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Telemedicine applications in an integrated mental health service based at a teaching hospital Peter Yellowlees and Craig Kennedy Royal Brisbane Hospital, Queensland, Australia

Summary Psychiatric applications have predominated in Australian telemedicine in recent years. This paper describes the development of the first telemedicine system for an integrated mental health service based at a teaching hospital. Much effort was devoted to training and education for staff. Within about six weeks of the system being installed, over 80% of all clinical administrative staff, from all the mental health disciplines of the integrated service, had completed a formal training programme. Applications within the service included direct clinical work and the use of videoconferencing in preference to standard telephony over short distances. Applications external to the service, over distances of thousands of kilometres, included clinical supervision and teaching. Evaluation is continuing.

Introduction

................................................................................. The use of telemedicine is rapidly increasing around the world. Recent reviews have described applications in various areas of health1–3. The success of recent conferences, such as TeleMed 95 in London in November 19954 and the international conference in Atlanta in February 1996, and the large number of telemedicine systems which have been introduced worldwide is a testament to the value of this health tool. Most telemedicine systems are still in their infancy, however, and few have been properly described or evaluated. In the USA, the primary applications for telemedicine have been in the clinical areas of pathology and radiology, while in the UK, dermatology and a variety of individual patient consultation systems have been developed3,5,6. In Australia it is the psychiatric applications that have led the way, with all states, as well as the Northern Territory, developing systems with mental health applications7–11. At present there are approximately 50 telemedicine sites in Australia which are primarily used for mental health work. A variety of Accepted 17 August 1996 Correspondence: Professor Peter Yellowlees, University of Queensland Department of Psychiatry, Mental Health Centre, Royal Brisbane Hospital, Queensland 4029, Australia (Fax: +61 7 3365 5488; Email: [email protected])

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other applications, particularly renal medicine11 and rural general practice, have also been developed. This paper describes the development of the first complete telemedicine system in Australia, and possibly the world, specifically for use in an integrated mental health service based at a teaching hospital (Fig 1).

Integrated mental health service The integrated mental health service is located at the Royal Brisbane Hospital, the premier teaching hospital in Brisbane, Australia. There are three components of the mental health service: (1) the hospital inpatient unit; (2) the psychiatric crisis unit; (3) the community mental health service. The Royal Brisbane Hospital has about 900 inpatient beds, of which 90 are for psychiatric use. These psychiatric beds are for the use of a catchment-area service to a population of 250,000 people in the north Brisbane area, as well as a state-wide tertiary-level service in adult and child and adolescent mental health for a population of approximately 3.5 million people. The psychiatric crisis unit is located in the Emergency Department of the Royal Brisbane Hospital. This unit

P Yellowlees and C Kennedy Telemedicine applications in mental health

Fig 1 Location of telemedicine systems. The Valley Community Mental Health Service is about 1.5 km from the Royal Brisbane Hospital.

provides acute assessment of patients before their admission. The Valley Community Mental Health Service is located in Fortitude Valley, the ‘red light’ district of Brisbane, about 3 km from the Royal Brisbane Hospital. This community mental health service has adopted a fully integrated model, with approximately 50 clinicians providing: intake, case management, extended hours, mobile intensive treatment, outpatient services, rehabilitation and vocational training programmes. These clinicians work in a multidisciplinary manner and comprise approximately 12 medical staff, 12 nurses, 15 social workers, five psychologists, four occupational therapists and ancillary research and administrative staff. Those in the community-based services work closely with the psychiatric crisis unit, and, in association with hospital nursing staff, manage a 26-bed psychiatric inpatient unit within the hospital. This fully integrated system, where patients can be treated by the same doctors and case managers in either community or inpatient settings, provides excellent continuity of care for patients; although it is extremely rewarding for staff, it is also clinically demanding, and depends on the ability of the staff to communicate easily throughout the system.

Need for telemedicine Several uses for telemedicine within the integrated mental health service were identified.

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There was a perception that communication between the nurses in the inpatient unit and the staff at the community mental health services could be improved if there was more face-to-face contact, since most interactions for most staff were by telephone. Essentially the telemedicine system could be used as a video telephone to allow staff to get to know each other, rather than simply appearing to be another voice on the telephone. A need was identified for staff from the other mental health areas to have access to the psychiatric crisis unit, which is extremely busy. This would allow doctors or case workers from the inpatient unit or community base to assist in the assessment of patients in the Emergency Department (or vice versa). There was a need for doctors and case managers in the community setting to maintain closer contact with their patients who had to be hospitalized, and to save the considerable amounts of time spent driving relatively short distances through the city centre. A need was identified to provide personal development programmes for staff from the integrated system, and for staff from other mental health services across the state. There was also a requirement for management meetings. There was a continuing need to maintain relationships with other mental health services, including the continuation of professional supervision that the first author was performing with staff from other mental health services in Alice Springs (2000 km from Brisbane) and Darwin (2500 km from Brisbane). Other mental health services also needed professional supervision of Journal of Telemedicine and Telecare Volume 2 Number 4 1996

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new graduates and sole practitioners working in rural areas of Queensland. Finally, there was a perceived need to develop the integrated mental health service as a showcase system that would promote the further development of telemedicine throughout the state, and would provide a focus for a possible extension of services to the rural areas at a distance from the teaching hospital.

Table 1 Outline of training programme Module

Contents

Introducing telemedicine (15 min)

What it is How to book and access the equipment What charges are involved Security procedures for system use What support is available Who the other users of telemedicine are

Using telemedicine12 (45 min)

How to turn the equipment on Placing a call Answering a call Ending a call Managing the image and sound transmitted and received Maintaining a listing of video numbers Solving basic problems with: placing a call managing image and sound Ethical standards Protocols and telemedicine etiquette

Conducting specific applications (1h sessions)

Clinical consultations Education and training sessions Meetings Interviews

Methods

................................................................................. Following the review of the needs, it was decided, with financial support from the state government, to install five telemedicine systems throughout the integrated mental health service. Two roll-about systems were purchased (PictureTel Venue 2000). One of these was installed at the Valley Community Mental Health Service, and the other was installed in the Department of Psychiatry at the University of Queensland, in the same building as the inpatient unit. These larger systems were purchased to allow a teaching facility within the service, as well as to be able to provide the highest-quality links to sites outside Brisbane. Three PCbased systems were also purchased (PictureTel PCS100), with cameras allowing pan, tilt and zoom. One system was installed in the crisis assessment area at the Valley Community Mental Health Centre, one was installed in the crisis psychiatric unit in the Emergency Department of the Royal Brisbane Hospital, and the third was installed in an interview room adjacent to the nurses’ station in the inpatient unit at the Royal Brisbane Hospital. It was intended that these three PC systems would be used on an everyday basis mainly within the service for patient-related matters. All the systems used dial-up digital connections (ISDN) at 128 kbit/s.

Training After the installation of the five sets of equipment, an active training programme for all clinical staff began. Within about six weeks of the system being installed, over 80% of all clinical administrative staff, from all the mental health disciplines of the integrated service (a total of 74 staff), had completed a formal training programme. This was more extensive than in the two previous systems set up by Yellowlees2,7, and had two main objectives, as shown in Table 1. First, it was intended that all staff should have a good working knowledge of the physical features and functioning of both the PC and roll-about videoconferencing units, so that they would be able to use them with relative ease. Second, and more important, a specific programme was introduced, with the aid of an external educational Journal of Telemedicine and Telecare Volume 2 Number 4 1996

specialist, to assist staff in their interview techniques, and in improving their communication skills with the telemedicine system. This particular part of the training programme was valuable to staff in that it allowed them to lose the inhibitions that many of them had about being seen ‘on television’. While the training programme was continuing, a series of policies and instruction manuals was written to aid the staff to use the telemedicine systems effectively.

Results

................................................................................. In the first three months, the system was used both for ‘internal’ applications (primarily between the three sites of the integrated mental health service, and the University of Queensland Department of Psychiatry) and ‘external applications’.

Internal applications (1) Clinical work. Direct clinical work involved patients being seen acutely in the community, or while in hospital, from any combination of the sites. (2) Internal communication. Staff were encouraged to use the telemedicine system if they wished, instead of telephoning, as the cost was similar over short distances. Internal communication improved as a result, through individuals getting to know each other by face rather than purely by voice contact on the telephone.

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(3) Nursing handovers. Nursing handovers commenced, by telemedicine, between the ward and the community mental health service. This meant that, for instance, on a Monday morning the community mental health teams could receive a rapid and complete review of their patients’ progress over the previous weekend, from the senior ward nurse. (4) Ward rounds. Hospital-based ward rounds, which were sometimes difficult for community-based case managers to attend, took place with the aid of telemedicine. Any case managers, or medical staff, who were unable to get to the hospital, or who only needed to be at the hospital for a short time for a ward round, were able to join the round using telemedicine, while remaining at their normal workplace (i.e. the community mental health centre). (5) Hospital grand rounds. These were relayed from the hospital to the community mental health service, so that community-based clinicians could take part.

External applications (1) Clinical supervision. Clinical supervision was provided to staff at both Alice Springs and Darwin, and to rural areas in Queensland. Clinical supervision included support for sole practitioners, new graduates, and peer review of clinical case management. The primary users were psychiatrists and psychologists. (2) Teaching. A variety of teaching activities, both into our system and out from our system, took place. These involved Queensland and other parts of Australia. The Department of Psychiatry began modifying its postgraduate educational programme to incorporate distance learning via telemedicine. (3) Interviewing. Job interviews were carried out by use of the telemedicine system. For instance, candidates for a psychologist position were interviewed in Adelaide (2500 km from Brisbane), Melbourne (1500 km from Brisbane), Canberra (1200 km from Brisbane) and Brisbane all in one afternoon. This represented a costsaving of some A$1500 (where A$1 is 0.6 ECU or US$0.75). (4) User group. A Queensland-based users’ group was established which met monthly via telemedicine using multipoint videoconferencing to develop state-wide standard policies and procedures, as well as to pass on advice and help to other users, in both the mental health and other health fields. This group was also able to act in an advisory capacity to the state Health Department, and national telemedicine groups. (5) Other meetings. The University of Queensland’s Department of Psychiatry used the system for its management meetings. This allowed participation by departmental members who worked in Townsville (1200 km from Brisbane).

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There are plans to develop a trauma and debriefing network for state-wide use, both following major disasters and to support clinicians who are living and working in isolated areas. This network is likely to be run in conjunction with the rural health units. Other clinical services are also planned. These include an expansion of clinical services to rural areas, although these services depend on increasing the available clinician time for the system. In other systems developed by Yellowlees7 or in the related telemedicine system being developed in Townsville, Queensland, there has been a greater concentration on activities directly related to patients, such as acute long-distance assessments, follow-up of rural patients after discharge, and discharge planning from the hospital back to the patient’s home, ideally with their local/rural GP, family and/or community mental health worker. Other mental health uses have been the provision of neuropsychology testing, and cognitive behavioural treatment, as well as a wide range of tertiary consultations. We also made the system available for other areas of the health service, as well as commercially to organizations who wished to pay to use the equipment for videoconferencing.

Discussion

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Evaluation and acceptance An evaluation programme was run concurrently with the development of the telemedicine system, and early results suggest a reasonable acceptance by clinicians. It is believed that a major factor in this acceptance has been the amount of training provided, and the fact that this training is ongoing, with the educationalist being employed part time for several months. The staff have been encouraged to use the system at will, and not to be afraid of it. All of our systems were set up in normal working rooms, in order to demystify telemedicine, so that it was not seen as being special or laboratory based, and it is believed that this has been important. Our major initial goal, over the first six months of the project, was to embed the use of the system firmly within the general clinical practice of our service. Already we have seen considerable gains in terms of improved staff communication, and also morale. Several individuals within our staff took a particular interest in the technology and the clinical applications, and they were particularly encouraged to do this. It is likely that they will be the prime clinical drivers of the system in the long run. Patients were gradually and increasingly involved in interviews, and certainly, to date, there have been no Journal of Telemedicine and Telecare Volume 2 Number 4 1996

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difficulties in this respect. In previous studies it has been reported that patients are very accepting of telemedicine7,8 and this was our experience in this project. Indeed, it is generally the staff, rather than the patients, who have difficulties in accepting the technique. We did originally have some concerns about having expensive and easily damaged equipment located in emergency rooms and in an acute psychiatric ward where very psychotic patients were managed. However, there were no difficulties in this respect and our patients appeared to have a remarkable respect for computers, which, given that computers are now so common in our everyday lives, is not altogether surprising. The initial evaluation methods included pre- and post-usage surveys for all staff involved at each of the three sites of the integrated service. The survey required staff to complete a questionnaire following their first training session. The response rate was high, with 57 of the 62 questionnaires returned (92%). The post-usage survey is still in progress. Further evaluation and research are planned to investigate quality of care, acceptance of technology, interviewing techniques, and the effectiveness of teaching using telemedicine. The costs and benefits associated with the telemedicine applications will also be evaluated11.

Future work Our most important objective is to continue the process of embedding telemedicine in normal clinical practice. We are, however, continuously finding new applications for the system and we will be exploring these, and in particular the staff development and administrative opportunities. There is a strong argument for developing a telemedicine network to service the entire State of Queensland, which is five times the area of the UK, yet has a population of only 3.5 million people. Such a network could be based at the Royal Brisbane Hospital, as well as at the North Queensland Rural Health Training Practice Units in Townsville, and could operate both state-wide and nationally, across a wide series of health areas, and health-related disciplines. Our

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experience in the setting up of the present project has been that attention to the human factors involved, and in particular staff training, has been crucial. Certainly these areas are very much more difficult, and more time consuming, than the technological side of telemedicine, yet they are probably relatively ignored in many projects, hence, one would suspect, leading some of these projects to collapse prematurely. Certainly it is our view that, with rapid improvements in technology, and reductions in cost, it is no longer the technology that is the major issue in developing telemedicine systems. We believe that the human factor is much more important. Acknowledgements: The authors thank the Queensland Health Department for its funding of the telemedicine system and all the staff and patients who have used it.

References 1 Preston J, Brown FW, Hartley B. Using telemedicine to improve health care in distant areas. Hospital and Community Psychiatry 1992;43:25–31 2 Yellowlees P, McCoy WT. Telemedicine a health care system to help Australians. Medical Journal of Australia 1993;159:437–8 3 Perednia DA, Allen A. Telemedicine technology and clinical applications. Journal of the American Medical Association 1995;273:483–8 4 Proceedings of TeleMed 95: London, 8–9 November 1995. Journal of Telemedicine and Telecare 1996:2 (suppl. 1): 1–124 5 Wootton R. Telehealth an international perspective. Conference paper, North Queensland Health Symposium, Townsville, March 1996 6 Gott M. Telematics for Health. The Role of Telehealth and Telemedicine in Homes and Communities. Oxford: Radcliffe Medical Press, 1995 7 Yellowlees P, Kavanagh S. The use of telemedicine in mental health service provision. Australasian Psychiatry 1994;2:268–70 8 Kavanagh S, Yellowlees P. Telemedicine clinical applications in mental health. Australian Family Physician 1995;24:122–5 9 Nagel T, Yellowlees P. Telemedicine in the top end. Australasian Psychiatry 1995;3:317–19 10 Mitchell JM. The Challenge to Embed Telepsychiatry. Report of an Evaluation for the South Australian Health Commission. Unley: John Mitchell & Associates, 1995 11 Mitchell JM. Establishing Rural Clinical Telemedicine. Report of an Evaluation for the South Australian Health Commission. Unley: John Mitchell & Associates, 1995 12 PictureTel. PictureTel Live User’s Guide. Danvers, MA: PictureTel Corporation, 1995

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