Experience With a Rural Telepsychiatry Clinic for Children and Adolescents

Access to medical specialty services, particularly psychiatric services for children and adolescents, is not readily available in many rural areas. In Kansas many underserved areas have no trained adolescent and child psychiatrists, and families in these areas may have to drive hundreds of miles to see a child psychiatrist.

Telepsychiatry clinics offer one solution to the problems associated with providing mental health services to rural areas (1,2,3,4,5). In 1991 a comprehensive telemedicine program was initiated by the University of Kansas Medical Center to meet the medical needs of rural Kansans. The program's psychiatry component includes medical evaluation for adults with chronic psychiatric illness, consultation for prison populations, and several child and adolescent clinics.

The program's most active child and adolescent telepsychiatry clinic is a collaborative effort between the medical center and the Crawford County Mental Health Center in Pittsburg, Kansas, located 120 miles away. Begun in 1996, the clinic receives between ten and 18 visits each week, and the program has logged more than 400 hours of clinic time and more than 1,000 visits in its first two years. The clinic has proven to be an effective model for providing child psychiatric services to an underserved area. This paper describes the procedure used for the clinic visits and discusses several lessons for telepsychiatry suggested by experience with this service.

The telepsychiatry clinic

The Pittsburg telepsychiatry clinic functions much like the traditional face-to-face clinic. All of the children and adolescents seen in the clinic are patients at the mental health center. The mental health center staff determine which patients will be seen by the psychiatrist using the telepsychiatry system, and the center contracts with a psychiatrist at the medical center on an hourly basis for the telepsychiatry services.

The patients are screened and assessed by mental health center staff before the first visit with the psychiatrist. Patient information, including notes on assessments and therapy carried out by the mental health center staff, school records, medical records, results of rating scales administered by school staff or mental health center staff, and a parental assessment of current functioning, are mailed to the psychiatrist a week before the visit for review before the child is seen. If an emergency appointment is needed, the pertinent information is faxed to the psychiatrist. Mental health center nurses are responsible for making the appointment for the clinic visit, doing a physical assessment of the patient before the clinic visit, remaining with the patient and family members during the clinic visit, and implementing the psychiatrist's recommendations.

Patients new to the child telepsychiatry clinic and their families are asked to arrive early for their first clinic visit to allow time for orientation to the clinic's operations. They receive an information sheet that introduces and describes the clinic operations and addresses common concerns, such as confidentiality. Patients are shown the equipment and how it operates before the first visit.

The telepsychiatry clinics at the medical center initially operated on wide-bandwidth (384 kbps) room-based systems, but the child and adolescent clinic uses lower-bandwidth (128 kbps) personal-computer equipment that is much cheaper and easier to operate, although it does provide somewhat lower-quality images. Both the psychiatry department at the medical center and the remote site in Pittsburg have dedicated personal computers with ISDN connections running at 128 kbps that provide an image at 15 frames per second. Both sites currently use videoconferencing software and low-cost cameras.

At the medical center the computer is located in a room that is dedicated for use in telepsychiatry; the color of the paint on the walls and the lighting were selected to maximize the quality of the transmission. The physician who conducts the interview sits facing the computer screen and camera.

Initial evaluations last 45 to 50 minutes. The parents and children are interviewed separately. Follow-up visits typically last 15 to 30 minutes. The clinic nurses usually sit with patients during the interviews. Medication orders, orders for laboratory tests, and other requests are faxed to the mental health center immediately after the clinic visit. Schedule II drugs, such as methylphenidate, are mailed to the mental health center and distributed by the nurses.

Lessons for telepsychiatry

Two years' experience with the Pittsburg child and adolescent telepsychiatry clinic suggests that clinicians, children, and families quickly adjust to the new technology and become relaxed and comfortable with this method of providing service. Other lessons from experience with the program are discussed below.

Severely disturbed children can be adequately assessed and treated.

The team approach used for this clinic lends itself well to the management of complicated child psychiatric problems. Many times the visit with a patient resembles a multidisciplinary team meeting that includes the therapist, case manager, crisis worker, and others involved with the care of the child present.

Children in crisis can be safely assessed and treated.

The telepsychiatry clinic has at least one emergency unscheduled appointment every two weeks. The range of patients in crisis served by the clinic includes children who have disclosed significant abuse during the interview, patients who are depressed and suicidal, and children whose behavior is aggressive and out of control. In all cases, it has been possible to appropriately contain the behavior, de-escalate the emotion, and come up with useful solutions.

The range of expressed emotion and the quality of clinical interactions appear similar in telepsychiatry and face-to-face interactions.

However, a more objective measurement of possible differences is needed. A subtle difference that has emerged is that telepsychiatry interviews are often more efficient than face-to-face interviews. The same amount of clinically relevant information is usually discussed in a shorter period of time in the telepsychiatry clinic. Another difference—and a possible explanation for the seemingly increased efficiency—is that both the patient and the psychiatrist appear to focus more on the interview during the telepsychiatry clinic.

Clinic, physician, and patient preparation are important.

The characteristics of the teleconferencing software and camera are important in producing lifelike images, but room characteristics are probably more important. The clinic room should be carefully chosen. A quiet, well-lit space, preferably without windows, is needed.

The equipment and ISDN lines used to transmit the information have been reliable.

Activating the clinic equipment is almost as easy as making a phone call. For clinicians, only a basic knowledge of common computer software is needed to begin planning the system. Knowledgeable technical assistance is needed in setting up the system and during the early stages of operation. After the telepsychiatry clinic is set up, it can be used by almost anyone.

The importance of teamwork between sites cannot be overemphasized.

Preliminary meetings and continual problem-solving discussions between the professional staff at the two sites are essential. The team approach extends beyond the mental health team personnel. Primary care physicians in the rural community refer patients to the clinic and are grateful for the help of the psychiatrist. The child telepsychiatry clinic also works with personnel from the local schools and juvenile justice programs. Meetings with representatives of these community groups over interactive television help to foster a spirit of understanding and teamwork.

Conclusions

Experience with a child and adolescent telepsychiatry clinic operated by the University of Kansas Medical Center strongly suggests that the psychiatric needs of rural children can be safely and reliably met in such clinics. Surveys done by the telepsychiatry program and other published reports indicate a high degree of patient satisfaction with child telepsychiatry clinics as well as with other telemedicine clinics, regardless of the bandwidth of the equipment being used (6,7). The children's symptoms improve with interventions done through telepsychiatry, just as they improve with face-to-face clinical interactions. The program has allowed many children at risk for hospitalization far from their families and other support systems to remain in their communities .

Many questions are still unanswered about this new way of serving children and adolescents who live in rural areas. Further study is currently under way at the medical center. However, more than seven years of experience with the medical center's telemedicine program suggests that telepsychiatry clinics appear poised to revolutionize the way rural psychiatric services are provided to children and adolescents. Interactive teleconferencing may also be useful in providing specialty care to all children and adolescents with behavioral, emotional, and social problems, regardless of where they live.

Acknowledgments

The author thanks Elizabeth Penick, Ph.D., and Pamela Whitten, Ph.D.

Dr. Ermer is clinical assistant professor in the department of psychiatry and behavioral sciences at the University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, Kansas 66160 (e-mail, [email protected]).