Experience With a Rural Telepsychiatry Clinic for Children and Adolescents

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.

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.

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.

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]).