthcare professional.

While focusing mostly on the upside of the technology, Dr. Jerome noted that inevitably there is also a downside: "new technologies, new pathologies". For example, more than 1 million users each year are "cyber-stalked". People can be impersonated or have their identities stolen, sometimes with victims watching as others purport to be them. And of course there can be malicious dmage such as hacking, introducing viruses, etc.

Finally, Dr. Jerome suggested "new foci" for clinical practice opportunities, and promotion of "expanded scope, and increased access to care". As an example of easy opportunities: why not introduce "kiosks" in waiting room areas wher patients can productively spend their time looking up information. In addition to evolving practice innovations, she looks towards new developments which will occur in reaction to improvements in areas such as wireless portability, bio sensors, and Virtual Reality.

Patrick DeLeon, Ph.D., J.D. , Past-President, American Psychological Association, served as Discussant. [I would like to add a personal note to acknowledge Dr. Leon's graciousness in sending me a personal, hand-written letter the year he was APA President, congratulating *me* on *my* work and my election as ISMHO President. I was very moved by his taking the time to do that, for such a small fish within organized psychology, as me.]

Dr. DeLeon began by sharing some of the history about Congressional actions regarding "telemedicine" versus "telehealth", including the fact that he had previously disagreed with Dr. Nickelson's efforts to change the term from "medicine" to "health" to protect against all of mental health online becoming "medicalized". At the time, Dr. Koop, surgeon general, was promoting "telemedicine" and had a great deal of prestige and clout, etc., and Dr. DeLeon's concern was that passage of a strong bill would be helpful in terms of litigation alleging "harm", as in medical suits the harm typically needs to be physical.

In any case, Dr. DeLeon also noted that psychologists, having 7 years training, typically, are among the most qualified of all professionals to be part of the telehealth/telemedicine revolution. Actually, he gave examples of how technology is used routinely on the Big Island of Hawaii, to make quick assessments, for example, of whether a helicopter evacuation was urgently neeeded. But still, the massive community health centers of Hawaii, as elsewhere, typically have an incredible potential which they keep "in the closet and don't know how to use it." He would personally like psychology to be in the lead here, given our training and expertise in behavior in mental health. He sees consumers as calling out for better and more accessible information, too, for example using the Internet independently to acquire useful information on asthma treatment for their children.

Dr. DeLeon continued with several examples of every day routine life among other professionals (e.g., pharmacists who routinely hold national elections for their association, online) and in daily lives of all organizations and their members. Dr. DeLeon noted how his daugher wondered why he keeps getting all this (snail) mail from APA.... "why waste money on mailings?". Why not utilize the net even more (something apparently APA does have as a goal, though elections may not happen online for a while).

Highlighting the importance of good information, Dr. DeLeon noted that 87,000 people died in hospitals last year, due to medical error. The biggest single factor? Medication. The error rate drops 70% if a clinical pharmacist is on duty making rounds. Now that everything is computer programmed in terms of injections, dosages, etc, he sees great potential in utilizing available knowledge to cut error rates, and thus save lives. "We need to move forward", he said. "This is the future." What are the hurdles? For one, there is the issue of national licensure. While he thinks it is realistically years off, he finds it insulting that one or another state would imply that a professional is incompetent simply because of not being a resident there. "How dare California say they're brighter than Hawaii?" Like Dr. Nickelson, he sited the "nurses' driver's license model" as an eminently simple and sensible solution.


Finally, there was a brief Q&A which included questions about the limited efficacy studies out there, the outlook for a voluntary licensing plan (as opposed to mandated), and about ethics. Asked how the concept of *privilege* might apply to telehealth, Dr. Nickelson said that one needs to think ahead, in accordance with normal ethical practice, by being sure to provide informed consent. He noted that even the American Bar Association is now struggling with the issue of privilege, given the current legal/regulatory climate.

And that was that....


DISCLAIMER- The preceding comes from my copious, messy notes [except for a few bracketed comments] and is a synthesis of the notes I took today. I believe the quotes to be accurate but would be happy to correct or clarify any of the statistics or other content, upon request. The problems and solutions are characterizations by the speakers I observed, and not necessarily my own opinion or brilliant ideas! :-) In this case, however, I agree with a great deal of this! ;-)

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