Law & Psychiatry: Telecourt: The Use of Videoconferencing for Involuntary Commitment Hearings in Academic Health Centers

The Michigan Mental Health Code states that all patients deemed dangerous to self or others and for whom an involuntary admission is sought must be certified by the court as requiring treatment and that "whenever practicable, the court shall convene hearings in a hospital" ( 3 ). Before 1998 the probate court judge had convened weekly hearings at the Adult Psychiatric Hospital of the University of Michigan Medical Center, but because of changes at court, he was unable to continue the hospital hearings except under extraordinary circumstances. Patients were then required to appear in court for these hearings. Transport of psychiatric patients to the courthouse required several staff from the inpatient unit (physician, social worker, and patient care worker), who remained with the patient throughout the patient's absence from the hospital, and two officers from hospital security, who drove the patient and staff to and from the courthouse but did not stay with them between trips. Costs for salaries and loss of an average of four hours of productive time per person were great to both the hospital and the department of psychiatry.

Although cost was an important consideration, the greatest impetus for changing to a videoconferencing system involved safety concerns. Minimal security was provided to assist the clinical staff while the patients were away from the inpatient unit. Hospital security dropped patients and staff off outside the courthouse. Court security was available only within, not outside, the courtroom. Often more than one patient was brought to the courthouse, which required additional clinical staff to provide security for multiple patients. These patients were often hostile and on occasion attempted to leave the building. Over the years there had been an increase in the number of patients who eloped or attempted to escape from the care of the staff accompanying them. These were serious concerns about patient safety and hospital liability, especially as patients with more serious psychiatric illness were admitted.

Discussions began around 2000 between the hospital and probate court to develop a telecommunications link for the involuntary commitment process. The University of Michigan Medical Center's Telemedicine Resource Center calculated both the costs and savings to be realized by installing the necessary equipment. It was expected that the return on investment would be realized in the first year of operation, with savings projected through five years to be approximately $315,000.

The university hospital administration was concerned about the legality of the hospital's paying for the court's infrastructure installation. The university initially took the position, based on the Stark Law prohibition on giving equipment to a client organization, that if it were to pay for any of the cost of the court's equipment the university would view the equipment as belonging to it and that other potential users could not have access. After discussions with the hospital attorney, corporation counsel for Washtenaw County, and the state court administrative office, and because our contribution was given to the county rather than to the court, the university administration was assured that there were no violations of Stark, and discussions progressed.

Another potential problem arose when we discovered that all telecourt hearings would be video recorded, thus providing an electronic transcript. Michigan Mental Health Code requires that written permission be obtained for any photographs or videotapes of persons and that videotapes be kept as part of the patient's record and destroyed when the patient is discharged ( 4 ). These requirements became moot when the hospital's rights advisor for mental health recipients ruled that because these video transcripts were the property of the court they did not fall under the purview of the Mental Health Code.

With these potential issues resolved, both the hospital and the court moved forward with purchasing videoconferencing equipment, improving infrastructure, and developing procedures for telecommitment hearings. Several meetings were held between the leadership of the inpatient unit and court administrators to discuss call-in processes, backup systems, and other procedural issues.

All of the legal paperwork and patient-attorney meetings have continued as they had before the implementation of telecommitment hearings.

For the hearing the patient, attorney, and testifying physician are in the conference room on the psychiatry inpatient unit. Observers, including a nurse and interested students, sit in the back of the conference room. In the courtroom are the judge, prosecuting attorney, other court personnel, and any witnesses, including family, who have been asked or want to testify.

When staff are unsure or concerned about the mental state or potential reactions of the patient to the proceedings, hospital security is called to stand ready either inside the room or just outside the doors.

Because the conference room is an extension of the courtroom, all court etiquette is observed. When the judge enters, all those present in the conference room rise, as do witnesses being sworn in. Examination and cross-examination occur as they would in the courtroom.

The conference room used for the hearings has less than optimal lighting for videoconferencing, creating shadows on what is viewed on screen in the courtroom. In addition, the image often looks overexposed because of natural lighting from windows on an adjacent wall in the courtroom. We hired a lighting consultant, explored different options, and ultimately asked the court to close the window blinds, which seems to provide sufficient contrast.

The need for security coverage for the hearings is a matter of judgment. Some of the social workers tend to be more cautious than others and request security coverage when it may not be needed, but we have had instances when a security officer should have been present and was not. Social work staff now discuss the need in advance with other caregivers on the team, and if there is even the slightest concern, security support is requested.

Although the videoconferencing system at the hospital has never failed, there have been instances in which the court's system has been unable to make the digital network (ISDN) connection with the inpatient unit. Therefore, a speakerphone must be available in the conference room separate from the videoconference speaker so that the hearing can continue. Although this procedure is not optimal because the judge cannot view the patient or other participants, this backup system has been necessary a few times for hearings to proceed.

Some attorneys had been hesitant to use the new system. A somewhat unexpected issue arose with the first attorney to participate in a video hearing—the attorney would not continue until flags were brought into the conference room, arguing that it was disrespectful to the court. (The judge allowed the flags to be brought in after the hearing.) Others expressed concern that patients would not get their day in court. And some had feared that patients would be unable to relate to the unreality of a television that was "talking" to them. However, the procedure is explained to patients before their hearing, and all have seemed to understand what to expect and have not been frightened or uncomfortable with the process.

The telecourt experience has been a very valuable one for both the department of psychiatry and the university hospital. Even with a large initial outlay of funds and the coverage of expenses not directly relevant to the hospital, there has been a significant savings in staff time and productivity. Another advantage has been improved patient safety. Patient elopement has been eliminated, thereby decreasing the hospital's liability risk. Also, the safety of patients, staff, and court visitors has been greatly improved by abolishing transport from hospital to courtroom. Furthermore, because it is often difficult for psychiatric patients to maintain control in unfamiliar and upsetting situations, not having to be in the courthouse has preserved the dignity of the patient.

The experience of the University of Michigan Health System and the Washtenaw Probate Court with telecourt hearings for involuntary commitment has proven to benefit the safety and dignity of patients as well as the financial health of the medical center.

Ms. Price is affiliated with the Department of Psychiatry, University of Michigan, 1500 E. Medical Center Dr., UH9C 9151, Ann Arbor, MI 48109-0120 (e-mail: [email protected]). Dr. Sapci is with the Health System Telemedicine Resource Center, University of Michigan. Paul S. Appelbaum, M.D., is editor of this column.