Tele-Practice Technology

Abstract

Telehealth is viewed as the removal of time and distance barriers in the provision of health care and patient education to underserved populations. Examined is a twenty first century clinical consultation model of healthcare. Offered are specific applications within a broad spectrum of services utilizing telehealth technology. Important technology shifts for administrative paradigms, clinical models, and educational information technology for healthcare services through telehealth technology are examined. The future of telehealth and its interface with various critical components of society needs to examine the potential benefits over risks in providing healthcare consultations and services through the educational settings available. Addressed is a technology model, which demonstrates the capability of reducing time and distance barriers in the provision of health care and education through telehealth technology. The use of telehealth technology in rural settings is seen as a viable medium for providing needed diagnostic and clinical consultation for underserved and rural.

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ABSTRACT
Telehealth is viewed as the removal of time and distance barriers in the provision of health care and patient
education to underserved populations. Examined is a twenty rst century clinical consultation model of health
care. Offered are specic applications within a broad spectrum of services utilizing telehealth technology.
Important technology shifts for administrative paradigms, clinical models, and educational information
technology for healthcare services through telehealth technology are examined. The future of telehealth and
its interface with various critical components of society needs to examine the potential benets over risks
in providing healthcare consultations and services through the educational settings available. Addressed
is a technology model, which demonstrates the capability of reducing time and distance barriers in the
provision of health care and education through telehealth technology. The use of telehealth technology
in rural settings is seen as a viable medium for providing needed diagnostic and clinical consultation for
underserved and rural [Article copies are available for purchase from InfoSci-on-Demand.com]
Keywords: Telemedicine, Technology, Rural Health Care
INTRODUCTION
Examined is the application of telepractice
technology in a rural community clinical and
educational system. Telepractice is viewed as
the removal of time and distance barriers in the
provision of health care and patient education
to underserved populations (Nickelson, 1996).
Offered is a video teleconferencing model of
health care for underserved populations and
where professional consultation with a team
of professionals may benet rural educational
systems and their students. Offered are specic
applications within a broad spectrum of services
utilizing telepractice technology. Finally, shifts
in administrative paradigms, clinical models,
and educational information technology for
healthcare services through telepractice technol-
ogy are explored. Distance learning technology
has provided society with new applications
for clinical and educational consultation that
enhance the quality of services offered to rural
Tele-Practice Technology:
A Model for Healthcare Delivery to
Underserved Populations
Thomas W. Miller, University of Connecticut, USA
Robert D. Morgan, Texas Tech University, USA
Jennifer A. Wood, South Texas VA Healthcare Center, USA

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school systems through telepractice (National
Advisory Committee on Rural Health, 2004).
Whitten, Cook, Shaw et al. (1998), Sargent
(1999), Miller & Miller (1999) Shaw, Goodwin,
Whitten, & Doolittle (1999) and Whitten &
Cook (1999) Miller, Miller, Sprang, & Kraus
(2003), Sammons & DeLeon (2004), Miller,
DeLeon, Morgan, Penk, & Magaletta (2006)
have all addressed telepractice service appli-
cation for rural school districts, their students
and families. Through this medium of service
delivery, children and adults in need of special-
ized care that might not be readily available
to them can receive the specialty consultation
of experts using telepractice technology. The
purpose of this model is to provide health care
practitioners with a consultation model for
health related delivery services for children and
adults in rural and underserved geographical
areas internationally.
Telepractice technology provides an elec-
tronic medium for healthcare practitioners and
their patients to realize health assessment, diag-
nosis, intervention, consultation, supervision,
education, and information across distances, has
become a well recognized vehicle for deliver-
ing services and disseminating information to a
variety of consumer populations as well as pro-
fessionals and practitioners (Nickelson, 1998;
Miller & Hutchins, 2008)). Given its ability
to transcend many of the economic, cultural,
and geographic barriers that often prohibit or
restrict the provision of health care, the use of
telepractice has begun to reshape traditional
systems of care. Moreover, due to its unique
capacity to negate many of the traditional ob-
stacles in service delivery, telepractice is often
a desirable option for the provision of health
care to rural, conned, underserved and isolated
groups (Miller & Holcomb, 2007).
Well noted is that a large proportion of
telemedicine studies have focused on evaluat-
ing the effectiveness of telecommunications
technology in delivering health services to
rural and specialty populations (Wood, 2000).
Numerous studies suggest that telemedicine
or telepractice applications can be utilized to
deliver health care services that are accessible to
rural or underserved populations that the qual-
ity of care delivered via video teleconferencing
is similar to or surpasses that of face-to-face
services (Bischoff, Hollist, Smith, & Frank,
2004; Miller, Miller, Kraus, & Sprang, 2003;
Norman, 2006) and that both consumers and
providers are satised with services rendered
via video teleconferencing.
From its initial use, one of the major ad-
vantages of video teleconferencing has been
its ability to improve access to health care
services for people living in rural or remote
areas where health care professionals are often
scarce or absent. In the words of Nickelson
(1998), “Telehealth is simply a tool that…
makes it easier to practice already established
professional skills across distance and to serve
individuals and organizations who may not, but
for telehealth, have access to such services”
(p. 527). This ability to transcend geographic
barriers has been the basis for three decades
worth of demonstration projects targeted at
rural populations. The use of this technology to
improve access to health care has since expanded
to include other isolated groups, such as inner
city families (McLaren, Blunden, Lipsedge, &
Summereld, 1996; Straker, Mostyn, & Mar-
shall, 1976), prison inmates (Ax et al., 2007),
and homebound elderly (Maheu, Whitten, &
Allen, 2001). Overall, these projects suggest
that the use of telehealth is an effective means
of improving access to both health care services
as well as improving the exchange of informa-
tion between providers (Blackmon, Kaak, &
Ranseen, 1997). Efforts to assess the quality
of telepractice services compared to traditional
face-to-face services indicate that there is little
difference in diagnostic and assessment out-
comes across the two treatment modes (Ball
& Puffett, 1998; Biggins, 2000; Zarate, et al.,
1997 and that telehealth applications may serve
to enhance the continuity and efciency of care
(Ghosh, McLaren, & Watson, 1997).
Clinical satisfaction with telepractice ap-
plications, the research assessing patient and
provider satisfaction with video teleconferenc-
ing services reveals uniformly positive results
(Miller, 2006; Morgan, Patrick, & Magaletta,

58 International Journal of Healthcare Delivery Reform Initiatives, 1(3), 56-70, July-September 2009
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2008; Wood, 2006). In one of the earliest studies
of patient satisfaction with telehealth, Solow,
Weiss, & Bergen (1971) reported that patient
acceptance was impressively high even among
highly paranoid patients. Since that time, further
research has indicated that satisfaction with
telepractice services remains high even when
patients are acutely or chronically psychotic or
agitated (Kavanagh & Yellowless, 1995).
Clinical satisfaction data are especially
relevant in the public sector where services are
often lacking. As a response to service de-
cits, prison systems (e.g., the Federal Bureau
of Prisons, the Texas Department of Criminal
Justice) have developed sophisticated telehealth
networks. It is noted that offenders are generally
satised with mental health services received via
teleconferencing (Leonard, 2004; NIJ, 2002).
Of particular importance is that incarcerated
mentally ill offenders, historically perceived as
resistant to mental health services, reported no
signicant differences in the working alliance
between treatment provider and client, post
session mood or treatment satisfaction when
receiving psychiatric or psychological services
regardless of method of service delivery (i.e.,
telemedicine vs. face-to-face) (Morgan et
al., 2008). Similar ndings have been found
among parents and children who participate in
telepsychiatric consultations (Blackmon, Kaak,
& Ranseen, 1997), geriatric clients (Wood,
O’Quin, & Eftink, 2004), inner-city families
(Straker, Mostyn, & Marshall, 1976), active-
duty military personnel (Jerome, 1999), veterans
(Wood, 2006), and adults with mild to moderate
mental retardation and their mental health care
providers (Wood & Hargrove, 2006).
A Telepractice Model for
Healthcare
With the noted high level of user acceptability
and distinct ability to transcend geographic and
social barriers, a visionary telepractice model
for public education that focuses on the role
of psychology and its interdisciplinary part-
ners can be used to create a national, regional,
state and local stratied network of health care
professionals and other stakeholders engaged
in a nationwide public education campaign
(Miller, 2007). The Telehealth Intervention
Project (TIP) is a proposed model designed to
offer teleconferenced psychological and health
related informational and demonstrational ses-
sions focused on a broad spectrum of health
related topics. Teleconferening technology is
uniquely suited to reach underserved popula-
tions and rural practitioners offering relevant
evidence-based psychological information to
the community. The telehealth network can be
used to educate a range of target populations
including clients, service providers, educators
and community personnel including children
and families, school populations, prison in-
mates, legislators, public ofcials, and inpatients
and outpatients in various public and private
sector programs.
As modeled in Figure 1, telepractice
provides a sophisticated medium for reaching
these targeted populations (consumers and
providers) by making psychology a house-
hold word. Outlined below are mechanisms
(processes) for successfully implementing the
Telehealth Intervention Project, a proposed
model for implementing a dimension of the
public education campaign to reach underserved
target groups in need of health and prevention
education information nationally.
Use of Telepractice in Health
Education and Prevention
Health communication encompasses the study
and use of communication strategies to inform
and inuence individual and community deci-
sions that enhance healthy behaviors and to
provide education toward achieving prevention
of disease and illness.. It links the domains of
communication and health and is increasingly
recognized as a necessary element of efforts to
improve personal and public health (Kreuter,
Strecher, & Glassman, 1999). Health com-
munication can contribute to all aspects of
disease prevention and health promotion and
is relevant in a number of contexts, including
(1) health professional-patient relations, (2)

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individuals’ exposure to, search for, and use of
health information, (3) individuals’ adherence
to clinical recommendations and regimens, (4)
the construction of public health messages and
campaigns, (5) the dissemination of individual
and population health risk information, that is,
risk communication, (6) images of health in
the mass media and the culture at large, (7) the
education of consumers about how to gain access
to the public health and health care systems, and
(8) the development of telepractice applications
(Miller, Burton, & Kraus, 2004; Wood, Miller,
& Hargrove, 2005; Miller, 2007).
Utilizing health communication can help
raise awareness of health risks (including physi-
cal and psychological) and solutions, provide
the motivation and skills needed to reduce these
risks, help consumers nd support from other
people in similar situations, and affect or rein-
force attitudes. Health communication also can
increase demand for appropriate health services
and decrease demand for inappropriate health
services. It can make available information to
assist in making complex choices, such as select-
ing health plans, care providers, and treatments.
At a macro level, health communication can be
used to inuence the public agenda, advocate
for policies and programs, promote positive
changes in the socioeconomic and physical
environments, improve the delivery of public
health and health care services, and encourage
social norms that benet health and quality of
life (Piotrow, Kincaid, Rimon et al., 1997).
Effective health communication may also
inform health care providers for improved
service delivery. The Institute of Medicine
criticized current health care training and
reported that training of health professionals
requires a “major overhaul.” Specically, the
IOM stated that health care professionals are
not properly trained with regard to changes
in patient demographics and health related
needs, evolving expectations within health care
systems, evolving practice methods and techno-
logical advances, or enhanced quality control.
Improved health communication among health
professionals may alleviate these shortcomings,
and telehealth offers a mechanism for improved
training that is immediate and accessible. For
example, the TIP could be used to offer health
Adapted from: Miller, T.W.; Miller, J.M.; Burton, D. (2003). Telehealth: A model for clinical supervision
in allied health. The Internet Journal of Allied Health Sciences & Practices, 1(2).
A Telepractice Intervention Model
For Rural Health Care
Health Care Specialists and
Underserved Patients
Community
Clinics
Regional
Medical
Center
Telepractice from Urban Medical
Center and Community Clinics &
Centers
•Secure two-way interactive
technology
•Internet based Health
Education
•Electronic Medical Record
•Chat rooms for support
•Electronic bulletin boards
for education & training,
p
ro
g
rams
consultation
between
Medical Centers
& Rural Clinics
3
Chat room for
community
support groups
2
Web Based Health
education and
referral information
1
Individual face-to-face
consultation with onsite
patient and clinician
4
Core Com
p
onents
Rural Health
care providers
Figure 1.

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professionals an opportunity to discuss physical
and psychological issues for targeted popula-
tions, interactive education, and face-to-face
consultations with specied experts.
Public Education via the Internet
The environment for communicating about psy-
chology and health has changed signicantly.
These changes include dramatic increases in
the number of communication channels and
the number of health issues vying for public
attention as well as consumer demands for
more and higher quality physical and psycho-
logical health information. Psychology has the
potential of communicating through the home,
the school, and the work environment through
group, organizational, community, and the
Internet interactive telehealth options (Stamm,
1999). For instance, health care providers can
take advantage of digital technologies, such as
CD-ROM, World Wide Web, and listservs to
target audiences, tailor messages, and engage
people in interactive, ongoing exchanges about
health. Brief sessions via web-based interac-
tive video can provide easier access to needed
information and reduce health care cost, travel
time, and expenses.
Research indicates that health communi-
cation best supports health promotion when
multiple communication channels are used to
reach specic audience segments with informa-
tion that is appropriate and relevant to them.
Evidence based decision-making suggests that
effective psychological health promotion and
communication initiatives adopt an audience-
centered perspective, which means that promo-
tion and communication activities reect audi-
ences’ preferred formats, channels, and contexts.
Targeting specic segments of a population and
tailoring messages for individual use are two
methods to make reaching home based health
promotion care through telepractice activities
relevant to audiences. Advances in health in-
formatics are changing the delivery of health
information and services and are likely to have
a growing impact on individual and community
health. Advantages include (1) improved access
to personalized health information, (2) access
to health information, support, and services
on demand, (3) enhanced ability to distribute
psychologically accurate information quickly,
and (4) just-in-time expert decision support
and advice. The health impact of interactivity
and customization through teleconferencing
technology can achieve making psychology a
household word.
Health Information a Telepractice
Model
The goals of community based and professional
organizations should dovetail with Healthy
People 2010 and other similar initiatives
worldwide with the focus on using commu-
nication strategically to improve health. This
can be accomplished through advocacy for:
households with Internet access, health literacy,
and the quality of Internet health information
resources (DeLeon, Crimmins, & Wolf, 2003;
Karlinky, 2004; Hilty, 2004). According to the
Computer and Internet Use Supplement to the
Current Population Survey, U.S. Department of
Commerce, Bureau of the Census (US Depart-
ment of Commerce, 2002), approximately 26
percent of households had access to the Internet
at home. Importantly, the greatest growth in
Internet access was for lower income households
(approximately 25 percent between 1998 and
2001). Continued growth in household access
to the Internet is critical to improve psychologi-
cal health as technical literacy, or the ability to
use electronic technologies and applications,
will be essential to gain access to health in-
formation. This is particularly important for
lower income individuals who may be lacking
health insurance or nancial means for regular
health care. Internet availability in the home
is an important indicator of equitable access to
health information among targeted populations.
The health and technology literacy of persons
with inadequate or marginal literacy skills data
indicate that approximately 90 million adults in
the United States have inadequate or marginal
literacy skills (Lenhart, 2003). Psychology
can play a role in the implementation of this

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initiative by increasing the proportion of health
communication activities that include research
and evaluation. Effective health communica-
tion programs are built on sound research and
evaluation (Casper, 2004; Web Based education
Commission, 2000).
The provision of clinical counseling and
patient education about health behaviors could
enhance adherence and compliance with healthy
behavior (both physical and psychological).
Culturally appropriate and linguistically com-
petent community health promotion programs,
substance abuse treatment, HIV counseling and
testing in prisons, worksite promotion of nutri-
tion education and weight management, public
access to information and surveillance data, per-
ception of risk associated with substance abuse
and tobacco targeting adolescents and young
adults are all potential targets for psychology
in the home (Deleon et al., 2003).
Establishing a Telepractice Inter-
vention Program
Establishing a telepractice intervention model
should begin by identifying existing programs
and/or local and national technological re-
sources. Although not formally described as TIP
networks, organizations such as the Department
of Veterans Affairs and the Texas Department
of Criminal Justice are currently using technol-
ogy to disseminate health care information to
providers as well as the consumers they serve.
Within the VA, employees have access to an
intranet, which contains training modules,
informational handouts, clinical guidelines,
etc. In addition, employees have the ability to
participate in local and national informational
broadcasts, videoconferences, and conference
calls. With regard to patient care, the VA has
developed an Internet-based program called
My HealtheVet, which serves as a gateway to
veteran health benets and services as well as a
tool for enabling veterans to better understand
and manage their health. It provides access to
trusted health information, links to Federal and
VA benets and resources, a Personal Health
Journal, and an online VA prescription rell
program. Eventually, veterans will be able to
view their appointments, co-pay balances, and
access portions of their VA medical records
online (My HealtheVet, 2006). By examining
programs such as these, it is possible to identify
the technological resources needed, learn from
challenges existing programs have overcome,
and to manage various types of informational
programs. In addition to reviewing established
programs for implementation strategies, it is
important to identify existing technological
networks, which might be more effectively used
to disseminate health information to consumers
and providers. For example, many states now
include videoconferencing or cable networks
in public school systems, public libraries,
health care facilities, and other community
facilities for efcient connection capabilities.
Such existing networks could be utilized to
broadcast health information programs targeted
toward specic populations or providers. For
providers who may not have access to large-
scale telehealth resources, there are simple
strategies for utilizing existing resources to
obtain and disseminate health information. For
example, health care providers who wish to
obtain information on evidence-based practice
or innovative techniques may consult reputable
websites or join one of the many professional
list serves designed to promote dissemination
of information. Providers may also refer their
clients to reputable websites (e.g., National
Heart Association, National Center for PTSD
Research) in order to assist them in gathering
information or obtaining support.
The issues for rural health care populations
and for rural school systems present additional
complexity. Rural school systems are often
faced with providing qualied care to their stu-
dent population and are not able to have ready
access to needed expertise. The need for such
specialized expertise to address a seriously dis-
ruptive student in a rural school setting was more
than 500 miles away and transportation was only
available by car. Realizing the complexity of
problems and the fact that there were no board
certied child psychiatrists in the area, it was
proposed that through the use of an innovative

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telecommunications approach, needed clinical
consultation could be provided to this school
system using telehealth technology. The clini-
cal consultation team included a child clinical
psychologist on site working with a school psy-
chologist, an advanced practice nurse, clinical
social worker, special education specialist and
the consultation of a child psychiatrist by video
link from a university based psychiatry clinic
through a cost effective model of telehealth.
Through the use of this specialized telemetric
link using video telephones, the needed inter-
disciplinary clinical consultation and service
could be provided to the rural school system
and its staff. The services included diagnostic
and treatment planning and classroom obser-
vation of the student in question with a secure
telehealth video link to the specialist.
Summarized in Figure 1 above is the con-
ceptual model that exemplies a community
based telehealth technology system. Telehealth
links in this model exist between health care
specialists at the university based medical
center, physicians at the rural community clinic
and psychologist social worker and advanced
practice nurse at the rural district. Within
this conguration a secure two-way video link
exists for interactive stafng of patients and
pediatric emergency care. In addition, Internet
based case conferences with a video link can
provide necessary and essential face-to-face
discussions, video images and streaming video
of case materials for review. The combined
web based and interactive videoconferencing
allows for clinicians and school personnel to
exchange information that can be to the benet
of both educational and health care planning
and consultation. Each of these segments is
noted in the model presented in Figure 1. This
model provides children with special needs in
rural settings the necessary and appropriate
consultation to the benet of client, clinician
and families in our society.
This collaborative partnership between
educators and clinicians may be enhanced and
facilitated by the use of telehealth using video
telephones designated for condential patient
care and planning. School related personnel
may wish the consultation of a local or regional
specialist and may use Internet video technology
through a community clinic. In some cases, the
need to have specialized psychiatric consulta-
tion services from a medical center-based child
psychiatric clinic linked to a community clinic
and to a school district may be offered through
telehealth technology. In this case, patient health
information, patient education materials, clini-
cal records can be shared through electronic
medical records sent to consulting clinicians,
thus providing them with an opportunity to re-
view information individually and then respond
to relevant clinical issues. A clinical stafng
of the child involving the referring clinician
in the rural setting, the community consulting
specialists and the university-based specialist
can be benecial and more effective when time
and distance barriers are removed via the use
of telehealth technology.
The need for telehealth technology is obvi-
ous in the face of the major obstacles clinicians
face in providing a high standard for health care
delivery in a time efcient and cost-effective
manner (Miller, 1998; Miller, Miller, Kraus,
Burton, Sprang, & Adams, 2003). Emerging
systems of managed health care that interface
with the educational system have the potential
to benet from the needed services for children
as noted in the Young and Iresaon (2003) study.
Telehealth is seen as the use of various models
of telecommunication, which connect the con-
sumer with the health care provider through live,
two-way video transmission, across, distances
and which permit diagnosis, treatment, and other
health care services. This denition stresses a
focus on delivery of services across distances
with a sense of concern for ethical provision of
services and condentiality of the health care
needs in our society.
The benets of video teleconferencing
technology for clinical health care and for
educational settings include: Increased access
to clinical consultative services and health
education programs for school and community
organizations and populations; Improved and
expanded psychiatric health care services to
underserved areas in rural communities and

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areas; provision of a feasible and sustainable
system of clinician-directed consultations using
video conferencing; access to current approved
education and training programs for health care
providers in settings where access to advanced
clinical training may be a barrier due to geo-
graphic location; reduction of the isolation for
educators and health care providers in rural areas
through the development of innovative consulta-
tion video conferencing systems that enhance
clinical support and consultation regarding the
diagnostic, treatment, consultative and educa-
tional services available to clinicians and other
health care providers in certain geographical
regions; and use of telepractice technology
in rural communities to decrease the time,
inconvenience, expense and risks of travel, as
well as other associated problems that distance
and isolation cause in obtaining psychological
and other health care services.
PRACTICE GUIDELINES FOR
TELEPRACTICE
Community based telepractice technology
services offers a visionary consultation model
for providing standardized and special needs
coverage to children by linking metropolitan
and agship university medical centers and spe-
cialist services with rural school districts. This
denition stresses a focus on delivery of services
through distance consultation technology with
a sense of concern for the ethical provision of
services and condentiality of the health care
needs of the patient provided with such services.
As an alternative way of providing traditional
health services, telepractice is considered by
some to be a solution to America’s toughest
health care challenges: increasing access to
clinical consultation service and involving
health care professionals while decreasing the
costs involved in providing quality care (Ofce
of Rural Health Policy, 1994). In order to insure
standardization of care based on evidence based
research and experience, practice guidelines
offer a way of incorporating quality care, con-
sistency in educational material and standard
models for information technology.
The clinical use of practice guidelines
generates algorithms that are used to provide
case management based on evidence based
research. The goal is to make the client man-
agement guideline the accepted professional
behavior and a reward in itself. To the extent
that this is successful, ve components occur:
(a) the guideline is widely used and becomes
habitual, (b) multidisciplinary professionals
can use it to anticipate care events, (c) clini-
cians can use it as a shorthand or outline to
guide their decisions and their communications
to others, (d) the logistics for delivering the
guideline components are convenient and reli-
able, and (e) the guideline denes the measure
of performance and incorporates information
collected that can be used for its evaluation
and improvement. The individualized plans
clinicians may use also contribute information
for guideline revision.
Case management through algorithms
presents a systematic perspective. Algorithms
try to answer the questions, “What is the best
way to systematically handle this problematic
condition?” Algorithms have a problem solving
orientation coupled with functional specic
actions or critical pathways to be taken. If
desired results are produced, the problem was
managed effectively. If the desired results are not
produced, adjustments can be made to achieve
the desired results.
The point to be made is that in our profes-
sional roles, it is important to be a creative prob-
lem solver who can translate relevant research
into functional interventions. The model prac-
tice guideline summarized in Figure 2 identied
the situation that the clinician recognizes that
it would be more efcient if telemedicine had
a place in the treatment intervention process.
Note that a question is asked as to whether a
telepracticeoption exists in the patients’ locality.
If yes then the clinician begins the review with
the client of the differences between tradition
and telemedicine delivery of care. Informed
consent is provided and compliance with all
state and federal laws is to be reviewed. Then
the clinician assesses the appropriate needs of
the medium for what need to be accomplished.

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Figure 2. Model alogorithm for telepractice consultation & healthcare
oN
Health provider* recognizes
need for consultation/care
through Telepractice services
Is patient/ caretaker
willing to use
telehealth services?
Provide traditional
referral to
appropriate
clinician
Review with client
Telehealth inclusion
criteria &
confidentiality
Inform client of
consent, privacy
&confidentiality
requirements
Comply with all
regulations and
requirements
Assess risk for
liability for negligence
and for abandonment
and duty of reasonable
Conduct patient assessment screening for
competence with Telehealth equipment
Provide patient education in use of equipment/procedure
No
Yes
Consider the need for written and verbal instruction in the use of equipment and
providing reasonable care
Provide patient plan of care to referring clinician, patient, and family for
review and approval
Provide assessment and intervention through
approved standards of practice
Has assessment &
intervention met
the needs of
Complete written report
and provide follow-up as
needed
Document and review
options for standard
referral to
clinic/specialist
Discuss with referring
clinician and patient
Review standards for
reasonable care
Make referral and
provide for continuity
of care and treatment
Yes
No

International Journal of Healthcare Delivery Reform Initiatives, 1(3), 56-70, July-September 2009 65
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is prohibited.
Appropriately training the patient in the use of
telemedicine and the equipment follows this.
Risk management options are offered, Practice
session is to occur to assure the patient can use
the telemedicine option. The use of web based
educational programs is provided. Finally there
is a review and monitoring process in place
so the clinician can monitor its use. Through
this conguration, issues related to liability
for negligence or liability for abandonment
would be considerable reduced and hopefully
eliminated.
Liability Issues in the Use of
Telepractice
Liability is a primary risk factor for clinical
healthcare practicioners utilizing telepractice.
Risk management strategies should educate
psychologists and consumers about telemedi-
cine equipment. Who will provide training,
what mechanisms are used to evaluate the ef-
fectiveness of training, and how to document
decits in knowledge following completion of
initial training. Another concern with respect to
liability involves “liability for abandonment.”
Abandonment may occur when the clinician
would unilaterally terminate the relationship
with a client or the relationship was terminated
without reasonable notice; and termination
occurred when further attention was needed.
Psychologists using telemedicine technology
continuously monitor the clients’ ability to par-
ticipate in telemedicine activities and conrm
their understanding of their responsibilities
in the use of telemedicine equipment. While
there are certain advantages, telepractice is
subject to many of the same shortcomings
associated with face-to-face care as well as
several technology-specic limitations. Most
notably, users should be aware of and attend
to the following issues prior to establishing a
telehealth network or practice.
Security Privacy, and Condentiality
In an electronically mediated society, concerns
regarding security, privacy and condentiality
may take on new meaning with telepracticeOne
of the most serious compromises to security
and to one’s privacy is the unauthorized access
to condential patient health and educational
information. Fortunately, these risks may be
reduced by utilizing secure or closed networks,
encryption programs, and by adhering to the
standards set forth in the Health Insurance
Portability and Accountability Act (HIPAA)
which provides national standards to reduce
health care inefciencies by encouraging the
use of information technology to better secure
and protect patient information. In addition,
one must consider technological risks that
originate from software or computer systems.
For example, computer viruses may be designed
to destroy data or disrupt computer systems.
To avoid these dangers, system managers must
continually update virus scan programs, be alert
for system glitches, and work to ensure compat-
ibility of all system components (Stamm, 1999;
Striefel, 2000).
Transmission Quality
Along with variations in the technical infra-
structure and expenses required for various
telehealth applications, the quality of data
transmission also varies accordingly. When
considering options for videoconferencing,
providers must take into account both the
clinical demands on the system as well as the
type of transmission infrastructure required
to reliably support a particular application.
Videoconferencing systems vary in the type
of transmission channel required and thus may
operate at different bandwidths. As a measure
of a communication channel’s ability to carry
information, bandwidth directly inuences the
quality of video transmission. In other words,
if detecting ne motor movements is critical, a
system with higher bandwidth would be most
suitable. On the other hand, lower bandwidths
might be more appropriate when movement is
not an important factor or when the cost of the
infrastructure needed to support higher band-
width is prohibitive. Among U.S. telehealth
programs, the most common transmission rate

66 International Journal of Healthcare Delivery Reform Initiatives, 1(3), 56-70, July-September 2009
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is currently 384-786 Kbps (Mahue, Whitten,
& Allen, 2001).
Level of Use Satisfaction
Regardless of the specic type of technology
implemented, the success of a telecommuni-
cations system often hinges on its acceptance
among participants. As noted by Young and
Irenson (2003), once providers and clients be-
come familiar with telehealth technology, there
seems to be an acceptable level of satisfaction
with the use of this equipment. Adequate and
appropriate training based on the intent of the
users of such equipment is essential. Beyond
training, it is important to normalize the equip-
ment as part of the environment to desensitize
those unfamiliar to telepractice practices and
technology.
Scope of Practice
The legal and ethical issue of licensure and
scope of practice in the use of telepractice may
well extend beyond state boundaries or jurisdic-
tions. Licensure requirements, as a limitation
to interstate practice, are often cited as a major
barrier to the development of services. As with
most health care professionals, licensure is
on a state-by-state basis, which requires that
a practitioner hold a full, unrestricted license
in all states him or her practices. For many
professionals, acquiring and maintaining mul-
tiple licenses is a signicant professional and
nancial burden, which falls particularly hard
on rural health care providers who often expe-
rience signicant travel, lost work time, and
other costs in complying with multiple state
regulations.
Technology Costs
The cost of acquiring and maintaining the
necessary technology including maintenance
and update expenses) should be considered.
Fortunately numerous options, which vary in
price point, exist for creating virtual connec-
tions. With availability of the Internet, e-mail,
listservs, and chat rooms may serve as a cost
effective, accessible medium of communica-
tion. Equipment needs are minimal; requiring
only a computer and Internet access at each
location.
Where practitioners at healthcare delivery
sites interested in incorporating technology-
mediated face-to-face contact, several types of
videoconferencing applications exist. When
considering these options, providers must take
into account both the clinical demands on the
system as well as the type of transmission
infrastructure required to reliably support a
particular application. Options for videoconfer-
encing applications include, but are not limited
to, videophones, PC-based desktop systems,
and/or high-quality integrated videoconfer-
ence units. Given the rapid pace of advances
in technology, prices for the above equipment
vary from a few hundred to several thousand
dollars. Ironically, the cost of developing and
maintaining telehealth systems tends to be the
highest in the regions where telehealth would
be most benecial (e.g., rural areas) (Nickelson,
1998). Fortunately, federal programs such as
the Universal Service Program for Rural Health
Providers may help to defray the operating costs
of such systems (Stamm, 1999).
In anticipation of legislative changes with
respect to the use of telecommunication technol-
ogy, there have been efforts on the part of the
medical and nursing professionals to develop
alternative licensure models for their profes-
sions. For instance, Texas offers a “special
purpose license” for out-of-state physicians
who provide telepractice services to Texas
residents. Similarly, the Joint Commission on
the Accreditation of Healthcare Organizations
recently revised its Hospital Medical Staff
Standards which now state that practitioners
who treat patients via telemedicine are subject
to the credentialing processes of the organiza-
tion that receives the telemedicine service (Joint
Commission on the Accreditation of Healthcare
Organizations, 2003). Utilizing a different ap-
proach, the National Council of State Boards
of Nursing has developed a mutual license
recognition program which allows nurses who

International Journal of Healthcare Delivery Reform Initiatives, 1(3), 56-70, July-September 2009 67
Copyright © 2009, IGI Global. Copying or distributing in print or electronic forms without written permission of IGI Global
is prohibited.
hold a valid license in one state to enjoy a
“multi-state licensure privilege” to practice in
states that are members of the licensure com-
pact (DeLeon, 2003). Legally and ethically
the direct and immediate delivery of patient
care is always the responsibility of the on-site
licensed professional.
Applications for Telehealth in
Rural Educational Settings
Numerous applications hold signicant poten-
tial for educational settings seeking to meet
the health related needs of students through
telehealth. These include:
1. clinical interview and/or evaluation by a
clinician specialist; consultations for crisis
stabilization in the school setting;
2. Brief screening and assessment prior to
comprehensive evaluations for various
diagnostic entities;
3. Team assessment and treatment planning
may include multiple links with physicians,
child psychiatrists, school psychologists,
occupational therapists, physical therapists,
speech-language pathologists, counselors,
nurses, teachers, social workers, and oth-
ers;
4. Diagnostic testing with the assistance of a
technician at the site;
5. Short-term health education and counseling
interventions;
6. Vocational assessment, placement and
counseling services;
7. Evaluations and diagnostics related to
second opinions;
8. Short-term case management for children
with special needs;
9. Consultation-liaison services for parents
and children;
10. Consultation with primary care physicians
and/or specialists, clinicians and educators
regarding children with special needs;
11. Continuing medical and health education
for administrators, faculty, students, parents
and others.
CONCLUDING COMMENTS
AND LESSONS LEARNED
Twenty-rst century use of electronic based
technology for the provision of healthcare
services internationally and its interface with
various critical components of society needs
to examine the potential benets over risks in
providing healthcare consultations and services
through the educational settings available.
Health care provision through rural school
systems utilizing telepractice technology must
be vigilant to the challenges and cognizant
of the added value when realizing that this
technology will reach populations who have
been traditionally underserved because of their
remote location to needed services.
Examined herein has been a model,
which demonstrates the capability of reducing
time and distance barriers in the provision of
health care and education through telepractice
technology. Best practice guidelines have
emerged and provide both ethical and legal
parameters for practitioners (Miller & Wader,
2002). Vignettes highlighting the usage of
this technology through educational settings
have been address as has the advantages and
potential disadvantages of its use. Several sug-
gested applications have been noted, as have the
changing paradigms in delivery of healthcare
through community-based services. When
consultation with a needed health care profes-
sional is not readily available, the use of video
teleconferencing technology by healthcare
clinicians and providers in rural settings is a
viable medium for providing needed diagnostic
and clinical consultation for underserved and
rural populations globally.
ACKNOWLEDGMENT
The authors wish to acknowledge the support
and assistance of Rob Sprang Director of Uni-
versity of Kentucky Telecare, Deborah Burton
Ph.D., Charles Lowe Ph.D. Chair Department
of Psychology, University of Connecticut and

68 International Journal of Healthcare Delivery Reform Initiatives, 1(3), 56-70, July-September 2009
Copyright © 2009, IGI Global. Copying or distributing in print or electronic forms without written permission of IGI Global
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Jeffrey Fisher Ph.D. Director Center for health
intervention and Prevention. In addition appre-
ciation is extended to Lon Hays, M.D., Patricia
Beckenhaupt RN, MS, MPH, Catherine Russell,
Jill Livingston MLS, Lane J. Veltkamp MSW,
and Brenda Frommer in the preparation of this
manuscript. This article is based on initial re-
search presented in the “Handbook of Research
on Information Technology Management and
Clinical Data Administration in Healthcare.”
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Thomas W. Miller received his PhD from the State University of New York and University of Buffalo, is
a diplomate of the American Board of Professional Psychology in Clinical Psychology, and is a Fellow
of the American Psychological Association, the American Psychological Society and the Royal Society of
medicine. He is Professor Emeritus and Senior Research Scientist through the Department of Psychology
& Center for Health Intervention and Prevention (CHIP) with the University of Connecticut and Professor,
Department of Psychiatry, College of Medicine, University of Kentucky. His professional interest includes
Telepractice applications in health care, ethical, legal and social implications of genetics; traumatic stress
disorder and stressful transition in the life span.
Robert D. Morgan received his doctorate from Oklahoma State University and is an associate professor
of psychology and director of the American Psychological Association accredited doctoral program in
counseling psychology at Texas Tech University. His public service and general research interests include
correctional mental health, Telehealth applications, forensic assessment, and training and professional
development.
Jennifer A. V. Wood received her MA degree in clinical psychology from Stephen F. Austin University and
her PhD in clinical psychology from the University of Mississippi. She completed her clinical psychology
internship at the South Texas Veterans Health Care System in San Antonio. She is currently a clinical
psychologist with the South Texas Veterans Health Care System. Her interests include research focus on
the use of telecommunications technology in the delivery of rural mental health and health care.