The University of Louisville School of Medicine is dedicated to implementing innovative technology to improve the lives of those in the community and the Commonwealth. Implemented by Robert Caudill, MD, professor and Residency Training Director in the Department of Psychiatry and Behavioral Sciences, the UofL Telemedicine program has revolutionized mental health care in Louisville. By creating a more accessible communication platform between patients and physicians, Telehealth has allowed medical care to be more easily obtained by people who may have otherwise gone without. As part of Mental Health Awareness Month, the University of Louisville School of Medicine interviewed Dr. Caudill to learn more of his contributions to the field of psychiatric medicine.

UofL School of Medicine: What has been your role in implementing telemedicine and information technology at the University of Louisville?

Dr. Caudill: I saw clearly the potential medical applications of video teleconferencing in 2001 after experiencing high-definition, real-time, videoconferencing conducted over the internet.  This followed the experience of having witnessed high-definition television transmissions replacing the previous standard definition resolution. In 2005, I developed a business plan and in 2009 brought the model to the UofL Department of Psychiatry, relocating my practice back to the medical school campus. I have sought to pioneer areas involving technology and mental health, volunteering to try new technologies and advocating for their mainstream adoption. In 2014, my role shifted from clinical innovation to also include an educational role as program director for the UofL psychiatry residency program. Before COVID-19, Telehealth technology was already mature enough to envision a larger role for it in healthcare. UofL psychiatry residents have been receiving this training for years. I promote the message that “telemedicine is medicine” through practice and education.

UofL School of Medicine: Explain the importance of Telehealth services for the general public?

Dr. Caudill: Patients have been way ahead of clinicians in terms of interest in and acceptance of Telehealth. Without Telehealth, most of the inconveniences associated with healthcare were borne by patients. At one point it might have been about bringing access to medical care to those who could otherwise not obtain it. Increasingly, it will be about bringing health care to the general public in a more patient friendly and cost-effective manner. We have required patients to make unnecessary and inconvenient trips to receive care that could easily have been rendered more efficiently via telehealth. “In-person” care has been held out as the “gold-standard” and of course it is the model against which alternative approaches must be measured. However, in-person care has its own drawbacks and a subset of patients who lacked the physical or emotional resources to access it has been uncovered and now is also eligible to receive high quality healthcare for the first time. It was never about replacing “in-person” care; Telehealth is simply another tool.  

UofL School of Medicine: How have Telehealth services changed modern day healthcare?

Dr. Caudill: I was highly influenced by the writings of Nicholas Negroponte and his exhortation to "Move bits not atoms." One need not have been terribly observant to live through and witness the fates of local bookstores, record stores, and video rental businesses to recognize that many of the cognitive services provided in healthcare were similarly situated. My hope would be that in the future we are not going around needlessly “moving atoms” when the same results can be obtained by “moving bits.” I hope that patients will not accept a future where their healthcare options are limited to those facilities to which they might easily drive which also coincidentally have an appointment available at a time and place where both clinician and patient can materially intersect in a timely fashion. Telehealth opens a wide array of options that would not have previously existed.

UofL School of Medicine: What are the benefits of having same day appointments with patients?

Dr. Caudill: Timeliness of the intervention has always been a factor in terms of outcomes. Telehealth is an amazing resource, yet it is not truly disruptive as the term is applied to technology innovations. That is to say that Telehealth does not allow a clinician to see more patients during a given unit of time – only different patients (often geographically distanced). Telehealth certainly offers the potential for gains in efficiency that are not possible in an exclusively “in-person” environment. Late cancelations are hard to replace if the waiting list patient must also arrange for transportation at the last minute. Telehealth can bring a patient into the virtual presence of a clinician with little more than a preparatory phone call. Time otherwise lost to practices can be gainfully recovered with this ability to rapidly fill vacated spots with patients hoping to be worked into such an opening in the schedule.  

UofL School of Medicine: What inspired you to create a partnership with PeaceNow?

Dr. Caudill: The planets just happened to align at the right time. The university now has a large referral base of primary care providers to complement its specialists and sub-specialists. I saw the potential to fill in a missing section in the continuum of care. The Covid response demonstrated the utility of Telehealth, and I have been doing Telehealth work with various rural community mental health centers in Kentucky since 2009. One of my contracts was up for renewal around the same time that PeaceNow was starting to take shape, and I saw the opportunity to play a role in creating a new virtual clinic. While PeaceNow can now efficiently direct patients from primary care to behavioral health services, there remains a great unmet need for skilled mental health care clinicians in the community. PeaceNow can be a highly effective endpoint for some, but its promise will be less than fully realized if it ceases to function as a conduit for moving patients from primary care into more definitive, long-term, behavioral health endpoints.

UofL School of Medicine: Who are the target populations for the Telehealth services? How has your program benefited these populations?

Dr. Caudill: While Telehealth enables the medical industry to serve certain populations better, there is still a small subset of patients who are not appropriate for virtual care. This group has historically been poorly managed, as they often self-selected their way out of existing health care systems. Telehealth has provided an opportunity to reach this elusive group. Certain populations, including those with mobility limitations, trauma issues relating to trust and travel, and many adolescents, are proving to be better served through virtual care. In the end, it is not about “either/or” but “both/and” as community-based, in-person interventions are still needed for some patients.

UofL School of Medicine: When working with people that lack resources such as a computer or internet, how do you see them coming to receive Telehealth services?

Dr. Caudill: This is a problem but the solution for it is bigger than the programs discussed here can solve. Telehealth doesn’t “replace” in-person care. Patients who struggle to receive Telehealth are also challenged when attending in-person care for many of the same reasons. The minimal point of entry increasingly appears to be the mobile phone. While I had been initially enticed about the potential of Telehealth after witnessing HD images transmitted over the internet and dreaming of the impending arrival of full-size 3-D hologram encounters, the introduction of the smart phone and its rapid rise to ubiquity took us in a different direction. At one distant time, not everyone had access to land line telephones. National, wireless networks and the widespread availability of internet-enabled smart phones are rapidly reducing the number of geographical locations inaccessible to virtual health care. Promising efforts to identify the barriers to care through use of digital health readiness screeners tied to systematic programs possibly offered through public health entities can help find, enroll, and socialize patients to virtual care.  

UofL School of Medicine: What advice would you give to someone dealing with mental health issues, but cannot afford a therapist? 

Dr. Caudill: Untreated mental health comes with its own associated costs, and sadly patients often prioritize activities of questionable benefit over addressing their mental health needs. Technology, including social media and Telehealth, has led to increased awareness of mental health concerns and the availability of definitive treatments. However, there is still a bewildering array of individuals and services offering mental health care, and not everyone has access to the necessary resources to obtain help through traditional mechanisms. Some options for those lacking resources include Seven Counties Services (our local public mental health center) and the teaching clinic at the University of Louisville Department of Psychiatry. While insurance often provides additional options, true parity of coverage with physical illness has not yet been achieved. Good clinicians motivate patients and help them achieve results that over time often offset the expenses incurred while working through difficulties. Telehealth reduces logistical requirements associated with in-person care, benefitting both patients and clinicians. Telehealth has rightfully taken its place in this group of options for care.

The University of Louisville School of Medicine recognizes Dr. Caudill and his revolutionary practices for providing more accessible mental healthcare to the Louisville community. If you or someone you know is struggling, we encourage you to reach out for help and seek treatment.