Telepsychiatry as a Case Study of Presence: Do You Know What You Are Missing?

Authors

  • Jeanine Warisse Turner

    Corresponding author
    1. Assistant Professor at the McDonough School of Business and Adjunct Research Assistant Professor at the School of Medicine at Georgetown University. She received her PhD from Ohio State University. Her research explores the human factors and management issues involved in the assimilation of new communication technology within organizations. Her publications and presentations span various technologies and are based in her applied experience. She has published and presented papers related to telemedicine and distance education at over 30 conferences nationally and internationally.
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Address: The McDonough School of Business, Georgetwon University, G-04 Old North, Washington, DC 20057. Phone: 202-687-6927 FAX: 202-687-4031.

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 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.

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 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 (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).

Figure 1.

Figure 1.

Presence Offered by Telemedicine Interactions Versus Presence Offered in Traditional Settings

Figure 1.

Figure 1.

Presence Offered by Telemedicine Interactions Versus Presence Offered in Traditional Settings

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 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 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 1–10 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.

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).
DimensionMinimum ScoreMaximum ScoreMean ScoreStandard Deviation
Information Exchange735305
Patient Comfort735244

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%).

Table 2.  Percentage of Recommendations Followed. (N of interviews considered 43)
Recommendation TypeRecommendation MadeRecommendation Followed
  YesPartiallyNo
Follow-Up appointment with psychiatrist27 (63%)17 (63%) 10 (37%)
Labs7 (16%)2 (29%) 5 (71%)
Medication Change39 (91%)18 (46%)6 (15%)5 (39%)
Onsite Pyschotherapy3 (7%)1 (33%) 2 (67%)
Other Consultation7 (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.

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 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 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.

Ancillary