"How are you doing today?"

"Could be doing better," her patient replied. "I've been having some personal problems. Not sleeping."

The 52-year-old woman has depression. She hadn't been taking her medication for two or three days. It made her too drowsy.

The exchange didn't happen in the psychiatrist's office. Patalinjug Tyner was in a conference room at Process Strategies in Charleston. She faced a 32-inch computer screen with a Web camera perched on top.

The patient was at Prestera Center's office on Main Street in Clay. She sat in a small room with a television screen - 50 miles away from her doctor, up a stretch of interstate and miles of winding rural roads.

Telemedicine like this uses videoconferencing technology to connect doctors with patients over long distances. Process Strategies, a sister company of Highland Hospital, has been using it for about seven years, Highland CEO Dave McWatters said.

"It all developed out of a shortage of psychiatrists," he said. "West Virginia is not seen favorably by folks that want to live in urban communities, so it's tough to get [psychiatrists] even to interview here."

Many people in Clay - a town of about 560 people - couldn't see a doctor if it weren't for the technology, said Patalinjug Tyner's patient, who didn't want her name used. 

"We really are lacking in medical help here," she said. "There's a lot of people around here without transportation, period."

'Behind the times' 

McWatters and other behavioral health-care providers say they could do more if the state approved Medicaid reimbursements for more telemedicine services.

In West Virginia, only psychiatrists, physician assistants and nurse practitioners can get Medicaid payments for telemedicine services. Psychologists, social workers and other's can't. The state Medicaid office pays for two services: psychiatric intake evaluations and medication management visits.

"West Virginia is very behind the times in approving services in telemedicine," McWatters said.

He wants to use the equipment to connect rural West Virginians with services like family therapy and substance-abuse counseling, but the state doesn't pay for that.

In 2003, West Virginia University's medical school got a federal grant to equip 14 community mental-health services with telemedicine technology, said Mike Mays, chief executive officer of FMRS Health Systems.

The equipment was state-of-the-art, he said, but many centers couldn't afford to keep it up, because they could only be paid for two services.

"It's been very frustrating that it's sat around all these years with limited utilization," Mays said.

In a hearing last month, Kanawha Circuit Judge Duke Bloom questioned the state Department of Health and Human Resources' limits on telemedicine payments. It was one of a series of hearings that examined the state's services to people with mental illness.

DHHR spokesman John Law declined to comment on the state's telemedicine policy, saying it's a pending court matter.

An agreement on telemedicine likely will be released next week, said attorney Jennifer Wagner of Mountain State Justice, one of the petitioning parties in the DHHR case.

Doctors acknowledge that the technology has some drawbacks.

Sometimes, technical glitches interrupt sessions, said Patalinjug Tyner.

Some patients are wary of telemedicine at first, "but eventually they sort of forget that they're on camera with me," she said.

She's had two patients who had to stop using it. One had paranoid delusions, and the other had severe anxiety. 

She sees about 15 patients a day on her telemedicine days, people with depression, anxiety, schizophrenia, bipolar disorders and other illnesses.

For the most part, she can observe all the cues she would in a regular, face-to-face session. She can see an anxious patient's fidgeting. She can watch the patient's facial expressions, posture and speech patterns.

"It's really a matter of tuning in," she said, "zeroing in on what you're looking for."

'It's different'

Psychiatrists first used telemedicine 50 years ago at the University of Nebraska, said Dr. Don Hilty, a psychiatry professor and telepsychiatry expert at the University of California, Davis.

Soon after, the doctors used a two-way, closed-circuit television to connect the Nebraska Psychiatric Institute with the Norfolk State Hospital.

Since then, psychiatrists have used it in jails, war zones and nursing homes, among other locations.

"It's been used virtually in any population in almost any setting," Hilty said. 

Telemedicine programs flourished in the 1990s, thanks to federal grants, he said. In many areas, though, health-care providers didn't have the research background to collect data that showed the impact of the programs, so they didn't receive further funds.

Medicaid reimbursement policies vary by state, and many states are picky about what they pay for, Hilty said.

He believes the technology empowers people. Eventually, patients might be able to "shop" around the Internet to connect with the best medical specialists in the country, Hilty said. Differences in state licensing laws now hamper that ability.

For now, Patalinjug Tyner's patient in Clay said her appointments help her cope with daily difficulties more calmly.

When she began her sessions, "I was very deeply depressed.

"I was so bad, you couldn't look at me without me crying," she said. "I cried all the time."

She doesn't mind that she can't sit face-to-face with Patalinjug Tyner, she said.

"It's different, but I have no problem with it," she said. "She's helped me a lot."

Reach Alison Knezevich  at alis...@wvgazette.com  or 304-348-1240.