The Telepsychiatry Advantage: Episode 18

The Surprisingly-Long History of Telepsychiatry (Before The Internet)

The Early History Of Telemedicine

 

Welcome back to The Telepsychiatry Advantage. I’m your host, Dr. Edward Kaftarian. What if I told you that telemedicine and telepsychiatry have been around for more than 50 years? Well, that would be an underestimation, because by some measures, telemedicine has been around for 150 years. You could trace it back to about 1875, where doctors started using the telegraph to communicate instructions to patients.

 

Now, when the telephone was invented, doctors started using that as well to communicate with their patients. And then the telephone became mainstream around the early 1900s, and so that’s when doctors really were able to communicate more regularly with their patients remotely. And why is this important, by the way? Let me take a pause here and say: why was it needed?

 

Why was telemedicine needed? Well, in the past, doctors could only provide care to patients that were located within a short distance. And we’re not even talking about when the automobile was invented—I mean, to get to a patient, the doctor had to walk or even use a horse. So we’re a bit far from those days.

 

But in those days, if a doctor was located far from the patient, you’d either have to bring the doctor to the patient, the patient to the doctor, or you wouldn’t have the patient seen. And this was a problem, especially in rural areas. And it’s still a problem. We still have a lot of patients in rural areas that are not being seen by doctors, because doctors like me—we like to live in cities, and we don’t like to live in rural areas for the most part.

 

The Beginning Of Telepsychiatry in Nebraska

 

So getting back to the history here, I would say the watershed moment—the moment where you’d say this was the birth of telemedicine, the birth of telepsychiatry—I would say it was in 1964. Okay, so what happened in 1964?

 

Actually, it happened earlier than 1964, because they started developing it in 1959. Well, it happened of all places at the University of Nebraska. So I hope I have some listeners in Nebraska that have all this dopamine firing now because I’m talking about Nebraska. I mean, how often do podcasts talk about Nebraska? I’m sure it’s a great place, but I usually fly over Nebraska—no offense! I would like to visit, though, so if you want to invite me, I’ll provide a lecture there.

 

But anyway, Nebraska was basically the most important state for developing telepsychiatry because we had a connection between the Nebraska Psychiatric Institute and the Norfolk State Hospital, located about 112 miles away. So let me ask you: who developed this program?

 

Does anybody like trivia? I love trivia, and I’m going to ask you this trivia question that you’re not going to know the answer to unless you’re really smart. Who was the person who developed this program in Nebraska? What’s her name? And yes, it’s a she. Her name is Doctor Reba Benschoter—and I apologize to her family if I pronounce the name wrong, but I think it’s Benschoter. So Reba Benschoter developed this program that allowed psychiatric consultation to happen 112 miles away from the hospital.

 

And it was used to help diagnose difficult psychiatric cases, but it was also used for other things like coaching med students, group therapy, long-term treatment of patients, case conferences, and medical education. So it was used for a lot of different purposes right out of the gate.

 

Thank you—thank you for doing that, Dr. Benschoter. Reba died actually not that long ago, on January 1st, 2023, and I saw a nice little tribute to her online. Thank you again for launching telemedicine and launching telepsychiatry. What Reba taught us was that remote psychiatric care was possible. Telemedicine can overcome geography, and we can reach people that are far away.

 

I think psychiatry is unusually well-suited for telemedicine because most of what we do is talk to the patients, and the way we diagnose mostly is by visualizing the patient and hearing the patient’s answers. Obviously, there are other parts that we need to consider with psychiatry, but telepsychiatry was one of the specialties that was most well-suited for telemedicine.

 

Some other specialties that got a quick start with telemedicine were radiology and dermatology. So these are some of the specialties that are particularly well-suited to telemedicine.

 

Logan Airport And Coining The Term “Telemedicine”

 

Okay, so when was the next major event in telemedicine history? I would say that it was in Massachusetts, at the Massachusetts General Hospital (MGH) and Logan Airport on October 4th, 1960.

 

There was a tragedy at Logan Airport. A commercial airliner that was taking off at Logan Airport struck a flock of birds and crashed into the harbor. A lot of the passengers died, but many surviving passengers survived for a short period of time and then died because they didn’t get medical care.

 

Why? Because there was a lot of traffic clogging up the streets between Logan Airport, Massachusetts General Hospital, and downtown Boston, and so patients couldn’t get to the hospital. What happened there was very tragic, and as a result, they set up a medical station at Logan Airport. But then there was another traffic-related situation that played a role in developing telemedicine.

 

In 1967, a Mass General physician, Doctor Kenneth Bird, was moonlighting as a medical director at Logan Airport. The airport is only about three and a half miles away from the hospital, but there was a lot of traffic. And so Doctor Bird had an idea to put a camera at Logan Airport so that he could examine the patients via television.

 

In fact, it was Doctor Kenneth Bird that coined the term “telemedicine.” He defined it as the practice of medicine without the usual physician-patient physical confrontation. I don’t know why he said “confrontation”—we’re not confronting our patients, we’re seeing our patients! But anyway, he set this up and coined the term telemedicine.

 

The First Boom And Early Technological Barriers

 

What about the evidence? Did anyone study the outcomes? Surprisingly, the American Journal of Psychiatry in 1973 published a study on telemedicine, and it showed that doctors and patients were both comfortable with using telemedicine and it actually led to good outcomes.

 

So we started doing research into the efficacy of telemedicine. And then in that decade, in the 1970s, it was the first telemedicine boom where government agencies, universities, hospitals, and other institutions—even NASA—started getting involved in telemedicine. Projects were launched all across rural America, inner cities, Alaska, and Puerto Rico.

 

So by the mid-to-late 1970s, there were multiple demonstrations of the effectiveness of telemedicine. But unfortunately, this boom did not result in a broader expansion of telemedicine in healthcare. Even though the concept worked, widespread adoption did not happen.

 

What were some of the reasons why? The equipment was very expensive. You needed large cameras, big computers, and microwave links—not like a microwave oven, but microwave transmission—that were very expensive. The technology was limited and wasn’t very good: connections would fail, resolution was poor, and it wasn’t clear who was going to pay for it—hospitals, governments, insurers, or patients.

 

We didn’t have a broadband infrastructure, no smartphones, and webcams were not in existence. We barely had computers at that point, and we didn’t even have the internet. So how was this going to expand? But the important thing is that telemedicine proved the concept—there was proof of concept that it could work, even before the technologies and economics could support the mass adoption of telemedicine.

 

Personal Connections And The 1990s Tech Shift

 

In the 1980s, not a whole lot happened to advance telemedicine, except for something that has a personal connection to me. My mother actually was involved in the history of telemedicine. In 1988, there was the Armenian earthquake. At that time, Armenia was a Soviet republic, so the Soviet Union worked with America—the United States—in order to develop telemedicine to help the survivors of the Armenian earthquake that killed at least 100,000 people.

 

My mother went on a flight to Moscow and worked with the government there to bring telemedicine support to the Armenian earthquake survivors who were injured and needed medical attention, and U.S. doctors were helpful to that. This was an incredible example of the United States and the USSR working together when they were sworn enemies of each other.

 

Anyway, this was another really important moment in telemedicine history that was a bright spot in the 1980s, when not a lot was happening with telemedicine and programs were no longer funded.

 

Then we had the 1990s with major technological changes: digital video, improved compression of digital signals, faster data transmission, and of course, the personal computer revolution. If anybody knows Moore’s Law, that’s the doubling of computing power every two years. Every two years, computing power doubles, and the 1990s were no exception to this.

 

And then we also had the internet! The internet—which Al Gore says he invented, but I don’t think he did—gave us an opportunity to communicate with each other online. Telepsychiatry now became a particularly important part of telemedicine because we started to see that rural communities could be served, several clinics could serve multiple communities across a large geographic area, and doctors could serve emergency departments remotely. They could do evaluations and consultations, and then correctional systems started to implement telepsychiatry.

 

Data, Regulations, And The Ryan Haight Act Become Holdups

 

Now in the 2000s, that’s where we started to gather more data. The shift was from “Can this be done?” to “Is it safe? Do patients like it? Do doctors like it?” I told you about a study in the ’70s from the American Journal of Psychiatry that talked about the efficacy of telemedicine, but now in the 2000s, there was more data and more studies.

 

Shout out to some of the names: Don Hilty, Peter Yellowlees, and my friend Robert Caudill from the University of Louisville. These were people that started to really study telepsychiatry. The American Telemedicine Association was born, and so there was this great collection of minds that talked about the importance of telemedicine and telepsychiatry. We started to share—I remember in the early days we used to share information about what worked and what didn’t work. It was an exciting time, and I’m fortunate that I was able to be part of it. As early as the late 2000s, I started to become involved in the American Telemedicine Association and the psychiatry section of that association.

 

In the 2010s, the technology was ready. We had really good smartphones that could transmit video calls—FaceTime started to become very popular—and internet connectivity improved. Me and my friends started doing more and more research on the efficacy of telemedicine. So the barriers had changed: the problem was no longer “Does the technology work?” Now we were talking about regulations like licensure.

 

And get ready, guys, because regulations are the most interesting topic—okay, maybe not, but that was the big problem, and it continues to be a problem. Licensure, reimbursement, privacy laws, and institutional policies—those regulations were falling behind the times. Just like technology was falling behind decades earlier, now regulations were falling behind.

 

One of the major problems is the Ryan Haight Act. If you haven’t heard the episode, go back—I have a four-part series on the Ryan Haight Act. The Ryan Haight Act was where the practice of telemedicine collided with regulations in a really impactful way, because it prohibited the prescribing of controlled substances unless you had an in-person visit. There were some telemedicine exceptions that I’ve talked about in past episodes, but the exceptions are not enough. We’re still falling behind. We’re waiting for the DEA to come up with their special registration process, but regulations currently are what is holding us back from broader adoption of telemedicine.

 

The Pandemic Boom And Beyond

 

But then there was the COVID-19 pandemic. The first great boom of telemedicine was in the 1960s and ’70s, but I would say the second big boom—the biggest boom so far—was the COVID-19 pandemic. This really established that there’s no way to provide care to patients without using telemedicine, because we couldn’t get together. There were people that needed to see doctors and they couldn’t because of the pandemic. We were afraid to even go to the hospital, the drugstore, or anywhere.

 

Remember when you couldn’t go anywhere? We had a massive problem with healthcare delivering to the needs of patients. In what was a very dramatic and amazing period of history in our country and healthcare, we moved very quickly to telemedicine. It was a huge boom, and it was the biggest experiment in history to see how we were going to see patients remotely.

 

Then people started to see that, “Oh wow, this telemedicine thing—it’s not just for COVID. It’s just better! You don’t have to go anywhere; you can see the doctor from your own home. It’s so convenient, and you can do follow-up appointments.” Doctors and patients discovered that this worked extremely well, and many of us haven’t gone back to in-person. We just thought, “What’s the point of going back to in-person when this is just a lot better?”

 

So what happened after COVID? Well, telepsychiatry started to grow up. We started to see a more sophisticated delivery of healthcare via telemedicine. The technology has become more secure, the protocols have become more deliberate, and everybody understands it now.

 

I remember when I developed the telepsychiatry program for the California prison system—I started developing it around 2009, and nobody even knew the word “telemedicine.” When I would talk to people and say that I was in the field of telemedicine and telepsychiatry, even doctors didn’t know that term. But now we all know that term; it’s part of the lexicon. It’s amazing how far we’ve come in such a short period of time. Even in the last 15 years, there’s been a complete transformation.

 

Where We’ve Been And Where It’s Going 

 

When I think back to this amazing journey that I’ve been on, there are some moments that are just burned in my brain—like when I went to China to see their telemedicine setup in 2014. There was a contingent of people from the American Telemedicine Association, and we went to China to see what they were doing over there.

 

On the way back on the plane, I was sitting next to the CEO of the American Telemedicine Association, and we were talking about telemedicine and how we were so excited about what the future would hold. He was telling me that the word “telemedicine” is not even going to be used in the future, because there’s going to be no distinction between telemedicine and medicine. Telemedicine, after all, is just a tool—it’s a way that we deliver care. As it blends into healthcare, the word telemedicine will no longer be necessary, because everyone will already know that technology and remote visits are part of healthcare.

 

What are some take-home points here? The lesson here is that technology is rarely the real barrier. For decades, telemedicine improved as the technology improved, but adoption was slow because there were other barriers that were bigger: regulation, reimbursement, licensure, and just resistance from people.

 

I remember when I was giving a lecture at a University of California hospital—I’m not going to say which one, I don’t want to throw them under the bus—and I got a lot of resistance about telepsychiatry. They were saying that you can’t establish rapport and you can’t get really important information through a telepsychiatry visit. And that was in the mid-2010s! When we resist technology and resist the future, the future comes anyway, and we have to adopt it faster in order to reap the rewards.

 

A lot of you right now are thinking about AI, and we’re really concerned about AI and how it’s going to change the future. But we need to adopt technology, because every time we’ve failed to really advance with technology, we’ve just delayed the inevitable. That’s probably the biggest lesson: technology is not the barrier; we need to get through some of the other bigger barriers.

 

Another thing that we should be mindful of is that even though telemedicine has helped to some degree solve the geographical problems that we have with healthcare, it hasn’t solved them all. Licensure is still geographic: I have a medical license in California, but I can’t practice in every single state. There are lots of political and financial reasons for this with medical boards controlling the licensure of doctors, and that’s a problem.

 

Regulations are still a problem when we talk about Ryan Haight and other regulations that limit our ability to provide care to patients. Lots of our patients are still located in rural areas, and they’re still not getting the care they need. We have to burst through these barriers to provide lifesaving care to patients.

 

Another thing to keep in mind is that convenience is not the same thing as quality. Yes, telepsychiatry is convenient, but we need to make it a quality experience for the patient. We need to make sure that the care that we’re providing is high quality.

 

How are we going to do this? Everyone needs to listen to The Telepsychiatry Advantage, because I’m going to tell you how to provide quality care to patients.

 

With that, thank you so much for listening. And until next time, keep raising the standard.

 

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