Telepsychiatry As A Case Study of Presence - Do You Know What You Are Missing - Turner - 2001 - Journal of Computer-Mediated Co

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Telepsychiatry as a Case Study of Presence: Do You Know What You Are
Missing?
First published:
July 2001 Full publication history
DOI:
10.1111/j.1083-6101.2001.tb00132.x
Citing literature
Address: The McDonough School of Business, Georgetwon University, G-04 Old North, Washington, DC
20057. Phone: 202-687-6927 FAX: 202-687-4031.
Volume 6, Issue 4
July 2001
Page 0
Jeanine Warisse Turner
Abstract
This study explores the use of videoconferencing technology as a means of providing mental health
consultations across distances. Analyses of 43 psychiatric interviews with 14 different patients using an
interactive videoconferencing system over an 18-month period reveal that the telecommunications link
compared favorably to face-to-face encounters in assessments by physicians and patients. However,
telepsychiatry may hinder many of the ancillary practitioner-patient relationships that contribute to a
psychiatric consultation and create a false sense of presence. The study stresses the importance of
examining the new context created by implementation of any new communication technology, and of
understanding the need for attention to secondary and peripheral contexts that could potentially be ignored
because of telepresence.
Telepsychiatry as a Case Study of Presence: Do You Know What You Are... http://onlinelibrary.wiley.com.remoto.dgb.uanl.mx/enhanced/doi/10.1111/...
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Telepsychiatry as a Case Study of Presence: Do You Know
What You Are Missing?
The implementation and integration of new communication technologies within organizations creates complex
changes in communicative practices. Advances in telecommunications and digital technology allow
organizations to extend their boundaries beyond physical and geographic barriers. Within healthcare settings,
telemedicine applications allow physicians to examine patients at remote locations via various types of
telecommunications technologies. These telecommunications connections allow psychiatrists and patients to
be present in a new way. This paper explores implications of this presence in the context of a psychiatric
exchange.
Presence
The concept of presence is defined as: the fact or condition of being at the specified or understood place
(Kim & Biocca, 1997). Kim and Biocca (1997) suggest that the experience of presence oscillates around
three senses of place: the physical environment, the virtual environment, and the imaginal environment (for
example, daydreaming). In a traditional, face-to-face environment, the physical environment is relatively
transparent to the interaction. Many information cues present in the physical environment can be incorporated
into a communication exchange without the conscious awareness of the individuals involved. For example, a
physician may notice that a patient seems to walk into an examining room in a reticent way. These nonverbal
cues may aid the physician in formulating a diagnosis.
When videoconferencing technology is used to bridge remote locations, a virtual environment is created.
Many information cues present in the physical environment are not available in the virtual environment. This
virtual environment can create a sense of telepresence. Telepresence describes the subjective sensation of
being in a remote or artificial environment, but not the surrounding physical environment (Kim & Biocca, 1997).
Lombard and Ditton (1997) suggest that telepresence creates an illusion of nonmediation where a person:
fails to perceive or acknowledge the existence of a medium in his/her communication environment and
responds as he/she would if the medium were not there. This illusion of the absence of mediation may
suggest to the participants they are receiving all information cues relevant to interaction, when in fact they are
not.
Telemedicine applications using videoconferencing technology provide the physician and patient an
opportunity to be present in a new space created by the telecommunications connection. The technology
permits participants to see just enough of each location so that additional information provided by visual cues
can enhance decision-making capabilities. However, participants often decide which visual cues are
interesting. As a result, telepresence may create a socially-constructed environment very different from the
actual physical environment. The presence provided by these technologies may have a profound effect on
decisions made in these environments. This study explored the concept of presence within telemedicine,
specifically telepsychiatry interactions.
Past studies of telemedicine using videoconferencing technology have focused on the efficacy of presence
for assessing and diagnosing patient concerns. The focus has tended to be upon the participants immediately
involved in the telemedicine encounter (for example, the doctor and patient or the consulting specialist and
healthcare practitioner). Individuals who support the telemedicine encounter (for example, other healthcare
practitioners who attend to patient needs) are rarely considered. However, personal relationships between
nurses and other healthcare practitioners who provide information and resources contributing to the
telemedicine encounter can be critical to the success of the healthcare encounter.
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A study outside the healthcare industry, of 250 firms from advertising, magazine publishing, women's apparel,
and the pharmaceutical industry, found that personal relationships were critical to coordination success
(Kraut, Steinfield, Chan, Butler & Hoag, 1998). Contrary to assumptions made by some of the virtual
organization literature that telecommunications networks can reduce costs of coordination (Davidow &
Malone, 1992; Malone, Yates & Benjamin, 1987), Kraut et. al. (1998) found replacement of personal
relationships with electronic networks negatively associated with order quality and efficiency. This suggests
that efficiencies gained from bypassing personal relationships can be problematic.
The present research contributes to the literature in several ways. First, very little research within the
telemedicine literature has examined the role of ancillary healthcare personnel and their contribution to the
telemedicine encounter. Some of this research has explored patients' perceptions of ancillary healthcare
personnel and their role within the telemedicine specialty clinic. (Mair, Whitten, May, & Doolittle, 2000). The
present research study explores how the absence of personal relationships among healthcare personnel
involved in the doctor and patient encounter can influence patient care. It also builds on literature exploring
presence by examining implications of perceived presence on task performance. In this report a case study of
telepsychiatry is considered.
Telepsychiatry
Telepsychiatry is one specific application of telemedicine that has been researched extensively. Psychiatry is
thought by many to be an ideal specialty for videoconferencing, because of the primacy of the face-to-face,
question-and-answer interaction (Baer, Cukor, Jenike, Leahy, O'Laughlen, and Coyle, 1995). This interaction,
researchers have contended, can be replicated by videoconferencing technology more easily than for other
medical specialty applications. A 1994 report in Telemedicine Today listed 16 programs that were using or
proposing to develop a telemental health component of their telemedicine program (Allen & Allen, 1994). This
number has increased with a 1997 review of telemedicine programs citing 25 programs actively pursuing
mental health consultations. (Grigsby & Allen, 1997). In addition, support groups and therapists are
investigating lower bandwidth technologies like the Internet for discussion groups and electronic mail as
means of asynchronous therapy (Zgodzinksi, 1996).
Focus upon the Doctor and Patient Dyad
Telepsychiatry has been explored for over 40 years through a wide range of technologies. Research has
compared the telepsychiatry interview to the traditional face-to-face interview across various diagnoses and
conditions. Though technology has evolved dramatically, many conclusions regarding the viability of
telepsychiatry over the years have remained very similar.
The first implementation of telepsychiatry was conducted by Wittson in the early 1950s at the Nebraska
Psychiatric Institute (NPI), where he investigated the potential of closed-circuit television as a teaching aid
(Wheeler, 1994; Wittson & Benschoter, 1972). Ten years later, the first telepsychiatry consultations were
performed at NPI. The researchers involved in the trial determined that the isolation of the therapist from
the patients had almost no effect on group sessions (Wheeler, 1994, p. 2). Additionally, researchers found
patients and relatives were very receptive to this form of communication (Wittson & Benschoter, 1972).
Similar results were found in New Hampshire where researchers explored the use of two-way-video
consultations between community family physicians and psychiatrists located at Dartmouth Medical School.
Dartmouth researchers argued: television has presented almost no difficulties as a medium for psychiatric
consultation. It has not proved to be a significant barrier in establishing rapport with the patient or in
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perceiving emotional nuances (Solow, Weiss, Bergen, & Sanborn, 1971, p. 1686). Telepsychiatry presented
an additional benefit in that local physicians became educated in the treatment of their patients through
observations of the interviews with remote psychiatrists. Local physicians reported notable changes in their
use and knowledge of psychotropic drugs.
A telepsychiatry program for children that linked a medical school and an inner-city, child-health station
received similar support from users, while also providing the additional benefits of improved access and
decreased travel time (Straker, Mostyn, & Marshall, 1976). Findings from programs developed in the 1960s
and 1970s suggest that both patients and therapists do not feel that televised sessions interfere with the
quality of therapeutic relationships (Maxmen, 1978, p. 452). Another study, conducted in the 1980s, directly
examined telepsychiatry, in comparison to traditional, face-to-face interviews and found no significant
difference in patient and physician perceptions of the two (Dongier, Tempier, Lalinec-Michaud, & Meunier,
1986).
These initial explorations suggest the technology may be adequate for diagnosis of some conditions. A pilot
study of telemedicine used for patients with obsessive-compulsive disorder showed that telemedicine resulted
in near-perfect inter-rater agreement on scores on semi-structured rating scales for obsessive-compulsive,
depressive, and anxiety disorders (Baer, Jenike, Leahy, O'Laughlen, & Coyle, 1995).
Presence within Telepsychiatry
Although there appears to be little difference in the perception of care on the part of psychiatrists or patients
from some of the research conducted, there are some obvious differences in the two methods of mental
healthcare delivery. Dwyer (1973) delineated some of the implications of telepsychiatry in his observations
and use of an interactive television system linking Massachusetts General Hospital to a medical station in
Boston. Dwyer noted that although acceptance by physicians and patients was high, the interaction via the
system was qualitatively different in a number of ways. This new form of interaction mediated by technology
called into question a number of the fundamental assumptions made about the nature of relationships. Dwyer
suggested that future research explore this new process to determine elements that support and disrupt the
building of relationships.
McLaren, Ball, Summerfield, Watson, and Lipsedge (1995) identified some of these factors when they studied
the use of a low-cost videoconferencing system in an acute psychiatric service over a four-month period.
They found increased interpersonal distance appeared to enhance communication. Some patients felt more
comfortable self-disclosing at a distance. However, they also noted the technology limited ability to perceive
certain nonverbal behaviors. In addition, both the patients and the psychiatrists were somewhat distracted by
the equipment and felt self-conscious viewing themselves on the monitor.
In evaluating overall success, it is important to consider the human factors of telemedicine specifically, the
characteristics of implementation by users and the ways they interface with the technology. Cukor and Baer
(1994) suggested the healthcare provider should be sensitive to several issues relative to videoconferencing
technology. Some of these included lack of synchronization between voice and the image, distortion of eye
contact by camera placement, and tiling (video technology) problems. Because asynchronous images of the
person can appear to stop speaking before the audio on some systems, it is important to monitor speech so
the therapist does not interrupt the patient. This can be accomplished by waiting a few seconds after the
image of the person's mouth stops moving. Secondly, it is important to maintain eye contact with the camera
rather than the image. Alternating gaze between the camera and the image will provide the appearance of eye
contact. Finally, avoiding rapid physician and/or patient movement reduces distraction from blurred motion
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(Cukor & Baer, 1994). Another study by May et. al., (2000) echoed these concerns, suggesting the video link
impeded normal interaction, requiring both the psychiatrist and patient to adapt their means of communicating.
Telepsychiatry has received tentative support across decades of use. However, more research is necessary.
Baer, Elford, and Cukor (1997) echoed this concern in their review of telepsychiatry applications and called
for more research, suggesting the current evidence of support is insufficient to suggest telepsychiatry's
widespread implementation. One concern associated with telepsychiatry, as well as other applications of
telemedicine, is the reduction of the physician- patient encounter to one episode. The focus of research tends
to be upon the participants immediately involved in the telemedicine encounter (for example, the psychiatrist
and patient, or the consulting pyschiatrist and healthcare practitioner). Individuals who support the
telemedicine encounter are rarely considered. However, these additional individuals may be critical to
accurate diagnoses and treatment. To examine the efficacy of telepsychiatry to provide the presence
necessary for effective care, it is important to understand the traditional psychiatric interview.
The Psychiatric Interview
Meyer and Mendelson (1961) suggested the consultation process begins with the request for a consultation.
This request involves the psychiatrist's redefinition of the patient situation and the impact that the participating
psychiatrist and the operational group (comprised of the patient, the nurse, and other healthcare professionals
responsible for the request) may have on the patient. A physician's request for a psychiatric consultation
arises from a combination of uncertainty regarding the patient's condition, and a desire to fulfill the patient's
needs (Meyer & Mendelson, 1961).
The great majority of requests for psychiatric consultation with hospitalized or institutionalized patients
originate with healthcare professionals involved with the patient's medical care, rather than the patients
themselves. As a result, patients may be unable to provide much information regarding their own need for
treatment. Therefore, the psychiatrist must collect information from many sources (for example, the other
healthcare practitioners involved, the patient's family, etc.) that expand the psychiatric interview. The
psychiatrist becomes a participant in and an observer of interpersonal relationships involving the patient. This
experience helps the psychiatrist better understand the patient's situation. In this way, disturbing behavior on
the part of the patient can be better understood within the context of interpersonal interactions, rather than in
isolation (Meyer & Mendelson, 1961). Schwab (1979) supports this role of the psychiatric consultant, arguing
the role involves a set of relationships between the consultant, the patient, the referring physician, the nursing
staff, and the patient's family.
In a telepsychiatry consultation situation, a virtual space is created via videoconferencing technology that
allows the psychiatrist and patient to converse without actually being in a room together. Although this new
situation offers economic advantages in terms of travel reduction, the absence of the psychiatrist from the
environment in which the patient is living may be important. A number of information sources that the
psychiatrist may traditionally rely upon are removed (e.g., contact with the referring physician, nursing staff,
family members). The videoconferencing consultation and the patient's chart potentially become the only
information sources available to the psychiatrist. The interaction between the physician and the patient take
place in a very different environment than a traditional face-to-face interaction (Figure 1).
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With traditional interactions, the psychiatrist talks with the patient in his or her room, and is able to experience
the environment that the patient is in, from the primary context to some of the secondary and peripheral
contexts.
With telemedicine interactions via videoconferencing, the psychiatrist and patient can see some of each
other's location. The primary context is provided by the camera view and some secondary context can be
viewed. Peripheral context is unavailable to both participants.
In a traditional encounter, where the psychiatrist goes to the facility where the patient is located, he or she
Open in figure viewer
Open in figure viewer
Figure 1.
Presence Offered by Telemedicine Interactions Versus Presence Offered in Traditional Settings
Figure 1.
Presence Offered by Telemedicine Interactions Versus Presence Offered in Traditional Settings
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has access to much more of the patient's context. For example, he or she can experience the walk through
the hospital, down the hallway to the patient's room, and the patient's room itself. In the telemedicine
encounter, the psychiatrist has access only to the context that is viewable on the video monitor. This
presence is very different. To clarify the various dimensions available during each encounter, Figure 1
illustrates primary, secondary, and peripheral contexts. Although the various contexts could be delineated in a
myriad of ways, this description helps begin to identify the presence available to participants, so as to
compare telemedicine interaction to traditional encounters.
Primary context refers to the immediate presence of the participants. It refers to what appears salient to the
participants. Within telemedicine, the primary context is the image on the video monitor. Within a traditional
encounter, the primary context is the immediate distance around the participants. Within that primary context,
some secondary context is available, but is not the focus of participants. Within the telemedicine encounter,
this may include sounds that give information regarding what is occurring outside the image displayed on the
video monitor. Within traditional encounters, secondary context refers to the room within which participants
meet. Peripheral context is the ancillary context that is not a part of the telemedicine encounter at all. Within
the traditional encounter, the peripheral context may include the walk into the building, the walk down the
hallway, and the impromptu meeting with nurses outside of the patient's room.
The Present Study
Whereas previous research focused upon specifics of the consultation between the psychiatrist and the
patient, the present study explores the new environment created by the telepsychiatric consultation and the
resources available through this environment to provide necessary information to the telepsychiatrist. This
study will examine the consultation itself, as well as the information sources available to the psychiatrist in
making patient evaluations. This research study will extend past research and further explore unique
characteristics of the communication process created by this form of mental health delivery.
Research Questions
The overall question for this study asks: How does the presence experienced by participants within the
psychiatric telemedicine interaction influence the encounter? It explores presence within the primary context
by examining perceptions of the physician and patient regarding the telemedicine encounter. It also explores
presence within the secondary context by examining the completion of follow-up recommendations by ancillary
healthcare personnel.
Context of the Study
A large academic medical center was partnered with a state prison hospital to provide psychiatric care. The
prison hospital needed a psychiatrist to conduct medication assessments. The prison hospital was
simultaneously instituting a telemedicine system to augment inmate specialty care. The psychiatric consultant
had never visited the prison hospital prior to the start of the telepsychiatry program. He was asked to offer his
services to specific patients at the prison hospital using a new telemedicine system. His relationship with the
institution began with his involvement in telepsychiatry. The psychiatrist met the patients within this study via
the videoconferencing technology only, not face-to-face. Psychologists at the prison hospital referred patients
to the psychiatrist. Prison hospital personnel told patients about the telemedicine system so they were
reasonably prepared for this method of seeing the physician.
The telemedicine consultations investigated in this study used CODEC-based videoconferencing equipment
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including room cameras, dual video monitors, a document camera, and a fax machine. The system used digital
telephone service at a bandwidth of 768 kbps (1/2 of a T1 line) and provided real-time interactive video
between the academic medical center and the prison hospital. Using the telemedicine system, a psychiatrist
located at the academic medical center was connected to a patient located at the prison hospital. The
patients were introduced to the psychiatrist by a nurse from the prison hospital. However, the nurse did not
remain with the patients during the consultations. After the consultations were completed, the nurse returned
to the video monitor site to retrieve the patient and receive instructions and recommendations from the
psychiatrist.
Sample
This study explored use of telemedicine for psychiatry over an eighteen-month period, between February
1995 and August 1996. During this time, the telepsychiatrist conducted 43 teleconsultations with 14 different
patients. The average age of the patients was 50. Eleven of the patients were male and three were female. All
were housed at the prison hospital at the time of the consultation and taking some form of psychotropic
medication. The average length of teleconsultation was 25 minutes. The eighteen months of treatment provide
a case from which to better understand presence within telemedicine interactions.
Methods
The methods for this case included surveys about each interaction on the part of the patient and psychiatrist,
tabulation of recommendations made and followed after each interaction, and observations of 10 interactions.
Surveys
After each teleconsultation, the telepsychiatrist rated the consultation on a 110 scale assessing the
appropriateness of the technology for performing the consultation, with 10 describing the technology as most
appropriate. Similarly, after each teleconsultation, the patient was asked to complete a 14-item scale that
addressed patient attitudes towards the teleconsultation. (Mekhjian, Warisse, Gailiun, & McCain, 1999). This
scale addressed two factors pertaining to the physician-patient interview: informational exchange, and patient
comfort with the technology (for more information on this scale and its development, see Mekhjian, et. al.,
1999). Information exchange described the effectiveness of the technology to transmit information between
the patient and the physician. For example: I am comfortable with what the doctor told me about my
complaint, and: The doctor communicated with me effectively. Patient comfort described the patient's overall
attitude towards the telemedicine encounter as a new concept. The patient-comfort dimension constituted
items comfort-oriented or affective in nature and focused upon the influence of the context of the telemedicine
technology. Example statements included: I think it would have been better if I had seen the doctor in person,
and: I would feel much more comfortable in a face-to-face meeting. These items described comfort in the
telemedicine interview, indicating a more relational component.
Recommendations
At the end of eighteen months, the telepsychiatrist reviewed the files for each patient and noted the
recommendations that were made as a part of the patient's treatment. These recommendations were
comprised of the following categories: medicine changes, on-site psychotherapy, labs, need for another
consultant, follow-up, or other. The status of the recommendations made for each patient was tabulated based
on whether the recommendations were followed.
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Observations
The author observed ten of the consultations. All participants were informed the observations were taking
place and consent was granted. Detailed notes were taken during the teleconsultations. These notes were
used to describe the chronology of the teleconsultation.
Results
Survey Findings
The average ranking on the telepsychiatrist's appropriateness scale was 8.8. In 17 of the 43
teleconsultations, the telepsychiatrist noted he had everything he needed to conduct a teleconsultation. The
remaining consultations could have benefited from more information regarding the patient's treatment plan.
With respect to patient satisfaction, factor-based scores for information exchange and patient comfort were
summed for each dimension. The higher the score, the more satisfied or positive the patients were toward
their telemedicine consultations on a particular dimension. The means on both dimensions were above the
midpoint of the scales, indicating overall relative satisfaction with the telemedicine encounter. Results
suggested patients may have been more satisfied with the telemedicine encounter on the informational
dimension (mean of 30) than on the dimension assessing patient comfort with the technology (mean of 24).
(see Table 1). These results are similar to those found in prior studies that used the patient satisfaction scale
(Mekhjian et al., 1999).
Table 1. Patient Satisfaction: Means on Informational and Patient-Comfort Dimensions. (Note:
On both scales, the potential scores are the following: minimum=7, maximum=35,
midpoint=16).
Dimension Minimum Score Maximum Score Mean Score Standard Deviation
Information Exchange 7 35 30 5
Patient Comfort 7 35 24 4
Recommendations
The assessment of recommendations made and followed provided interesting results. Table 2 indicates the
types of recommendations (N=83) made by the telepsychiatrist and the extent to which these
recommendations were followed. Recommendations complied with included: follow-up by the telepsychiatrist
(63%), on-site psychotherapy (33%), laboratory tests (29%), consultation by another therapist (14%), or a
medication change (46%).
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Table 2. Percentage of Recommendations Followed. (N of interviews considered 43)
Recommendation Type Recommendation Made Recommendation Followed
Yes Partially No
Follow-Up appointment with psychiatrist 27 (63%) 17 (63%) 10 (37%)
Labs 7 (16%) 2 (29%) 5 (71%)
Medication Change 39 (91%) 18 (46%) 6 (15%) 5 (39%)
Onsite Pyschotherapy 3 (7%) 1 (33%) 2 (67%)
Other Consultation 7 (16%) 1 (14%) 6 (86%)
Observations
Observations of the interactions themselves revealed some of the richest and most interesting findings
regarding presence. When the telepsychiatrist entered the telemedicine consultation room, the patient was
already visible on the monitor. A typical encounter involved an initial greeting, followed by a brief discussion of
the patient's current situation, the patient's assessment of the medications he or she was taking, and a
farewell salutation. The monitor would then be turned off so the telepsychiatrist could take notes. The monitor
would be turned back on when the nurse was present and recommendations were given to the nurse regarding
the patient. The monitor was turned off again for the telepsychiatrist to review the folder of the next patient.
The monitor was then turned on when the next patient was ready for his or her teleconsultation. Various
nurses participated on different consultation dates. The telepyschiatrist never traveled to the prison hospital.
As a result, the only context available to him was the primary context and some secondary context based on
the extraneous noises he heard during the teleconsultation. (see Figure 1).
Of the ten teleconsultations observed, most adhered to the above chronology of events. However, one was
particularly unusual. It involved a female patient with a multiple personality disorder. The telepsychiatrist
believed he had established an especially close relationship with this patient and decided to hypnotize her
during the session. The patient was very excited about this possibility. During the course of the session, the
telepsychiatrist determined the patient needed the opportunity to play more. After the session, both the
therapist and patient were satisfied with the telehypnosis experience.
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The hypnosis demonstrated an extraordinary level of trust on the part of the patient in the telepsychiatrist.
Sitting in a room by herself, miles away from thephysician, a patient watching a video screen was actually
hypnotized. It also revealed the physician's' confidence in the strength of the technology's effectiveness.
However, this session also highlighted a limitation of telepsychiatry. Consistent with other sessions, the
monitor was turned off after the session for the physician to make notes. When the nurse was present, the
monitor was turned back on and the physician recommended the patient be permitted to play more. He
suggested riding a bicycle outside. The nurse was incredulous: You mean Ms. Smith?Yes, Ms. Smith,
replied the telepsychiatrist. The nurse responded: But Ms. Smith is in a wheelchair!.
The physician had never seen Ms. Smith, only an image of her on the video monitor. He did not have her
medical chart. The charts of patients were not digitized, and it was believed that delays in transmitting charts
would defeat the efficiencies of the system. The doctor's only view of Ms. Smith was her primary context.
Although he could have moved the monitor around to see various parts of the room, he in fact never did. He
developed assumptions from the primary context and his own perceptual filters to fill in the missing secondary
context. Although this isolated incident was anomalous in comparison to the other 43 interactions, it speaks
volumes regarding the role of context and the experience of presence when comparing traditional and
telemedicine interactions.
Discussion
A traditional encounter reveals many information sources. Within this case example, observations of the
hospital itself and the conditions in which patients were living were not available to the telepsychiatrist. In
addition, many aspects of the peripheral context that might have been available during a traditional encounter,
for example, impromptu meetings with nurses who knew the patients, or observations of other patients
interacting with one another were not available during telemedicine interactions. It is difficult to do a proper
comparisong of the telemedicine interaction and the traditional interaction because it is impossible to calculate
the impact of potential missed opportunities gained through access to the peripheral and secondary context.
Although patients and the telepsychiatrist seemed reasonably accepting of telemedicine technology as a
vehicle for delivering healthcare, the teleconsultation needed to be comprised of more than just the
relationship between the telepsychiatrist and the patient, or their combined attitudes towards telemedicine.
The information sources available to the telepsychiatrist were limited to information uncovered during the
patient's interview. Since patients' medical records were required to remain at the prison hospital, the
telepsychiatrist had access to an abbreviated medical record only. Introduction of electronic medical records
could facilitate the process; however, this technology was not available. Because the telepsychiatrist never
visited the prison hospital, he never developed relationships with other potential information sources (e.g.
medical doctors, psychologists, and nurses. Similarly, because the telepsychiatrist never developed
relationships with the healthcare practitioners at the prison hospital, his credibility with them may not have
been established, leading to a lack of incentive on the part of healthcare personnel to carry out
recommendations.
The results revealed that not all recommendations made by the telepsychiatrist were followed. No control
group was available through which the follow-through of recommendations could be observed in a traditional
psychiatric-patient relationship to serve as a baseline for comparison. However, the reason for the
telemedicine installation was to provide psychiatric care without the need for face-to-face consultations. The
very presence of a control group would have negated the need for telemedicine, which points to a fundamental
problem among the organizations involved. The basic problem in integrating the technology within the two
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organizations was the lack of a relationship developed between the telepsychiatrist and the prison hospital.
There was no control group to compare because he never traveled to the prison hospital itself. Both
organizations viewed the telemedicine connection as an opportunity to provide psychiatric care with little
change in the routines of either organization. The prison hospital wanted to show that they were providing
psychiatric care, and the telepyschiatrist did not want to travel to the prison hospital. Unfortunately, stressing
the initial efficiencies provided by telecommunications connections can often overlook long-term drawbacks to
efficiency created through shortcuts.
One potential explanation for lack of follow-through on the telepsychiatrist's recommendations is lack of an
established relationship between the telepyschiatrist and staff. Without an understanding of each
organization's needs and the routines for collaboration, integration might have been unlikely to occur.
However, the data is inadequate to provide firm conclusions. Another explanation might be traced to a feeling
among the healthcare practitioners at the prison hospital that the telemedicine solution was implemented
solely to address the needs of administrators. Information from these healthcare practitioners would have
been helpful in understanding the lack of follow-through.
The implementation problems were not necessarily with the prison hospital or with the telepsychiatrist. The
fault, if it can be placed anywhere, lies in the false assumption that a psychiatric relationship can be
established between a healthcare organization and a group of patients by relying solely on a
telecommunications connection. Providing healthcare requires a process that is choreographed by many
individuals. These individuals must be able to work together and collaborate; therefore, relationships must be
created and established to support this collaboration.
Warisse (1996) discussed creation of virtual organizations through the implementation of new communication
technologies. She suggested a false assumption that a telecommunications link can serve as a viable
connection to an organization may arise from a misunderstanding of virtual organizations. A
telecommunications link between two distinct organizations facilitates the creation of a new virtual
organization that can extend the boundaries of work practices past the geographic and physical boundaries of
the underlying organizations themselves. However, this link requires cooperation between individuals within
each organization to create the virtual organization and make it work. Just as a psychiatric consultation is
made up of more than the psychiatrist and the patient, so too is an effective telepsychiatric relationship.
Nurses, psychologists, and administrators all contribute to this relationship and need to be included in the
virtual organization.
The implementation of telecommunications technology provided the opportunity for healthcare providers to
understand the importance of communication processes to the healthcare encounter. By removing the
presence created by peripheral and secondary context, organizations can be made aware of the important
role that these information sources play in providing information regarding the healthcare context.
Limitations
This study provides a longitudinal exploration of one application of telepsychiatry. It did not explore
perceptions of the healthcare practitioners at the hospital, which might have improved our understanding of
why follow-up recommendations were not completed. It only assessed the telemedicine encounter from the
view of those individuals involved in the primary encounter. Additionally, it involved an implementation of
telemedicine within an inmate setting for the express purpose of avoiding face-to-face contact between the
psychiatrist and the inmate patients.
Although the environment provided a unique opportunity to study an implementation of telemedicine limited
specifically to the physician- patient encounter, thus providing an extreme example of the use of technology as
12 of 13 5/23/2014 6:13 PM
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a replacement for traditional interaction, this unique environment may influence the generalizability of the
findings. In fact, it is impossible to be certain whether the findings regarding noncompliance with the
psychiatrist's follow-up recommendations were in fact atypical and peculiar to this particular prison, or reflect
a broader problem across prison hospitals generally. However, this study raises interesting issues regarding
the role of context and healthcare practitioner relationships within telemedicine settings. Therefore, it is crucial
that further work be done to explore whether such problems are encountered in other prison contexts as well
as in other settings with both telemedicine and traditional face-to-face encounters.
Future research should continue to expand the assessment of the implementation of telemedicine outside the
primary context of physician- patient encounter. The telepsychiatry encounter must be able to include the
healthcare practitioners, family members, and information sources that contribute to and assist in the mental
health of a particular patient. Organization scholars should continue to question the information sources
provided by a new communication technology, and the information sources removed. Additionally, research
into the complications created by telecommunications connections in securing compliance gaining between
healthcare practitioners and physicians could be fruitful.
Telemedicine can provide a number of opportunities for access to mental healthcare that are not available in
some areas of the country. However, telecommunications connections must be supplemented with processes
that encourage supportive working relationships that include healthcare practitioners involved with the
physician- patient encounter. These processes can include face-to-face meetings, videoconference meetings,
and opportunities for healthcare practitioners to work together at one location so as to create a shared
understanding regarding patient care. An over-reliance upon the efficiencies provided by new communication
technologies may create a communication context surrounding the telepsychiatrist and patient unsupported by
necessary information sources from secondary and peripheral contexts. Establishing these relationships is
critical to telemedicine's success.
References
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Telepsychiatry As A Case Study of Presence - Do You Know What You Are Missing - Turner - 2001 - Journal of Computer-Mediated Co

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