Child Telemental Health and Handling Emergencies: Ethical Issues in Delivering Pediatric Telehealth in Your Community
This is the last of our series of articles highlighting topics explored at the Telehealth Summit 2012. Today’s article will focus on a pediatric program located at the University of Kansas Center for Telemedicine and Telehealth (KUCTT) and as discussed by Dr. Eve-Lynn Nelson, who not only works directly with children, but also is the Director of Research, Institute for Community Engagement at the University of Kansas Medical Center. KUCTT has been delivering telemental health services for over 20 years. Currently it treats about 1500 patients each year. They use point-to-point encrypted video conferencing with the provider located at KUCTT while the patient goes to a distant site such as a school, rural health clinic or health education center. The patient’s experience is facilitated by a trained coordinator, generally a nurse, at the distant site. This traditional telehealth model provides a practical balance for managing logistics and ensuring the patient’s safety while allowing expanded access to quality mental health services regardless of the patient’s locale.
Provision of telemental health services requires a unique set of competencies. Of course practitioners must have the same general clinical skills they use in face-to-face settings. Comfort with technology and the ability to handle the inevitable problems that arise when using technology are also core competencies. Cultural sensitivity to geographic differences, rural vs urban issues and language barriers must also be addressed when reaching out to distant populations.
Video-conferencing appears to be practical and effective when used in pediatric treatment. Kids love to see themselves on-screen and they tend to be very comfortable with technology. Research shows a high degree of patient satisfaction although good quality outcome research using randomized trials for pediatric telemental health care is still lacking. More data is currently available for adult based telemental health service outcomes and this data is very favorable. For now, it is necessary to use our best clinical judgment based on available research to inform our practice, which is really no different from how we inform our in-person service delivery.
KUCTT uses the same intake packet for on-site and distant treatment. Prior to the visit, the patient and their family complete a standard informed consent document that has a few additional sentences specific to telemedicine. They use the same HIPAA privacy form, the same history form and the same questionnaires. The same patient registration process is used and billing procedures are identical except for use of the GT-billing modifier that designates telemedical service delivery.
Most of KUCTT’s referrals come by word-of-mouth or from rural clinics and schools that participate in the program as distant treatment sites. Because rural areas are generally underserved, cases seen at KUCTT tend to be more complicated than those seen face to face. Patients also often present later in their illness trajectory than in areas with better access. KUCTT treats children with behavior disorders such as ADHD and ODD, as well as mood disorders, anxiety disorders and adjustment reactions. Since providers are usually interacting with more complicated patients than those they see in more traditional settings, scheduling and treatment planning considerations specific to these populations must be taken into account. The same kinds of safeguards used on-site must be adapted to the telehealth setting. Staff at the distant site must be trained to handle emergencies and a detailed emergency protocol must be in place.
In addition to training in emergency protocols, staff at the distant site must have solid training in technology and confidentiality issues.
Technology presents a unique set of confidentiality issues. The room where the patient is located must be private, quiet and free from distractions and interruptions. Children must be socialized to the idea of using technology as a clinical interaction rather than a social one. The room where treatment takes place must be conceptualized as a clinical space, even if it’s in a school or other non-traditional setting.
Before serving a distant community, it is recommended that practitioners visit that community in person. It’s important to talk with people in the community that you’re planning to serve to understand their needs and local resources. This dialog will also alert you to what resources are not locally available so prior arrangements to accommodate these referral and resource needs can be made proactively.
There are many resources available to help clinicians who want to set up a pediatric telemental health practice like KUCTT’s. The American Academy of Child and Adolescent Psychiatry’s telepsychiatry subgroup has published an excellent set of telemedicine guidelines. The American Telemedicine Association’s Telemental Health Special Interest Group has developed both a short practical guidelines document and a longer evidence-based guidelines document. Federally funded regional Telehealth Resource Centers can also provide valuable guidance regarding telemental health start-up.