Christine Kearsley contributed to this article.
In Durham, North Carolina, the child psychiatrist comes to the classroom. By telehealth. For the past eight years, Duke University Medical Center has teamed up with Durham Public Schools to export child psychiatry to where the kids are. Duke fellows in child psychiatry travel to three elementary schools and one upper-school site to offer in-person mental health services to children with diagnosed mental health disorders. To supervise the fellows, the attending physician conferences in. As Dr. Richard D'Alli, the leader of the program, explains, supervising the fellows by telehealth has opened a world of possibility.
Why supervise by telehealth?
The major advantage of supervising by telehealth is clear; it lets the attending "be in three places at once." In this case, Durham community partners have set up self-contained therapeutic classrooms embedded in ordinary schools, which enable children with acute needs to continue their academic progress alongside their peers. These classrooms bring together more than seventy students with special-ed qualified teachers, counselors, case managers, and family members. The Duke psychiatry fellows visit once a week to offer evidence-based cognitive therapy, behavioral therapy, and on-site medication management. Telehealth lets the attending psychiatrist be present to supervise and offer advice without having to travel to the multiple sites. If problems arise in the middle of the week, it is as easy as a phone call to dial up the doctor. Plus, the kids love it; "my doctor's on TV!" As Dr. D'Alli observes, psychiatry is all about the face-to-face encounter. Telehealth makes that encounter possible, even at a distance.
The legal how
To move the telehealth project off the ground, Duke had to work through the legal how. That legal how involved ensuring valid supervision, establishing contracts, and finding the proper technology.
For ensuring valid supervision, the basic rules are simple. If a trainee is practicing off a medical campus, an attending supervisor must be present. With sites at four schools, though, bringing in a busy attending would be no small task. To overcome this hurdle, the Duke project leaders conferred with the Accreditation Council for Graduate Medical Education, the Duke risk management team, and other stakeholders. Would telehealth supervision of fellows be equivalent to in-person supervision? "To my surprise, shock, and delight," Dr. D'Alli relates, the answer was "Yes!"
Contracts were another key piece of the legal picture. First, the Duke Departments of Psychiatry and Pediatrics developed a training letter of agreement with Durham Public Schools, to establish the classrooms as their official training sites. Second, Duke University Medical Center entered into a contract with Durham Public Schools for flat-rate, hourly compensation for services rendered, opting out of the more complicated billing arrangements that are sometimes common in telehealth. Third, Duke signed agreements with each child and family served, making the children official Duke patients that the fellows and attending physicians had the right to treat.
The final ingredient in the legal picture was the technology itself. In medical consults, and particularly in mental health, the confidentiality of health information takes on greater significance. To protect the information, the Duke telepsychiatry program uses encrypted teleconference technology, so that the students' health information is secure in transmission. Duke doctors do not record or otherwise store the video consults. They keep the medical records in Duke's electronic medical record system, rather than at the schools. Through all these precautions, Duke can help keep the students' medical information safe. From supervision to the use of secure technology, Duke and the Durham Public Schools seem to have found a way to make the initiative work.
Looking Back, Looking Forward
Looking back on the project over the years, Dr. D'Alli's advice for others is to embrace telehealth technology: "As medicine evolves, we are being asked to serve more and more people with less and less, and telehealth is a fantastic example of efficient, effective delivery of medical care versus brick-and-mortar, traditional centers." Telehealth can improve "not just efficiency, but outreach."
In fact, telepsychiatry has helped mental health professionals improve outreach since 1959, when the University of Nebraska School of Medicine wanted to connect patients a hundred miles away with psychiatric care. At that point, the work involved a rudimentary, closed-circuit television interface. Fortunately, technology has evolved over time. Today, the interface is so good that a doctor can spot a subtle side effect of a psychotropic medication or a tic that might be caused by an ADHD medication. Through this new technology, the Duke-Durham telepsychiatry project brings care to kids in their very own classrooms, where they can sit side-by-side with their teachers, parents, and the visiting fellows. Telepsychiatry may be an old model, but the initiative in Durham is demonstrating new possibilities for it every day.