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Telemental Health Services In U.S. Frontier AreasLetter to the Field No. 3by Walter F. LaMendola, Ph.D., Consultant Table of Contents IntroductionThe Frontier Mental Health Services Resource Network, under a contract with the Center for Mental Health Services of the Substance Abuse and Mental Health Services Administration, was created to gather, analyze, and disseminate information about mental health needs and services in "isolated rural areas" in the United States-often called frontier areas. An earlier Letter to the Field (No. 2) defined these areas. This letter uses that work as the basis for looking at telecommunication applications-called "telemental health services"-that support and enhance communication among mental health providers, administrators, and consumers in frontier rural areas. The application of telecommunication technologies in health systems has been defined in a number of ways, using terms such as "telemedicine" and "telehealth." Little agreement exists about the meaning of these terms (GAO, 1997). Whatever term is used, however, the common dynamic is always the use of telecommunications as a medium. Telehealth has been used to include the broadest meanings of health-such as community health education or the administration of health services. Telemedicine is usually used to refer to "medical" or "clinical care" events. In specialized areas the notion of telemedicine is advanced by adding "tele" as a prefix to the specialization, such as in "telepsychiatry" or "teleradiology." We have followed that convention here; the term telemental health services is meant to connote all mental health services whose delivery is assisted by telecommunications technologies, including telepsychiatry. Indeed, mental health services include an array of related social, medical, counseling, and case management services needed by persons suffering acute to severe and sometimes persistent disabilities. Such services could include, but are not limited to, prevention, diagnosis, consultation, outreach, case management, education, and treatment. It also includes the transfer of mental health data for use in the provision of services to specific clients-a service array consistent with what Mechanic (1996) has termed the "key considerations" for managed care in mental health. The telecommunication technologies used to provide these telemental health services can range from telephone and fax to live interactive video. The Emergence of Telemental Health Services in Rural and Frontier AreasA true count of the number of rural and frontier telemental health programs in the United States is a moving target. Estimates have ranged anywhere from 6 to 50 programs. One conclusion, however, is consistent-the number and visibility of telemental health services in rural and frontier areas is small. The Joint Working Group on Telemedicine (JWGT) provides a picture of telemental health service activity in the US through reports on the Federal Telemedicine Gateway. They list 28 projects that provide mental health services, of which 6 are located in states with significant frontier populations-Alaska, Colorado, Kansas, Montana, Nebraska, and South Dakota (JWGT, 1997). In two specific surveys of telemental health applications, Telemedicine Today (Allen & Allen, 1994) and the Office of Rural Mental Health Research (LaBella, 1995) found few telemental health projects-7 and 20 respectively. A more recent study by Abt Associates (1997) found 159 non-federal rural hospitals and other providers actively using telemedicine; 31% of which reported the use of telepsychiatry. This was the fifth largest group of reported specialty use. This may be an under-representation of telemental health activities. The 18 respondents most likely to be in frontier areas probably reported what the study called telepsychiatry. Though the published study did not define telepsychiatry, it was presumably understood as a service in which at least one participant was a psychiatrist-the list of specialties in the study actually excluded psychology and social work, and listed "substance abuse" as a separate specialty. If these other groups were included, presumably the occurrences of telemental health services would increase. In fact, the Mid-Nebraska Telemedicine Network reported 209 individual mental health consults last year-the largest single specialty use and 40% of the total use. The current on-line Telemedicine Information Exchange (TIE) database lists 33 programs under telepsychiatry and 17 programs under mental health (Telemedicine Research Center, 1997). This also may be an underestimate. For example, the Department of Veteran Affairs uses the listing to indicate that there are a number of VA hospitals that offer telemental health services. They list these separately at their own web site. The Abt (1997) study went on to estimate that nearly 30% of all rural US hospitals would have telemedicine applications in place in 1996. Interestingly, the survey found the greatest penetration of telemedicine (23% of the reporting hospitals) in the Rocky Mountain area-an area with large numbers of frontier residents. In contrast, however, the JWTG (1997) lists only two states with significant frontier populations, Texas (with 6 projects, ranked 9th) and Colorado (5 projects, ranked 10th), among the ten states with the highest number of telemedicine projects. The Abt survey also found that the smallest hospitals were generally more likely to have telemedicine services. Though it would be sensible to deduce that this phenomena was driven by the hospitals having the highest need for access to specialists, frontier telemedicine programs also constituted 62% of those whom both received and delivered services. Frontier and Rural Telemental Health ProgramsThis project identified 30 telemental health programs operating in frontier or rural areas. The services they report providing are organized in Table 1 into four broad categories: education, consultation, therapy, and administration. Education services reported included continuing education and training. Consultative services were made up of medication reviews, assessments, psychiatric supervision and case review, and involuntary commitment appraisals. Also included were varieties of case conferences and supervision between psychiatrists, primary care providers, mental health professionals, and other allied health personnel. The range of administrative services included meetings, record sharing, information transfer, and utilization review. Ninety-three percent of the identified sites offered consultative services, 70% offered education services, 43% offered administrative services, and 17% offered therapy services. Only 2 (7%) offered all four services. Ten (33%) offered three services and 10 (33%) others offered two services. The remaining 8 (27%) offered one service. Three sites reported performing court evaluations. Three sites plan to do discharge monitoring and three plan to do substance abuse counseling. Almost all of the sites identified are using interactive technologies that involve video conferencing or television. Equipment and telecommunication requirements for these interactive technologies are generally among the most expensive arrangements available today (the topic of hardware, software and interconnectivity costs will be covered in more detail in a subsequent Letter to the Field). A majority of the sites are also using "store and forward" technologies. This is less expensive as it does not demand live interaction. Two of the sites list telephone based technologies. These are the least expensive telecommunications technologies. There is a relationship between the type of services offered and the technology in use. For example, live therapy where participants see each other in real time requires different equipment than a therapeutic telephone conversation. Unfortunately, minimum requirements matching equipment to problem to service to outcome do not exist. Indeed, the fundamental question of whether telemental health services increase access and/or improve outcomes for under-served populations has not been sufficiently studied. Nevertheless, the telemental health service innovation is underway in rural and frontier areas. A robust example of telemental health services in a frontier area today is the RODEO Net (Rural Options for Development and Educational Opportunities Network). In 1991, the Eastern Oregon Human Services Consortium was awarded a three-year grant of approximately $700,000 by the Rural Health Outreach Grant Program of the Office of Rural Health Policy (Health Resources and Services Administration) to demonstrate an innovative model of mental health care in a rural area. The mission of RODEO Net was to pioneer advances in the delivery of human services by connecting people using appropriate communication technologies. RODEO Net uses three ED-Net networks created by the State of Oregon in 1989. Network 1 provides live, interactive, one-way video and two-way audio services to 45 "receive" sites in eastern Oregon. Network 2 provides two-way video, audio, and data services using digitally compressed video technology in 10 studios. Network 3, COMPASS, is a local "dial-up" computer data network that provides a variety of information services. These include user-friendly access to local, national, and international databases and the Internet; government and academic libraries; bulletin boards; electronic mail; and computer-conferencing services. RODEO Net currently uses all three networks to train mental health providers in eastern Oregon. For example, both professional and paraprofessional staff, who work with children and adolescents with severe emotional disturbances, participate in a certificate program to upgrade staff qualifications. Individual training is also provided. In addition to training, RODEO Net also provides crisis response. Using Network 2, personnel access the oncall psychiatrist at the Eastern Oregon Psychiatric Center in Pendleton to help deal with persons suffering extreme emotional or behavioral turmoil. Such a response system often saves the time and money required to transport an individual and keeps that person in the community. RODEO Net provides clinics for medication management and case consultations on an ongoing or as needed basis, reducing the number of admissions to acute care facilities. Interviews for preadmission, predischarge, and transfers are now accomplished via Network 2, and precommitment and psychiatric review board hearings are conducted using interactive TV. The project also plans to work with consumer groups to help them create their own computer networking conferences within the COMPASS system (Britain, 1996; Telemedicine Research Center, 1997; Witherspoon, Johnstone, & Wasem, 1993). Analysis of RODEO Net and the 29 other frontier and rural programs listed in Table 1 suggests that schools of medicine and hospitals are the primary promoters of frontier and rural telemental health services. Sixteen of the programs are sponsored by hospitals; seven by schools of medicine. Four have been developed by some form of managed care entity. The type of sponsoring organization appears to have important consequences for the type of telemental health activities undertaken. All of the hospital-sponsored programs were interested in consultative services. The programs sponsored by schools of medicine were interested in educational uses. All of the managed care sponsored programs were interested in administrative applications. Unlike the hospitals and schools of medicine, the four programs developed by the managed care entities did not use federal funds and had systems that tended to use technologies that were not based on full, two-way interactive video. RODEO Net seems to be the only program of the 30 identified evolving from a non-medical, human service perspective, which may explain its broad applications. It is important to recognize that without the involvement of the federal government it is likely there would be very little public sector provision of telemental health services in frontier areas. Twenty-three of the thirty programs highlighted received money from federal sources. It is highly probable that hospitals would develop such services even without federal funds, but they would most likely be "filler" or "addons" to the provision of other telemedicine services. Developing and enlarging a revenue stream for these services will be the paramount preoccupation for those who invest in these services for the next five years. Further, while the Internet holds special promise as a quickly proliferating, locally available and relatively inexpensive network for inter-connectivity, none of the projects report using the potentially more cost-effective Internet service providers as intermediary telecommunication providers in their networks. Cost and Access ProblemsAfter careful examination of the literature and existing telemental health services, it appears that telecommunication services in rural and frontier areas in the United States are severely disadvantaged. Not only are expertise lean and prices high in rural areas, but in many cases service connections are unavailable. For example, it would seem that the telephone could be used to support many mental health services. Indeed it often is in urban areas. Unfortunately, some rural and frontier areas still have relatively low telephone penetration. In fact, a number of rural and frontier areas have no 911 service, which may indicate a lack of digital switches essential for advanced telecommunication services. Further, because of a lack of appropriate switches, in some parts of frontier Colorado it has been cheaper to call Chicago than Denver. Stated differently, geographic distance from mental health services is not the only prevailing determinant of cost; instead, it is the framework of telephone companies serving the local area and their connection to the long distance carriage system. Basically, unlike urban areas-where prices are falling rapidly, in rural and frontier areas the price of telecommunications continues to be high. Equally important, as a consequence of divestiture by major telephone companies, some observers expect the costs to rise under the new telecommunications policies. US West, the regional Bell Operating Company with the highest amount of frontier territory, has already divested itself of $1.1 billion dollars worth of rural service lines because they are "high cost" and "unprofitable." However, the intent of the new Universal Fund set up by the Federal Communications Commission (FCC) implementation of the E-rate under the Telecommunications Act of 1996 is to reduce overall telecommunication costs for qualifying non-profit rural healthcare providers. Each of the programs listed in Table 1 uses some combination of audio and video systems at all participating sites. The cost for on-site equipment at each location can range from $30,000 to $150,000 (a subsequent Letter to the Field will include a detailed discussions of these costs). These sites are then physically connected to each other by different levels of service provided by telephone companies. The costs for connecting lines vary due to individual circumstances and bargaining power. Costs are also related to carrying capacity and sometimes to the distance to a switching device capable of moving the signal on to the next connection. Carrying capacity is directly related to the speed of transmission. Though costs are changing, generally the faster the transmission time the higher the costs. If a user is interested in seeing the other person's movements and talking interactively, higher transmission rates are required so that images look natural and movements are relatively smooth. A cost effective solution used by the Southwest Montana Telepsychiatry Network is achieved by combining pairs of switched 56k or ISDN (Integrated Services Digital Network) lines (N. Cobble, personal communication, June 18 1997). At the moment, telemental health service development is strongly related to the ability to see and talk to the consumer as though the service provider was there. One can expect that telemental health service providers will also prefer high quality audio and specialized camera capabilities, such as zoom and pan. This is because service providers will want to use the technology at first to replicate-as much as possible-the manner in which they do their work today. To mimic face to face interactions, they will want as many technological tools as possible to replicate that context, which will require the highest line types available today. This can make telemental health services a natural complement to hospital-based teleradiology services that use high bandwidth and can support interactive video. Rare but important use in telemental health services is being made of technologies that do not require anything more than a telephone connection. Additionally, new, less demanding devices are now available. These will be discussed in a subsequent Letter to the Field. One example of costs and line connections in frontier counties can be found in the Telemedicine Alliance of Healthcare Organizations (TAHO) project of the Office of Rural Health Policy. Six telephone companies needed to be involved in the beginning phase of this project because of significant engineering and cost of service issues. The first service bids ranged from $18,000 to $29,000 a month for two urban and six frontier participating sites. After a substantial vendor identification and negotiation process, TAHO was able to reduce their service costs considerably. The service connection costs, after installation costs and equipment purchases, were about $7543 per month in 1995. In contrast, the monthly service connection costs of an identical system contained entirely in the Denver metro area would be $805.26 a month or roughly 10% of the fee charged in the rural areas. A discussion of the specific costs of each of the telemental health sites identified by the Office of Rural Mental Health Research is contained in their report (LaBella, 1995). Further, each site listed on the TIE exchange gives information about funding and technology in use (Telemedicine Research Center, 1997). In all cases, collaboration was an important key to cost effectively linking computer networks and interactive sites with one another. SummaryMental health services delivered using telecommunications technologies, or telemental health services, are not yet common in most frontier rural areas. Those programs that do exist are primarily supported by federal money and the services provided tend to vary depending on the sponsoring organization. Programs are now placing a high priority on the development of revenue streams beyond federal funding. At the same time prices for rural telecommunication services continue to be high in rural areas and in many cases service connections are unavailable. Even with these availability and cost problems, frontier areas will probably have a much higher adoption rate of telemental health services in the future than other types of rural areas because of a greater lack of local providers. There already seems to be a higher concentration in the largely frontier Rocky Mountain area. In addition, rural areas where managed care approaches are in place or are emerging are likely to be subjected to telemental health services as a matter of course. Managed care providers often see telemental health services as a competitive advantage to consolidate provider resources, to review the work of local providers, or to provide cost-effective expert consultation. Currently, telemental health service development is strongly related to the ability to see and talk to the consumer as though the service provider was there. The technology is being used at first to replicate-as much as possible-the face to face manner in which service providers work today. This is why current telemental health services frequently use high bandwidth that can support interactive video. Universal access and adequate service to support interactive, mixed video, audio, and text messaging for rural and frontier areas constitute the fundamental telecommunications considerations in developing rural and frontier telemental health services. From a mental health service system point of view, consumer access-particularly for underserved populations, provider use, and service outcome are more fundamental considerations for telemental health service development. ReferencesAllen, D., & Allen A. (1994). Telemental health services today. Telemedicine Today, 2(2), pp. 2, 1215, 24. Abt Associates. (1997). Exploratory evaluation of rural applications of telemedicine [On-line]. Office of Rural Health Policy. Available: ftp://158.72.84.9/ftp/finalabt.pdf Britain, C.S. (1996, August). Making the connection in rural mental health. Behavioral Healthcare Tomorrow , 67-69. GAO Report. (1997, February 14). Telemedicine: Federal strategy is needed to guide investments (Publication No. NSIAD/HEHS-97-67) Washington, DC: U.S. Government Printing Office. Joint Working Group on Telemedicine. (1997). Reports 5 and 6 [On-line]. Federal Telemedicine Gateway. Available: http://206.156.10.7/gateway/ LaBella, S. (1995, October). A compendium of telecommunications projects with mental health applications. Washington, DC: ORMHR, NIMH, NIH. Mechanic, D. (1996). Key policy considerations for mental health in the managed care era. In Mental Health, United States, 1996, (CMHS, SAMHSA, HHS Publication No. (SMA) 96-3098) Washington, DC: U.S. Government Printing Office. Telemedicine Research Center. (1997). Telemedicine Information Exchange [On-line]. Available: http://tie.telemed.org Witherspoon, J.P., Johnston, S.M., & Wasem C.J. (1993). Rural telehealth: Telemedicine, distance education and informatics for rural health care. Boulder, CO: WICHE Publications. Additional Suggested ReadingsJoint Working Group on Telemedicine. (1997, January 31). Telemedicine report to Congress, Washington, D.C.: NTIA, Dept. of Commerce. Kansas Telemedicine Policy Group. (1993, November). Telemedicine: Assessing the Kansas environment (Vols. 14). Kansas: Author. McCarthy, J. (1995). Colorado health care telecommunications (monograph). Denver: Colorado Rural Health Telecommunications Coalition. Mecklenberg, S., & Green, L. (1995). Progress report for the Office of Rural Health Policy. Ft Morgan, Colorado: High Plains Rural Health Network. National Rural Health Association. (1994, September). Health care in frontier America: A time for change. Rockville, MD: Office of Rural Health Policy. Office of Rural Health Policy. (1994). Reaching rural. Rockville, MD: Author. Puskin, D. (1992). Telecommunications in rural America: Extended clinical computing by hospital computer networks. Annals of the New York Academy of Sciences, 670, 6775. Schoech, R., & Kelley Smith, K. (1995). Use of electronic networking
for the enhancement of mental health services. Behavioral Healthcare Tomorrow, 4(1),
2329.
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