The University of Texas Medical Branch--Texas Department of Criminal Justice Telemedicine Project: findings from the first year of operation.

BACKGROUND: The University of Texas Medical Branch (UTMB) and Texas Tech Health Science Center (TTHSC) are responsible for providing health care for approximately 130,000 inmates of the Texas Department of Criminal Justice through a health maintenance organization (HMO). Telemedicine was considered a way to solve some of the problems presented. OBJECTIVES: To develop approaches to patient care, technology, support systems, evaluation, and uses of the system for applications other than patient care as part of the first stage of implementation. METHODS: Four prison delivery unit models were utilized. After a pilot study, the first patients were seen from October 1994 to November 1995, when 1715 consults were conducted in 18 scheduled specialty telemedicine clinics. Patients and providers were surveyed by interviews and questionnaires for their views on this form of providing care. RESULTS: Ninety-five per cent of the telemedicine consults saved one or more trips to UTMB for outpatient specialty appointments. User surveys indicated a high degree of satisfaction on the part of patients, presenters, and specialty consultants. CONCLUSIONS: Preliminary review of the data indicated favorable care outcomes, and initial economic analyses suggested that telemedicine is likely to be cost-effective in this environment. The project will be continued.     

Tertiary telemedicine support during global military humanitarian missions.

OBJECTIVE: The U.S. military medical units face the challenge of delivering the latest medical knowledge and advances to remote areas of the world. This study details the tertiary care telemedicine support by Walter Reed Army Medical Center (WRAMC) for these humanitarian missions in several locations worldwide. METHODS: This study encompasses data from all clinical consults received at WRAMC, from the earliest deployment of a satellite-based system in February 1993 through February 1996. The analysis of the consultations include type of consult, medical specialty consulted, response time, and technology used. RESULTS: Two hundred forty consults were received from 12 remote telemedicine sites supporting military medical missions. The consults used a combination of "store-and-forward" technologies and interactive video conferencing systems. Establishment of a telemedicine service at WRAMC, including medical and technical support personnel, facilitated the delivery of telemedicine consultations. Several concurrent missions were supported. The distribution of consults included medicine (40%), surgery (36%), radiology (21%), and dentistry (3%). The most frequently consulted medical subspecialty was dermatology (29%) followed by orthopedic surgery (16%). Most consults were routine (88%). Ninety-four percent of the consults were completed within the predefined telemedicine response criteria (24 hours for routine consults and 3 hours for emergencies). CONCLUSION: The study illustrates the importance of a responsive telemedicine service at a tertiary facility supporting simultaneous medical missions. Access to the complete spectrum of medical and surgical specialties was essential to enhancing the delivery of medical care. The critical analysis and evaluation of this experience will assist in designing future prospective studies for evaluation of telemedicine.     

Psychological Consultation in a Children's Hospital: An Evaluation of Services

The pediatric psychologist's role in children's inpatient medicalhospitals has rapidly expanded. Few studies have examined thetypes of referrals for psychological consultation or programevaluation of these services. This paper describes an archivalevaluation of the types of referrals received by a pediatricpsychology inpatient service over a period of 4 1/2 years andan evaluation of these services by physicians, nurses, and socialworkers. The survey of services indicated that the most frequentreferrals were for depression/suicide attempt, poor adjustmentto a chronic illness, and behavior problems. Medically relatedproblems accounted for 42% of all of the consults. Approximatelytwo-thirds of the children were referred for outpatient psychologicalservices. The pediatric psychology service was more likely tofollow, on an outpatient basis, children with medically relatedproblems. A 26-item questionnaire obtained an overall responserate of 48% and response rate of 84 and 60% for faculty andresident physicians having contact with the pediatric psychologyconsult service. The evaluation of the pediatric psychologyservice by physicians, nurses, and social workers indicatedoverall satisfaction with the services they received. The levelof satisfaction was strongly related to the level of diagnosticagreement between the physicians/nurses and psychologist. Thelowest level of satisfaction was on verbal and written feedback.Suggestion for further research was offered.     

Can't have one without the other: Mental health providers and community parents reducing barriers to services for families in urban poverty

University–community partnerships are widely recognized as critical to the success of community research and advocacy work but difficult to form and sustain. This article will describe a unique facet of that partnership, namely the collaboration between mental health clinicians and community consultants, a partnership that our data suggest was a cornerstone of our school‐based mental health service program called PALS, an ecological model designed to engage African American families living in urban poor communities in mental health services. The service model was designed to promote children's learning and positive behavior through supporting teachers and encouraging parental involvement in school. In PALS, parent representatives from the community and clinicians from the university worked together in school‐based teams to support children, families, and teachers. This article will discuss the evolution of our clinician–consultant partnership and several lessons that emerged regarding the incorporation of community members into the world of academia, research, and mental health service delivery. © 2007 Wiley Periodicals, Inc. J Comm Psychol 35: 435–446, 2007.     

Psychology in primary health care: effects of brief targeted therapy on children's medical care utilization

Evaluated the impact of psychological treatment for 93 children (ages 1-15) with common behavior, toilet, school, and psychosomatic problems. Children and parents, who were members of a health maintenance organization, had 1-6 visits to a primary care-based psychological consultation service. Individualized treatment was guided by problem-specific behavioral protocols. Parent outcome and behavior checklist ratings indicated improvement or resolution for 74% of children and high satisfaction with the psychological service. Children's use of medical services, especially acute primary care visits, was reduced during the year after treatment; a matched comparison group's use was unchanged. Addressing children's unmet mental health needs reduces medical care utilization. A primary health care model of psychological services provides an integrated system for serving the health and mental health needs of children.     

Clinical Child Psychology in the 1990's: Broadening Our Scope

Examined trends in population demographics, education, technologies and economics for the 1990s, particularly as they relate to clinical child psychology and the mental health service delivery system. These trends indicate that the mental health system will encounter a rapidly changing ethnic mix, a growing proportion of new immigrants, few minority mental health professionals, and increasing poverty for young children in our society. Our current mental health service delivery system faces a shortage of well-trained professionals to work with children and diverse ethnocultural groups; problems in distribution, coordination, and integration of our limited mental health resources; and overdependence on traditional service models that may be ineffective with new, difficult-to-serve populations. Innovative service delivery models that overcome many of these obstacles are discussed in the context of recommendations for the future.     

Improved health care delivery in an inner-city well-baby clinic run by general practitioners

The delivery of health care has been improved in an inner-city well-baby clinic by staffing the clinic with members of a primary health care team and by offering a therapeutic service together with a preventive service. Over a three-year period attendance at the clinic has doubled and the uptake of immunization has increased. Of children registered with the practice supplying the health care team, 95% are up to date with diphtheria, tetanus and polio immunizations and 93% have been immunized against measles. It is suggested that general practitioners should have greater involvement in the running of well-baby clinics.     

Efficiency analysis of a multi-specialty telemedicine service.

OBJECTIVE: The goal of this project was to assess case turn-around times for store-and-forward and real-time video consultations in the Arizona Telemedicine Program. MATERIALS AND METHODS: Five components contributing to total case turn-around time were analyzed. Each parameter was submitted to statistical analysis and compared for store-and-forward and real-time sessions. RESULTS: Turn-around for real-time are longer than for store-and-forward sessions. Real-time sessions take longer, from when the consulting clinician is contacted to the time the case is reviewed. This is compounded by the fact that real-time sessions sometimes need to be rescheduled. For both types of consults, the time to deliver the final report is the longest segment of the total turn-around time. CONCLUSION: Several factors contribute to case turn-around times. By identifying and analyzing each contributing factor, it is possible to revise consult protocols to improve efficiency.     

Using Modular Psychotherapy in School Mental Health: Provider Perspectives on Intervention-Setting Fit

The “fit” or appropriateness of well-researched interventions within usual care contexts is among the most commonly cited, but infrequently researched, factors in the successful implementation of new practices. The current study was initiated to address two exploratory research questions: How do clinicians describe their current school mental health service delivery context? and How do clinicians describe the fit between modular psychotherapy and multiple levels of the school mental health service delivery context? Following a year-long training and consultation program in an evidence-based, modular approach to psychotherapy, semistructured qualitative interviews were conducted with 17 school-based mental health providers to evaluate their perspectives on the appropriateness of implementing the approach within a system of school-based health centers. Interviews were transcribed and coded for themes using conventional and directed content analysis. Findings identified key elements of the school mental health context including characteristics of the clinicians, their practices, the school context, and the service recipients. Specific evaluation of intervention-setting appropriateness elicited many comments about both practical and value-based (e.g., cultural considerations) aspects at the clinician and client levels but fewer comments at the school or organizational levels. Results suggest that a modular approach may fit well with the school mental health service context, especially along practical aspects of appropriateness. Future research focused on the development of methods for routinely assessing appropriateness at different stages of the implementation process is recommended.     

Telemedicine in support of peacekeeping operations overseas: an audit.

BACKGROUND AND OBJECTIVE: Since 1993, the Department of Defense has augmented the medical support for Army units on peacekeeping operations in Macedonia through the medium of telemedicine. This project, known as Operation Primetime 1, was the first satellite-based telemedicine system deployed in support of remote primary-care physician in the U.S. military. Its declared aims are: (1) to improve the standard of care; (2) to reduce evacuations; (3) to support junior physicians in the field; and (4) to improve the military effectiveness of the deployed units. This paper audits the success in attaining those goals for the period January 1994 to April 1995. METHODS: A log was collated from the referring units and questionnaires completed by both referring and consulting physicians. The referring physicians were interviewed on their return from Macedonia, and a more detailed study was undertaken of cases in which a change in outcome was noted. Follow-up interview of consultants was not possible. RESULTS: A total of 53 consults were undertaken on 47 patients. The use of telemedicine affected the decision to evacuate 13 times (13/47), with a net reduction of 9 evacuations. Management of individual cases was changed in 30 of the 47 cases in which telemedicine was used. Physician confidence and military effectiveness were also improved. The level of utilization of the system was largely dependent on a training and sustainment program. Units and General Medical Officers who were trained in the clinical use of telemedicine and the technical sustainment of the equipment used the system; those who were not, did not. Most patients (45/47) were treated satisfactorily with a single consult. Telemedicine under these circumstances seems to be cost effective. The deployed sites chose the referral centers that provided the best service. CONCLUSIONS: Telemedicine is a valuable tool capable of augmenting medical support to deployed military units. A successful deployed telemedicine project requires an integrated support package that includes adequate provision for training and equipment sustainment at both ends of the link. Experience with telemedicine in Operation Primetime indicates the potential for substantial cost savings as well as cost-effective medical care. Further application of telemedicine should be encouraged. Successful deployment of telemedicine projects may hinge on an integrated support package.     

Mapping patient path in the Pediatric Emergency Department: A workflow model driven approach

The workflow models of the patient journey in a Pediatric Emergency Department (PED) seems to be an effective approach to develop an accurate and complete representation of the PED processes. This model can drive the collection of comprehensive quantitative and qualitative service delivery and patient treatment data as an evidence base for the PED service planning. Our objective in this study is to identify crowded situation indicators and bottlenecks that contribute to over-crowding. The greatest source of delay in patient flow is the waiting time from the health care request, and especially the bed request to exit from the PED for hospital admission. It represented 70% of the time that these patients occupied in the PED waiting rooms. The use of real data to construct the workflow model of the patient path is effective in identifying sources of delay in patient flow, and aspects of the PED activity that could be improved. The development of this model was based on accurate visits made in the PED of the Regional University Hospital Center (CHRU) of Lille (France). This modeling, which has to represent most faithfully possible the reality of the PED of CHRU of Lille, is necessary. It must be detailed enough to produce an analysis allowing to identify the dysfunctions of the PED and also to propose and to estimate prevention indicators of crowded situations. Our survey is integrated into the French National Research Agency (ANR) project, titled: “Hospital: Optimization, Simulation and avoidance of strain” (HOST).¹     

The case of Powhatan Correctional Center/Virginia Department of Corrections and Virginia Commonwealth University/Medical College of Virginia.

OBJECTIVE: To implement a cost/benefit analysis of telemedicine subspecialty care provided between the Powhatan Correctional Center (PCC) of the Virginia Department of Corrections (Corrections) and the Medical College of Virginia campus of Virginia Commonwealth University (MCV/VCU). METHODS: We evaluated the costs and benefits of the implementation of telemedicine for HIV-positive inmates. Benefits included dollar savings in transportation and medical reimbursement. Costs included those of operating the telemedicine system and of medical care. Non-dollar benefits included implementing more consistent and timely treatment of inmates and reducing security risk. RESULTS: Over the 7-month study period, the total number of HIV consults by telemedicine was 165. The Department of Corrections was able to achieve transportation and medical savings of $35,640 and $21,123, respectively. The operating costs for the telemedicine services totaled $42,277. The net benefit, which is the difference between cost savings and total operating costs, was $14,486. CONCLUSION: Telemedicine increased access to care for HIV-positive inmates and generated cost savings in transportation and care delivery.     

Evaluation of a counselling intervention in primary schools

The emotional needs of children within a school setting may fall between health and educational service provision. There has been a growth of school based counselling provision and this study reports on an evaluation of counselling provided through a charitable organization for primary school children. The study was set up to explore the differences on educational and emotional parameters between children referred for counselling and those not referred and to examine change over time on these parameters after six months of counselling provision. A consecutive cohort of children referred to the project by teachers (n=24) were compared with matched class peers (n=25) on a set of standardized educational and emotional measures, repeated at six months follow‐up. There was little difference between the groups prior to intervention except on number skills. Overall scores were low, with the majority of mean scores for standardized tests more than one standard deviation below average normative levels. There were few differences after the intervention, except for the fact that intervention group children were significantly less worried in school (p=0.03). The small pilot study suggests that there were no significant differences between control and intervention groups on cognitive or emotional functioning prior to intervention except for number skills. Pre–post‐intervention analysis revealed an improvement on block design—perhaps accounted for by improved concentration skills—and an improvement in self‐esteem. This study highlights the challenges facing children in inner city schools and the gains made by counselling provision. It sets the agenda for future studies to examine content of counselling and explore cost effectiveness of provision. Copyright © 1999 John Wiley & Sons, Ltd.     

上海市区学龄儿童行为问题及相关因素研究

目的：研究学龄儿童的行为问题及相关因素。方法：用Ｒｕｔｔｅｒ儿童行为问卷及自编的相关调查表对上海市区小学一年组至初中二年级（７－１４岁）学生８６１名,男４４５名,女４１６名进行调查,结果：显示行为问题父母问检出率为６．３％,教师问检出率为１０．５％。相关分析表明,Ａ因子两问卷均与性别有关,父母问卷还与母孕期健康状况有关。Ｎ因子在教师问卷中有与儿童照料者,考试压力、课外读书环境有关;在父母问卷中与考     

The role of the school medical officer in secondary schools

This paper describes the children seen during a typical morning session in a London girls' comprehensive school. Although many of the problems are similar to those encountered in general practice, it is argued that these children, who give rise to considerable anxiety among teaching staff, would not present to their family doctors. The way in which they are managed requires particular skills and an understanding of the complicated interaction between adolescents, their families, and their educational environment. With the move towards primary care child health surveillance, and the appointment of consultant community paediatricians, the future of the school health service is under debate.     

Preimplantation genetic diagnosis for myotonic dystrophy type 1: upon request to child

Preimplantation genetic diagnosis (PGD) is an alternative to prenatal diagnosis for patients at risk of transmitting an inherited disease such as myotonic dystrophy type 1(DM1) to their offspring. In this paper, the clinical application of preimplantation diagnosis for DM1 upon request to children born is described in a large cohort of risk couples. PGD could be offered to all 78 couples opting for PGD regardless of the triplet repeat size. The incidence of major complications was minimalised following a careful assessment in affected DM1 females anticipating possible cardiological, obstetrical and anaesthetical problems. A live-birth delivery rate per cycle with oocyte retrieval of 20% was the outcome. Forty-eight of the 49 children born are in good health and have normal psychomotor development.     

Telemedicine and rural health care applications

Telemedicine has the potential to help facilitate the delivery of health services to rural areas. In the right circumstances, telemedicine may also be useful for the delivery of education and teaching programmes and the facilitation of administrative meetings. In this paper reference is made to a variety of telemedicine applications in Australia and other countries including telepaediatrics, home telehealth, critical care telemedicine for new born babies, telemedicine in developing countries, health screening via e-mail, and teleradiology. These applications represent some of the broad range of telemedicine applications possible. An overriding imperative is to focus on the clinical problem first with careful consideration given to the significant organisational changes which are associated with the introduction of a new service or alternative method of service delivery. For telemedicine to be effective it is also important that all sites involved are adequately resourced in terms of staff, equipment, telecommunications, technical support and training. In addition, there are a number of logistical factors which are important when considering the development of a telemedicine service including site selection, clinician empowerment, telemedicine management, technological requirements, user training, telemedicine evaluation, and information sharing through publication.     

小学生行为问题综合干预效果的研究

目的:观察小学生行为问题综合干预效果.方法:应用自编儿童心理卫生调查问卷、Achenbach儿童行为量表(CBCL),以整群抽样的方法,抽取社区所属的两所小学一年级学生1482人为研究对象,随机选取其中一所小学学生738人为干预组,另一所小学744人为对照组,对干预组进行为期2年的综合干预,前瞻性观察行为问题干预效果.结果:按CBCL的中国常模判断行为问题的标准,干预前符合此标准者干预组109人,检出阳性率为14.8%;对照组113人,检出阳性率为15.2%,两组比较差异无显著性(χ2=0.51,P>0.05).干预前两组家庭环境及父母对子女教育等情况比较,差异无显著性(P>0.05).经过对干预组进行2年综合干预后,对两组再重新进行问卷调查,评估干预效果.干预组儿童行为问题检出阳性率明显下降至8.8%,与干预前比较差异有非常显著性(χ2＝12.58,P<0.01).干预组在干预后父母关系、亲子关系、教育方式等方面均有明显改善,与干预前相比差异有显著性(P<0.05).对照组两年后儿童行为问题检出阳性率为14.1%,前后比较差异无显著性(χ2=0.33,P>0.05).结论:对小学生的行为问题早期进行综合性干预,有助于减少行为问题的发生.     

Schools,Children's Mental Health,and the Advocacy Challenge

Draws on a recently completed 2-year national study. Highlights some of the mental health service related problems in the schools, describes ways in which schools and mental health agencies (either singly or collaboratively) are trying to enhance the school life of children and strengthen their access to mental health services, and explores the implications for advocacy. Increasing attention is being directed to the role of the schools in serving children with behavioral and emotional problems under the mandate of the Education for the Handicapped Act, as well as those with problems who are not referred to special education.     

温州地区托养儿童行为问题调查

目的：了解温州市6-16岁托养儿童行为问题发生情况。方法：根据分层整群抽样的原则,对温州地区8340名6-16岁学生采用自制问卷和Achenbach儿童行为量表（CBCL）进行调查。结果：温州市6-16岁的儿童行为问题检出率为14.4%（1202/8340）略高于中国常模13.0%,但无统计学意义（P〉0.05）。2520名为托养儿童,占30.2%（2520/8340）,6-11岁托养儿童840位,行为问题检出率18.6%（156/840）高于非托养普通儿童检出率13.4%（396/2960,χ2=14.2,P〈0.05）;12-16岁托养儿童1680位,行为问题检出率19.2%（322/1680）高于非托养普通儿童检出率11.5%（328/2860,χ2=51.1,P〈0.05）。托养儿童行为问题的危险因素有出生时患病、学前所处环境（单亲）、性别（男）、托养家庭结构（矛盾）、托养方式（全天）、托养人受教育程度（小学）及教育方式（专制、放任）（OR=1.287～2.582）,保护因素有托养人数（3人以上）、居住地（城镇）,（0R=0.412～0.499）。结论：6-16岁托养儿童行为问题检出率较高,心理健康状况应引起关注。