Telepsychiatry and Technology Applications
Telepsychiatry funded studies
The UC Davis Center for Health and Technology (CHT) was founded in 1999 by Thomas S. Nesbitt, M.D. as part of the University's outreach to rural areas. The program provides video consultations in 30 specialties to approximately 80 rural sites, particularly dermatology and psychiatry. The CHT has received funding from the National Institutes of Health, Office of Rural Utilities, Office for the Advancement of Technology, California Endowment, and other non-profit grant foundations.
Telepsychiatry at UC Davis began under the direction of Don Hilty, M.D. in 1995 and to date over 2,000 video consultations have been completed to 50 rural sites. A consultation care model is used, whereby the psychiatrist evaluates the patient and offers suggestions to the primary care physician (PCP) regarding the delivery of mental health services. Psychiatry faculty, fellows, and residents consult on adult, child, and geriatric patients. Clinical care is a well-liked educational experience for trainees. The faculty research satisfaction, models of service delivery, and outcomes of telepsychiatry versus usual care. In addition, a pilot project is providing culturally sensitive care to patients and is surveying needs for such care in rural areas.
Model 1: Randomized controlled trial (RCT) for depression in adults
A RCT funded by an early career grant from UC Davis, compared depression outcomes at 10 rural sites. Self-report and structured psychiatric interviews were used for screening. Subjects were randomized to: 1) usual care with a disease management module (DMM) using telephone and self-report questionnaires; or 2) a DMM using telephone, questionnaires, and repeated televideo psychiatric consultation coupled with training of the PCP. There was significant clinical improvement for depression in both groups at 12-month follow-up, with a trend toward significance in the more intensive module. Satisfaction and retention were statistically superior in the intensive group; no difference was found in health status.
Model 2: Formal, multi-specialty phone and email physician-to-physician consultation system regarding adults and children with developmental disabilities
The UC Davis Health System and California Department of Developmental Services (CDDS) developed the Physician Assistance, Consultation and Training Network (PACT Net) to assist PCPs' treatment of patients with developmental disabilities (e.g., autism) in rural California. PACT Net was a 24-hour warm-line by design and was funded from CDDS at approximately $450,000 over three years. Data were collected on 30 consultations: 28 by telephone and 2 by e-mail. The average duration of consultation was 47 minutes, and 24 responses occurred within one business day. The top three services requested for consultation were psychiatry (e.g., management of behavioral disturbance), medical genetics (e.g., diagnosis), and gastroenterology. PCPs rated satisfaction on a 7-point Likert scale: 1) pre-existing local services at 3.37; 2) timeliness of the PACT Net consultation at 5.45; 3) quality of the communication at 6.3; and 4) overall quality and utility of the consultation at 6.2. Specialists rated the quality of the communication at 6.45 and the ease of the service at 6.46. These ratings demonstrated that phone and e-mail consultation is a satisfactory method to provide specialty consultation to rural patients.
Model 3: An integrated program of mental health screening, therapy on-site, and telepsychiatric consultation to rural primary care
The UC Davis Health System and Northern Sierra Rural health Network collaborated to develop a program for rural Northeastern California, funded by the California Endowment. Over a three-year period, 10 rural sites learned how to utilize screening instruments for multiple disorders (e.g., depression, alcoholism, and anxiety disorders) and collect basic outcome measures for depression at regular intervals, in concert with telepsychiatric consultations and on site therapy visits. Continuing medical education (CME) was provided annually for PCPs and other providers. This grant paid for 25% time for a therapist on-site and planning meetings between rural primary and mental health care staff. Outcomes being measured at present include patient depression and PCP knowledge. System problems are being identified to inform policy.
Model 4: Use of videoconferencing, secure e-mail, and phone consultation to adults and children in rural California
The UC Davis Center for Health and Technology received a $250,000 grant from the California Center for e-health and Technology to provide telepsychiatry and telepsychology service to 10 rural primary care clinics over a 1-year period. The overall goals of this project are to: 1) increase consultations by at least 70%; 2) integrate the consultations into the UC Davis psychiatric consultation-liaison service for long-term sustainability; and 3) assist the PCP with triage of cases. An implicit goal of this project is to shift the method of consultation for PCPs from the more time consuming videoconferencing patient consultation to the more efficient and less time consuming e-mail and telephone consultation. Preliminary results show that the number of consultations this year increased by 120% versus the previous year. While PCPs were initially slow to use the secure e-mail, there has been gradual improvement through the program's intervention.
Model 5: Response to disasters like a bioterrorism attack
The literature on disaster response is replete with examples of rapidly set-up debriefing programs with limited success following sudden environmental or man-made disasters. Such programs generally involve pre-trained mental health professionals who receive mentoring and support from more experienced colleagues depending on availability. Now, plans for potentially widespread disaster scenarios via bioterrorism are in the works, which would involve substantial trauma related issues and public panic related to the risk of infection. In this event, PCPs will need help in rural areas, both from psychiatrists and other physicians. It will be best delivered electronically via the Internet in short courses using "just-in-time training" approaches.
Cross-cultural store and forward telepsychiatry
This project is designed to assess whether psychiatrists can accurately diagnose patients and create treatment plans when supplied with carefully formatted electronic histories and video clips of patient interviews with their primary care providers. The patients are clinically assessed in both English and Spanish, with cross-translation by trained interpreters, allowing us to also measure diagnostic reliability across languages, as well as between psychiatrists. The two-year project is funded by Blue Shield and commenced in July 2007.
Virtual reality environments
Principal Investigator: Peter Yellowlees, M.D.
Virtual reality environments have developed rapidly in recent years, especially in the computer gaming industry. "Virtual worlds," or computer simulations of the real world, are now accessible via broadband Internet. These are attracting thousands of users on a daily basis, most of whom build fantasy environments. Our research program at UC Davis is exploring the use of these environments in healthcare. In one project, we have built a demonstration of examples of virtual auditory and visual hallucinations of patients with schizophrenia which occur in a 3-dimensional model of the Sacramento County Mental Health Treatment Center. In a second project, we have constructed a scale model of the Sacramento Exposition Center set up as it was in May 2006 when it was used as for a large-scale bioterrorism response emergency medical clinic. The virtual environment includes moving "patients" who automatically flow through the clinic, and allows health and security staff to take up practice positions in the clinic and experience what working in such an environment would be like. We have evaluated the environment from both technical and human perspectives.