Raymond A. Folen, PhD, Stephen L. Jones, MD, Melba C. Stetz, PhD, Brenda Edmonds, PsyD, and Judy Carlson, EdD
Discussion of Hawaii tends to conjure up images of palm trees, clear blue water and Hawaii 5-0. What is not commonly known is that Hawaii is the most isolated population center on the Earth. We are 2,400 miles from our closest neighbor, California. In the other direction, Japan is more than 3,800 miles away. This isolation has contributed to the uniqueness of the islands and the more than 10,000 native species found nowhere else on the Earth.
The state is spread over an extensive land area as well. The collective land mass of approximately 6,500 square miles, making it the fourth smallest state, is spread over 1,500 miles, making Hawaii the widest state in the U.S. While the populated areas of the state span a distance that is significantly smaller, the eight major islands are separated by water, limiting inter-island travel to air and sea, which in Hawaii are relatively expensive forms of transportation.
Tripler Army Medical Center (TAMC), located on the island of Oahu, is the only Federal tertiary health care facility in the Pacific. It supports 264,000 active duty and retired military personnel, families and VA beneficiaries based in Hawaii and supports forward-deployed forces in more than 40 countries. Civilian residents of U.S. affiliated jurisdictions (American Samoa, Guam and the former Trust Territories) are also eligible for care at TAMC. All told, TAMC’s area of responsibility covers 52 percent of the Earth’s surface.
By necessity, Tripler became an early adopter of telemedicine for behavioral health and medical specialty care. Using both asynchronous store-and-forward and synchronous real-time technologies, significant improvements in access to care began in the mid 1990s. Prior to that time, all patients needing specialized care not available at their home site required air transportation to Honolulu, housing and a living allowance in order to receive services. For behavioral health services, which often require multiple treatment sessions over a period of weeks, this became an extremely expensive proposition. In addition, removing the patient from familiar surroundings, cultural touchstones, and family and support systems for an extended period of time did not facilitate the recovery process.
One case in particular illustrated the need for our involvement in telehealth. We were asked to assist in the treatment of an Army helicopter pilot stationed in Japan who was experiencing increasingly frequent migraine headaches of growing intensity and duration. The soldier was referred to TAMC’s Behavioral Medicine Service within the Department of Psychology, which had a highly successful biofeedback program for the treatment of migraine headache. At the time, standard migraine treatment via medication would have grounded the pilot for six months. Pilot shortages had the flight surgeons in Japan looking at other nonpharmacologic options. The pilot was flown to Hawaii for six weeks, where our TAMC behavioral medicine psychologists conducted twice-weekly biofeedback sessions in addition to having the patient engage in daily home practice. As psychophysiologic control is a skill learned with practice, it took the full six weeks for the pilot to gain sufficient control to significantly reduce the frequency of headaches. During this time, the pilot lived in a Waikiki hotel; his only duty assignment was to attend his treatment sessions and engage in daily practice. The success of the treatment was widely communicated by the pilot to the aviation community resulting in a large number of requests for biofeedback-assisted self-regulation of migraine and other psychophysiologic conditions.
The potential contribution of a six week Waikiki vacation to the successful treatment of the pilot’s migraines notwithstanding, the behavioral medicine providers decided to create a biofeedback system that would allow the biofeedback sessions to be conducted remotely. In this scenario, the patient remains at his or her home station and has regular videoconferencing treatment sessions with health psychologists from TAMC. Unique to the treatment, the TAMC providers packaged and sent biofeedback equipment to the remote sites and, using off-the-shelf software designed for the purpose, controlled the biofeedback software remotely. The remote site only needed to provide the appropriate safety measures, adequate privacy and a technician to apply the biofeedback sensors to the patient. A number of soldiers were treated via this protocol with good success. The patients were able to continue working at their duty station during the treatment period. Thus, there were minimal operational and personal interruptions in providing services. There were also substantial medical cost savings to the government. Avoiding the travel, hotel and per diem expenses of a single patient paid for the entire cost of the remote biofeedback system.
We subsequently began providing other services that had limited availability in the catchment area. TAMC’s highly successful lifestyle management program, the LE3AN program, focused at that time on providing evidenced-based care to overweight soldiers. Chaptering out or separation of an overweight but highly trained service member proved to be extremely costly to the armed services, as the costs to train replacements ranges from a minimum of $50,000 to $500,000. Being on a deployed status made it difficult for the soldier or sailor to receive regular assistance, however, so individual and group treatment sessions were provided over low-bandwidth videophones. Our research found that treatment was equally effective either face-to-face or via teleconference.
As a training facility, telehealth became an effective tool with supervision. With a psychology training mission that includes internship, residency and post-doctoral fellowship programs, the availability of consultation and supervision to trainees subsequently assigned to remote sites became a necessity. Research findings also supported the efficacy of supervision via this modality.
One of the challenges in providing behavioral telehealth services to remote areas led to an important discovery. In the mid 1990s, the availability of broadband connectivity, such as a DSL or a cable connection, was extremely limited. In many areas of the Pacific this remains true today, as many of the islands served by TAMC have telephone service only. We started out using dedicated video phones that only required telephone connectivity to function (what is referred to as POTS, or plain old telephone service). Maximum bandwidth for these videophones was around 28K compared to standard videoconference bandwidths of 364K. Despite the low bandwidth, we found that both patients and providers tolerated a jerky, pixilating screen reasonably well. Providers reported they were able to get adequate visual information to do both the assessment and treatment. What could not be tolerated was dropped verbal information or any significant deviation in voice quality. Currently, we typically have much higher connectivity in our videoconferencing or webcam sessions. Even so, we insure that a phone is available. When the high-tech equipment starts to fail, we simply pick up the phone, dial the patient on the other end and continue.
Safety has been an important consideration from the outset. The concern for a patient being left in a dark room when the power goes out at the remote site or the fear of having a distraught patient verbalizing suicidal or homicidal intent and then walking out of the videoconference made us insure that someone at the remote facility is always stationed by a phone during the telehealth session. Even then, the unexpected happens, as when a power outage at a remote site killed the power to the phone where the backup person was stationed.
Conducting clinical assessment or treatment via videoconference or webcam requires a new set of skills and attention to aspects unique to the medium. While the providers found that they were able to adequately assess and treat, they also reported that the telehealth sessions were tiring. Providers who easily managed 8 sessions a day reported fatigue after 3-4 sessions via videoconference. To a large extent, this was attributed to a perceived need for greater attention and focus. This may be due to the videoconferencing medium itself, as studies have demonstrated that individuals appear more attentive and focused in these environments. The provider’s need for more attention and focus may also be due to a greater requirement to acquire limited nonverbal information that is otherwise more easily obtained in a face-to-face encounter. Over time, however, our providers reported greater comfort and less fatigue as they became more experienced with the medium.
Providers need to practice and feel comfortable with the technology so that it is not intrusive in the clinical encounter. Patients will often take their cue from the provider, and a frustrated therapist struggling to establish a good connection or set a proper camera angle may significantly influence the patient’s comfort with the process as well. Once this basic skill set is established, the therapist must attend to the fact that verbal and non-verbal behavior is perceived differently in the videoconferencing or webcam environment. Camera placement, for example, will determine if the patient perceives the provider as looking at him/her or looking at the floor. The typical web camera is placed on top of a computer screen; the image of the provider is seen on the computer screen positioned below the camera. As a result, the provider is not looking directly into the camera and the patient’s perception is that the provider is not looking at them. Many patients may interpret this directly or vaguely as disinterest on the therapist’s part. If not adequately addressed, this may have a negative effect on the therapeutic relationship. Fortunately, there are several ways to manage this potential problem. If the camera has a zoom feature and the screen is sufficiently large, positioning the camera and screen further away from the provider helps reduce the perceived difference in angle between camera and screen. Alternatively, one can purchase a high quality gooseneck camera the diameter of a pencil and place it directly in front of the screen. The small camera diameter does not interfere with the view of the patient and the camera position creates the perception that the provider is looking directly at the patient. The last and most commonly used option is to simply explain to the patient that, while it appears that the provider is looking down and not at the patient, he or she is actually looking directly at the patient on the screen itself. Addressed early in the process, this appears to allay patient concerns that the therapist is disinterested or otherwise not attending to the session. Therapists can be trained to look directly into the camera when emphasizing a point or at critical moments in the session.
There are a number of ways in which a provider can unwittingly undermine the effectiveness of a telehealth encounter. Our observation and training of therapists who want to work in this electronic environment provides fertile ground for the discovery of new differences between telehealth and face-to-face encounters. Many of the pitfalls we’ve identified are completely out of the awareness of the provider. For example, one provider we worked with liked to use his laptop to take notes when conducting a session. In a face-to-face encounter, the computer was visible to the patient who observed the provider occasionally turning to the side to write a note. In the telehealth encounter, however, the computer was not visible to the patient. During one initial treatment session, the patient looked visibly shocked when, from the patient’s perspective, the therapist would at times simply turn away from the patient and attend to something else. The patient at the time said nothing, but in a post-session interview conducted as part of the therapist’s training, he reported feeling that the therapist was rude and not interested in the patient’s concerns. We advised the therapist that, in the first telehealth session with a patient, he needed to explain that he occasionally turns away from the camera to take notes. This eliminated similar misperceptions in the therapist’s subsequent patient encounters.
Another overlooked potential problem is the loudness of the provider’s voice at the remote end. A comfortable listening level for one patient – particularly one hard of hearing - may be absolutely deafening to another. Interestingly, many patients perceive a loud volume level as yelling on the part of the therapist. They do not perceive it as something simply needing a volume adjustment like they might make with an overly loud TV commercial. Thus, at the start of a session it is crucial that providers insure the volume is at a comfortable level for the patient.
Providers tend not to attend to other aspects of the telehealth environment as well. Videoconferencing and webcam environments often default to a two screen display. Provider and patient typically see both themselves and the person at the remote end (i.e., near and far views) either as equal size images or in a picture-within-a-picture format. Patients may find this to be very distracting, as they are not used to seeing their own image on the screen and thus become overly self-conscious. Therefore, we recommend that the patient’s screen show only the therapist. On the provider side, we advise that both images be present on the screen. While initially distracting, therapists adapt to it and it provides important information regarding the image portrayed to the patient, posture, position in the camera, and lighting. In general, an image that extends from the waist to the top of the head appears most comfortable for both. Avoiding the “Wizard of Oz” talking head is recommended. Therapists are also advised to remain relatively still during the session as frequent movement may tend to pixilate the screen, adding a distracting element. We discovered that many providers have a tendency to rock back and forth in their chairs, something that proves to be extremely challenging for maintaining a focused image. Videoconferencing also introduces a delay in the conversation, similar to what one typically sees in simultaneous live satellite newscasts. Therapists need to factor in a one to three second pause before responding to the patient as the conversation will otherwise be frustrating, with each party talking over the other. If the provider engages in proper pacing, the patient will follow suit.
The ability to provide culturally-informed care, a critical competency in any circumstance, is a major consideration when providing care across thousands of miles. Huge differences arise out of the myriad of cultures present in the Pacific region. While simply being open and understanding can go a long way toward bridging differences, the challenge for providers is that “they don’t know what they don’t know and can easily turn off” a patient without intention or awareness. There are a number of books about the Samoan warrior culture, for example, but this basic knowledge may be woefully inadequate when discussing matters of family with a Pacific island village chief. We recently began providing services to American Samoa, where behavioral health providers, as well as every other health care specialty, are extremely limited. Prior to doing so, we conducted interviews with a broad sampling of individuals in American Samoa and found that they were extremely receptive to the concept of telehealth. Several told us that behavioral health services via telehealth were preferred, as nothing is confidential in Samoa. They also noted that not having the provider on the island reduced the chance of what they perceived could be an uncomfortable social encounter with the provider. We were told of the culturally inappropriate treatment styles and interpersonal behaviors of the transplanted providers from the U.S. mainland and of the relatively short duration of their stay in Samoa.
While providing behavioral telehealth services to patients in American Samoa increases the availability of providers with a variety of specialty skills and provides some comfort with regard to patient confidentiality, the cultural issues still remain prominent. With that in mind, we hired a master’s-level native American Samoan to serve as a cultural mediator during the telehelath sessions. Having received his master’s degree in psychology at a university in Hawaii, he was firmly grounded in Samoan and Hawaii western culture. His participation in each telehealth session was invaluable as he frequently explained concepts in ways that were more culturally meaningful and appropriate. He was often heard saying, “I think what Dr. Smith means to say is….”
In response to the stresses associated with frequent redeployments and the high operational tempo of Operations Iraqi Freedom and Enduring Freedom (Afghanistan) in the longest war in U.S. history, the Vice Chief of Staff of the Army (VCSA) in 2009 directed that behavioral health providers touch every soldier at specified times in the Army Force Generation (ARFORGEN) cycle. These touch times included immediately postdeployment, again approximately 120-180 days postdeployment, and several months prior to deployment. The challenge was insuring that an adequate number of providers be available during these surge periods, when thousands of soldiers would need to be seen within a 2-4 week period of time. In order to meet this requirement, a large number of providers was needed and the typical military behavioral health facility did not have the staffing required to accomplish the additional task. The VCSA directed that other options be considered, including the possibility of flying in and telecommuting providers to various locations.
In October 2009, Tripler conducted a quality improvement project to determine if soldiers and providers experienced interviews conducted over high-definition videoconference (VTC) or webcam (DCO – Defense Connect Online) as equivalent to face-to-face (FTF) interviews. Five hundred and twenty soldiers from the 2-35 Infantry, 25th Infantry Division, returning from war in Iraq received a post-deployment screening, with one-third having the screening conducted over VTC, one-third via DCO, and one-third FTF. An anonymous post-screening questionnaire was completed by those soldiers.
The soldiers were scheduled in groups of 45, with each group first receiving a two minute briefing to reduce stigma and reinforce the importance of engaging the process in an honest, forthright manner. The soldiers then completed a five minute, 42 item online questionnaire that assessed their current psychological status in a number of areas (e.g., substance use, anger, risky behavior, self worth, depression, PTSD symptoms, quality of relationships, financial difficulties, sleep, etc.). This was followed by the interview with the behavioral health provider who had immediate access to the results of the online questionnaire. Unlike prior screenings where soldiers were seen by a behavioral health provider only if they reported a positive behavioral health issue on a paper and pencil screening questionnaire, all soldiers, regardless of their questionnaire results, were seen for an interview. In addition to screening for psychopathology and risk, the overall tone of the encounter was a positive psychology approach focusing on strengths and resiliency. The providers provided reassurance and normalized the challenges of the readjustment process. They provided recommendations for managing some of the most common problems faced by returning soldiers, to include insomnia and hyper-arousal, the latter being adaptive in theater but less functional in garrison. Recommendations for follow-up care were also made to nip problems in the bud, for example when soldiers reported the beginnings of marital discord or child-parent conflicts. The goal was to have each soldier - who may never have met or seen a behavioral health provider in his or her entire life - experience the encounter positively. With that accomplished, it was expected that soldiers would be more willing to follow up with any referrals made by the provider. In addition, it was hoped that the positive experience would further reduce stigma and resistance should the soldier consider or have the need for future behavioral health services. Following the interview with the behavioral health provider, soldiers met briefly with a nurse case manager who scheduled any referrals made by the provider and further reinforced the value and importance of the soldier following through with the referral.
The soldier post-interview results were extremely interesting. Given that the soldiers were required to participate in the post-deployment interview and the fact that these interviews occurred on days and times where the soldier would likely have been engaged in more pleasurable R&R activities, we did not expect there to be a high satisfaction rate with the process. We were surprised to find that between 86-88 percent of the soldiers found the interview to be helpful. This may have been due to the positive psychology-based nature of the interview, which was significantly different from an interview that screened only for psychopathology. Also of interest, there was no difference in satisfaction rates between interview venues (VTC - 88%; DCO - 86%; FTF - 87%).
The soldiers’ satisfaction (VTC - 97%; DCO - 95%; FTF - 96%) and level of comfort with the overall process (VTC - 98%; DCO - 93%; FTF - 95%) were extremely high. Similarly, soldiers reported no difficulty seeing or hearing the provider (100-96%) and perceived the provider as equally able to do so (98-95%). Most surprising, when asked if there were concerns they did not feel comfortable discussing, a significantly greater portion of those seen electronically disagreed with the statement compared to the FTF group (VTC - 94%; DCO - 81%; FTF - 76%; p < .01). Soldiers may be more comfortable in a therapeutic context disclosing personal information to someone located remotely than in the same room, a phenomenon one often finds as well in the internet social networking environment. It is interesting to consider the possibility that behavioral telehealth may be superior to a face-to-face encounter.
The providers were also asked to complete a post-interview questionnaire after each encounter and at the end of each day. Each of the 19 providers had an approximately equal number of days conducting interviews in each of the three modalities. In contrast to the high comfort levels reported by the soldiers, the providers reported significantly greater comfort with interviews conducted face-to-face and via VTC than they did with webcam (VTC - 89%; DCO - 56%; FTF - 100%; p < .0001) and reported being less able to establish rapport with the soldier (VTC - 94%; DCO - 72%; FTF - 89%; p < .03) when using the webcam. Contributing to this may be the fact that the providers reported greater difficulty seeing and hearing the soldier via DCO. Interestingly, there was no significant difference between the three modalities in the providers’ ability to assess the soldiers’ psychological health needs or provide appropriate recommendations or interventions. Approximately half of the providers recommended that the post-deployment interviews be conducted via VTC, while less than one-fourth of the providers recommended the webcam (VTC - 53%; DCO - 22%; FTF - 84%; p < .0001).
Given that webcam communications (e.g., Skype, DCO, etc.) are significantly less expensive and in greater widespread use than VTC, the finding that providers did not recommend webcam interviews warranted further investigation. Post-project interviews with providers revealed some interesting perceptions. The providers in this QI project were, for the most part, newcomers to VTC and webcam services. Like most individuals who have grown up watching TV, images that are smooth and interference-free are the natural expectation. Images that are at times jerky or pixilated were viewed by the providers as inferior, which they are. Despite reporting that they were able to adequately assess and treat using all three modalities, the webcam images did not meet expectations. Audio quality and audio delay were also identified as factors that significantly impacted the provider’s satisfaction with webcam.
In other webcam and low bandwidth projects we have conducted, providers initially reported less satisfaction with the lower quality video but, with practice and experience, they developed greater comfort and satisfaction using these systems. It appears that it may take some habituation to the lower quality images before they become non-distracting. Soon we will conduct a study to further clarify the minimum levels of video and audio quality needed to adequately assess and treat a variety of psychological and physical conditions. Thankfully, this is becoming less and less an issue as bandwidth capabilities at remote locations are expanding at a phenomenal rate.
We used webcam technology (DCO) to subsequently screen 3,500 redeploying soldiers at Ft. Richardson, Alaska. As VTC was not an option given severe bandwidth limitations, DCO was used exclusively. Providers at TAMC and Madigan Army Medical Center (MAMC, located in Washington State) telecommuted to Ft. Richardson and successfully conducted these screenings over a four-week period. Again, DCO was more than adequate to meet the task. In areas not directly patient related, the telecommuters were faced with challenges similar to those experienced by our civilian colleagues. Despite being a unified health care system, Army providers are credentialed and privileged by local or regional committees and the TAMC providers had to be evaluated and privileged at Ft. Richardson before they could screen soldiers. Similarly, in the civilian sector, providers are typically required to be licensed in the states and privileged in the facilities where both provider and patient are located. This can be a lengthy process, particularly if the provider is not registered with, or the state does not participate in, one of the available mobility mechanisms. Workload credit (billing in the civilian sector) was also an issue. The Soldiers were not registered in our Pacific Region, thus the work produced by the TAMC providers was credited to the region where the soldiers were registered. Our civilian counterparts find similar challenges when the distant patient has insurance with a company with which the provider has no relationship.
As a result of its successful implementation of behavioral telehealth services, TAMC recently received funding to establish a Tele-behavioral Health and Surge Support (TBHSS) program in the Pacific Region. The funding provides for the hiring of 10 psychologists, 3 psychology technicians, 3 nurse case managers, 1 psychiatrist, 3 technical support staff and 2 administrative support staff. Funding for building renovation and equipment is also included. The staff will be dedicated 100 percent to telehealth and will be provided with the clinical, technical and military cultural training required to do the job. In addition to worldwide surge support, the program will provide services to soldiers down range in Iraq and Afghanistan, to other military units in the Pacific Regional Medical Command’s area of responsibility to include Japan, Korea, and Guam, to National Guard/Army Reserve Families and Soldiers living on the Hawaiian Islands and remote islands of the Pacific, and to uniformed service members living on Oahu who would like to avoid the two hour commute it may take to get to Tripler from their place of duty. TBHSS will also enhance continuity of care, as it allows us to maintain a therapeutic relationship with our soldiers wherever they may be deployed or stationed. In addition to the dedicated telehealth staff, behavioral health specialty providers also provide long distance care. See Table 1 for a listing of available treatment and diagnostic services. We are giving serious consideration to the possibility of providing behavioral telehealth services to the Service Member or Family Member when they are at their home. While a number of safety and liability concerns will need to be addressed before moving into this new area of service provision, it is not hard to recognize the increased access to care and the reduced stigma this method of treatment can offer.
Synchronous telehealth services are certainly not a new phenomenon. When Alexander Graham Bell spilled battery acid on himself when testing out his telephone invention for the first time, little did he know that he was making telehealth history when he called out over the wire to Watson for help. Behavioral telehealth was taking place as early as 1959, when the University of Nebraska started using closed-circuit television between locations to provide psychological treatment services. Since then, the increasing availability of videoconferencing technology has resulted in a greater number of behavioral health providers engaging their patients via this medium. Nevertheless, despite its demonstrated success, the great majority of behavioral health providers do not utilize what this technology has to offer. For example, how much more convenient would it be for a patient to access their therapist during a workday from a webcam located at the worksite? How helpful might it be for a patient to contact and get assistance from his or her therapist within moments of a critical event? How helpful would it be for a patient with a rare condition to receive treatment from a national expert located thousands of miles away? More and more individuals of all ages are utilizing e-mail, chat rooms, social networking sites, video phones, and instant messaging to provide for their social and psychological needs. While these new technologies can present problems, there is space for psychology to use these new communication mediums to increase access to care and improve the effectiveness of treatment. Recently, an agoraphobic patient I was treating for an extended period of time was able to make her first trip in a decade to a crowded shopping mall. She attributed her success less to the treatment I provided than to the importance and influence of her one thousand friends – many of whom also suffered from the same condition – who were cheering her on and offering encouragement via Twitter during this important challenge.
Specialty Psychological Services
Raymond A. Folen, PhD, is the Chief of the Department of Psychology at the Tripler Army Medical Center in Hawaii, where he was previously the Chief of Behavioral Medicine and Health Psychology Service. He has been credentialed by the National Register since 1979 and was recently elected to the National Register Board of Directors.
Brigadier General Stephen L. Jones was responsible for the activation of the Warrior Transition Battalion, the opening of a traumatic brain injury clinic at Tripler, and a brain concussion clinic at Schofield Barracks. He also helped launch the telemedicine initiative which allowed behavioral health specialists at Tripler and Schofield Barracks to conduct confidential interviews with soldiers to assess their mental health status and design treatment plans upon their return from combat.
Melba C. Stetz, PhD, currently serves in the Department of Psychology as Chief of Research Psychology, Chair of Performance Improvement, and Director of Psychology Practicum. Her main contribution is the use of Virtual Reality in psychology to assess and assist warfighters. She received her PhD in Industrial and Organzational Psychology from Carlos Albizu University in San Juan, Puerto Rico.
Brenda Edmonds, PsyD, is currently the Chief of Behavioral Health, Health Policy and Services, for the Pacific Regional Medical Command. She graduated with a doctorate in clinical psychology from the American School of Professional Psychology, Argosy University, Hawaii Campus.
Judy Carlson, EdD, is a Senior Nurse Scientist with the Nursing Research Service, Tripler Army Medical Center.