Although American Indians make up less than 2% of the US population, certain individuals of this extremely diverse ethnic group may be a significant target market for telemedicine interventions.

Researchers from different universities recently published an article summarizing their experiences offering this group of Americans telemental health services for over a decade.

The researchers summarized the lessons learned from a decade of published research articles on the effectiveness of telemental health services. They found that not only costs were lower and utlilization higher, the subjects actually had a stronger sense of privacy using telemental services than rural clinics. Of course, there were also challenges.

Unique Military Service and Health Needs of American Indian Veterans

The researchers of the study pointed out a little known fact in this article. American Indians serve in the US Armed forces at a rate higher than any other ethnic group. As a result, this demographic group has a unique set of health care needs related to their service. Their health care needs include disproportionate rates of post traumatic stress disorder and alcohol/drug dependence.

More Rural Than Most Veterans

In addition to the unique health care needs of these military veterans, they also live in some of the most rural areas of the country. They also live in the most rural areas of any American veterans, with over half living in tribal regions in thes rural areas. Like other rural locations, these regions face a variety of challenges which stem from their inability to attract health care personnel. This factor impacts access to care, cultural competency of providers, and the funding of health care institutions in rural areas.

Need for a Telemedicine Solution

The combination of disproportionate frequency of military service, impact of the service on health status, and geography created the need for a telemedicine solution to help these American heroes live healthier lives. The US Department of Veteran Affairs and the University of Colorado Denver’s Centers for American Indian and Alaska Native Health responded to this unique need in 2001 with the creation of American Indian Telehealth Clinics. The goal of the clinics was simply stated, but tremendously difficult to achieve: to improve the mental healthcare of rural American Indian veterans with community based, telemental health services.


The intervention entailed VA-credentialed psychiatrists in Denver providing telemental health services to patients on rural reservations. The providers were trained to be culturally competent including training focused on the particular tribe they were working with. Patients received telemental health services weekly or bimonthly. Most services that could be offered in person were offered from afar including diagnosing of disease, case management, ordering diagnostic tests, and treatment. Even medications were prescribed from afar and mailed to patients.

The VA’s electronic medical records system helped providers offer a wide range of services to patients. Tribal/Telehealth Outreach Workers helped providers and staff interact with patients in a culturally competent manner. Tribal Veterans Representative helped patients identify all the VA benefits that applied to them. The clinics also developed collaborative relationships with traditional healers in order to offer patients this option if they preferred it over a non-traditional, allopathic provider.

Key Findings/Lessons

Researchers summarized key findings and lessons from prior studies into two major categories: administrative and clinical. The key administrative lesson was that multi-organization collaborations were required in order to provide care to special populations in remote environments. There were a number of clinical findings. One of the most important is that telemental health services were similar to face to face psychiatric services indicating that this modality of care is useful. Another lesson was that the costs of telemental health were less expensive than in-person interviews. Researchers indicated that more cost studies were needed to support or oppose this point.

Also, some patients perceived telemental health services as more confidential than seeking care in their small communities. Patients also had an increased feeling of personal space/safety. Prior studies also indicated that the reliability of diagnosis made remotely was similar to that made face to face. Utilization of health care services also increased for those using the telemental health services.

Prior work revealed a number of problems that researchers label as liabilities. One is that the lack of a physical presence can impact rapport with some patients. This is particularly important for American Indian veterans who may already be wary of government sponsored treatment according to the researchers. Distance can make some diagnosis more difficult to determine, namely those which are internalized, such as depression.

Potential Lessons for Rural Populations – Vets and Non-Vets

Overall, telemental health services are useful for American Indian veterans living in rural areas. Other rural populations can benefit from the decade of experience of the researchers as well. Their dedication to designing a program that was culturally competent and designed to fit within unique communities instead of opposing communities helped the interventions work. As the researchers indicate, this approach is a best practice method which can inform telemental health work in other settings throughout the US.