Thursday, December 12, 2013

Telepsychology Update

C. Munro Cullum, PhD, ABPP
C. Munro Cullum, PhD, ABPP
C. Munro Cullum, PhD, ABPP
Professor of Psychiatry and Neurology & Neurotherapeutics
The University of Texas Southwestern Medical Center
Dallas, TX

This is an adapted version of an article by Dr. Cullum that appeared in the Texas Psychologist, Fall 2013.
Telemedicine or telehealth technology is spreading rapidly and promises to become increasingly prominent in the future of healthcare worldwide.  Telehealth programs are growing rapidly in the U.S., particularly since the technology has become more available and less expensive.  At least four professional journals now focus on telehealth and telemedicine, and the literature has seen a tremendous increase in “tele-“ based publications in the last decade.  Programs in telestroke, teleradiology, teledermatology, and telerehabilition are among the most commoly reported, although telepsychiatry, telepsychology, and telemental health references have seen a three- to four-fold increase in the past decade, now with over 200 such references in the PubMed database.  The VA system has made wide use of telehealth services through its various outreach clinics, and Medicare’s announcement in 2012 that tele-based services (albeit with some restrictions) will be covered has also helped to increase awareness and availability of distance-based healthcare services.  Numerous companies now offer practitioners assistance with information, technology setup and monitoring of telehealth-based services.
The evidence base supporting the provision of mental health services using electronic means continues to grow (e.g. see Myers and Turvey, 2013, for a comprehensive review).  For example, there is now good support for many of our standard psychological services (particularly therapies) being provided via video teleconference.  Provider- and patient-satisfaction ratings with telemental health have consistently been high, suggesting good receptivity and acceptability.  Although it may take some getting used to seeing your patient or doctor over a monitor rather than in person, adaptation is usually realized quickly, and a majority of patients and providers find it to be an “acceptable” means of service provision in many cases.  Most individuals prefer in-person interactions even if they have to travel a few hours, but distance and time are often cited as determining factors for consumers in terms of selecting telehealth-based services.  Data regarding outcome efficacy in various telemental health interventions is somewhat more limited, although research suggests similar results when compared to tradition in-person therapeutic interactions for most studies.  Most of the literature in this area has been conducted in adult and underserved populations, however, with less known about efficacy of telemental health interventions in children.

Application of telehealth technology to the provision of mental health services requires a number of adaptations and special considerations (e.g. see Grosch et al., 2011).  In terms of informed consent, clients must be made aware of the special circumstances that exist or may arise in the remote provision of clinical services.  This includes the fact that their confidential information (visual and verbal) is being shared across a distance via electronic transmission. This raises the possibility of inadvertent compromise of confidentiality in various ways, and implications for HIPAA also must be considered.  For example, there is ongoing debate about the level of security offered by various popular internet-based videoconference applications (i.e., which ones are truly HIPAA compliant?).  This merits careful exploration before services are offered, and clients must be informed of the additional potential risks of loss of confidentiality when using electronic transmission of information.  Other questions that arise include:  Is the transmission of data (i.e., the entire interaction during the session) fully encrypted?  Is it in fact HIPAA compliant just because the vendor indicates so?  Are there appropriate safeguards in place, such as firewalls, etc.?  Who might have access to the information? Are third-parties involved in the process (e.g. IT personnel), and if so, what is their role and access to data?  Depending upon the far-end set-up, what is the possibility of a third-party wandering into the area where the client is being seen?  What is the likelihood of interruptions in that setting? If any data are being stored as part of the process, this must be disclosed and appropriately safeguarded.  

The provision of mental health services using distance technology also requires that the provider be competent in this mode of intervention. Continuing education to support training in this specialized application of services is encouraged, even as preliminary guidelines are developed by the American Psychological Association and American Telemedicine Association (e.g. see their respective websites for information).  Practical issues must also be addressed, including preparedness for potential emergencies during distance-based interactions.  Appropriate review of procedures with clients should be conducted, in addition to consideration being given to staff availability at the far end, appropriate training in emergency situations, and IT personnel availability in the event of equipment failure should be considered.

From a diagnostic interviewing standpoint, psychological interviews appear as valid when conducted via videoteleconference as in-person, although less information exists with respect to the validity of psychological or neuropsychological assessments administered in this fashion.  Preliminary studies of videoteleconference-based neuropsychological assessment have been promising in terms of patient satisfaction (e.g. see Parikh et al., 2013) as well as validity of the measures that have been studied to date, although many tests have not been studied in this environment.  Our research group has demonstrated the comparability of video teleconference-based and traditional in-person administration of neuropsychological tests using a brief battery of generally language-based instruments that are commonly used in dementia evaluations (Cullum et al., 2006). This has included tests of attention, naming, verbal fluency, verbal memory, and visuoconstructional ability that required little to no modification of standard test instructions.  We have also experimented with other tasks that require the use of manipulable test materials, but such tasks require the availability of equipment for the remote client as well as alteration in instructions and in some cases, administration procedures.  Our results are also limited to tests studied to date, although a list of many tests used under video teleconference conditions can be found in Cullum and Grosch (2013). If significant modifications to procedures are required for the administration of some tests, for example, this must be noted, and the potential impact upon traditional scoring and interpretation must be understood.  As such, more research needs to be done to ensure the validity of our procedures administered remotely, as some tests may require modified instructions, procedures, and/or norms, and these factors must be considered by clinicians conducting this work.

As noted above, Medicare and some insurance companies have approved reimbursement for telemedicine-based mental health services, although it is incumbent upon clinicians to verify local provider procedures along these lines, as many payors are yet to get on board with reimbursement despite good headway being made by the American Telemedicine Association.  A related issue in the provision of distance-based services is that of licensure, since many states require that the provider be licensed not only in her or his own state, but also in the state where the client is located.  

As telehealth technology continues its rapid growth, opportunities for psychologists’ services will expand.  Familiarity and training with these technologies, including advantages, limitations, and evidence-based support for various procedures and services, will become increasingly important for psychologists.  Fortunately, many of our services are amenable to the telehealth environment, and with appropriate education and experience, we should be in a good position to help drive and participate in the provision of behavioral health and mental health services using telehealth technologies within our changing healthcare environment.


Cullum, C.M. & Grosch, M.G. (2013). Teleneuropsychology. In K. Myers & C. Turvey (Eds.), Telemental health: Clinical, technical and administrative foundations for evidence-based practice. Elsevier (pp 275-294).

Grosch, M.C., Gottlieb, M.C., & Cullum, C.M. (2011). Initial practice recommendations for teleneuropsychology. The Clinical Neuropsycholgist, 25, 1119-1133. 

Myers, K., & Turvey, C.L. (2013).  Telemental Health: Clinical, technical and administrative foundations for evidence-based practice.  Elsevier. 

Parikh, M., Grosch, M.C., Graham, L.L., Hynan, L.S., Weiner, M.F., & Cullum, C.M. (2013). Consumer acceptability of brief videoconference-based neuropsychological assessment in older individuals with and without cognitive impairment.  The Clinical Neuropsychologist, 27,5, 808-817.