Project Outreach

Health and the Information Highway Division, Health Canada
December 31, 2003

Table of Contents

• Acknowledgement
• 1.0 Introduction
• 2.0 Project Description
• 3.0 Achievements
  • 3.1 Goals Reached
  • 3.2 Additional Successes
  • 3.3 Unreached Goals
  • 3.4 Documents or Products Generated
• 4.0 Main Impact
  • 4.1 Human Resources Impact
  • 4.2 Privacy and Protection of Information
  • 4.3 Policy and Research Implications
• 5.0 The Future
• 6.0 Communications
• 7.0 Other

• Data Collection. Project Outreach collected extensive data over a one-year time period, regarding the use of telepsychiatry by clinicians and patients. Additional funding would facilitate the collection of data over a longer time period, and assessment of the long-term impact of telepsychiatry. The data and research would be of value for policy development purposes and fiscal accountability.
• Electronic Health Record Module. Compared to other fields of medicine, psychiatry has special needs regarding privacy, confidentiality, and security. The project had originally requested funding from CHIPP to research, design, build and produce a software module that would enable various types of Electronic Health Record systems to meet the particular database and reporting needs of psychiatrists. Only partial funding was received. The project researched and designed the module. Additional funding would facilitate the development and production of the module.
• Telepsychiatry - Military Application. Telepsychiatry could provide the means for delivering specialized psychiatric services in a timely manner, to Canadian troops on active duty in regions of the world where they are exposed to traumatic conditions on a daily basis. The same technology could be used to provide service to personnel and veterans who have returned to Canada, and live in communities where specialized psychiatric services are not readily available. As a project, we could provide: a) expertise in setting up a network of telepsychiatric resources, b) recruit and train psychiatrists to deliver service, c) collect utilization data necessary for policy development and fiscal accountability, and more.
• Telehealth Library for Patients. Patients could dial into a web site to see video clips and interact on various health issues. That capability would enable patients and families to actively participate in the treatment process.
• First Nations. It is important to establish collaborative efforts with FNIHB and AFN and the department of Indian Affairs to set up a needs analysis with initial requests coming from interested FN groups in a non competitive environment.

Acknowledgement

We would like to acknowledge the support and contribution of the many people and organizations listed below, who helped to make CHIPP Project Outreach a success.

1.0 Introduction

Your projects offer an exceptional opportunity to learn how best to deliver health care in Canada through leading edge technologies. This information is vital to determining and influencing future government directions and policies.

This document is designed to help you prepare the Final Report. The final Project Report will draw heavily upon the more in-depth presentation and analysis of the project Evaluation Report. But it will go beyond the questions in the evaluation report to look at other important matters.

2.0 Project Description

The following is the project description we have on file and is posted on the OHIH website for your project. If you feel the description needs modification, please make the necessary changes and add "Revised Description" at the beginning of your new Project Description.

Project Description (revised)

Introduction

CHIPP was an $80,000,000 matching grant program. As of, August 31, 2000, CHIPP had received 185 applications. Twenty-nine projects were selected to receive funding, ranging from $436,000 to $12m per project. CHIPP Project Outreach received $2,530,000 in matched funding.

The purpose of CHIPP Project Outreach was to better meet the need for specialized mental health in remote Ontario communities. The project focused on mental health because that field of health care includes some of the most difficult spiritual, psycho-social and medical problems such as: mood disorders, suicide, substance abuse, and abuse of other people.

Five medical Hubs (university schools of medicine and their affiliated research hospitals) are collectively responsible for delivering a major portion of mental health services, education, and research in Ontario. Four of the Hubs (London, Hamilton, Toronto, and Ottawa) and a First Nation (the Chippewas of the Thames First Nation) came together under the umbrella of CHIPP Project Outreach to: a) expand the use of telepsychiatry in Ontario, and b) begin development of a module for Electronic Health Record systems that would support the specialized clinical, administrative, and technical needs of Telepsychiatry.

Telepsychiatry uses video conferencing equipment and high-speed telecommunications to connect psychiatrists and other clinicians to patients and colleagues in under serviced communities. Telepsychiatry reduces the need for clinicians and patients to travel and meet face-to-face. By reducing the need for travel, telepsychiatry provides a means of making a wider range of clinical specialties available to more patients and more communities, increases the hours of treatment available, increases the speed with which treatment can be provided, increases the capability for patients to be effectively treated in the community, reduces the need for hospitalization, shortens the time that patients must stay in hospital, and more. It should be noted that Telepsychiatry is designed to complement, rather than compete with conventional face-to-face psychiatry.

The Reach

Ontario is currently a world leader in the field of telepsychiatry, supported in the past by financial assistance from the former Ontario Ministry of Energy, Science and Technology. More recent funding from the Canada Health Info structure Partnerships Program (CHIPP) of Health Canada, and the Ontario Ministry of Health and Long Term Care, enabled CHIPP Project Outreach to significantly build upon that position. The project was instrumental in launching and/or connecting 72 telepsychiatry service and clinical sites, over 12 months.

The Vision

Project Outreach envisioned a provincial model with the intent of working with the provincial health care regional system to introduce an economical delivery system that would address access to mental health care issues in rural and First Nation communities without compromising the quality of care. From the outset Project Outreach met the challenges of community, regional/provincial and federal concerns in the delivery of health care and was able to make a significant contribution toward integrated solutions.

The Results

CHIPP Project Outreach results over the one-year period from Oct 1/01 - Sept 30/02 were impressive and include: 3,920 patient interventions and 3,587 man-hours of utilization (by over 118 psychiatrists, and countless other clinicians, administrators, and technicians), logged on 1874 hours of equipment utilization. Patients reported that telepsychiatry is as effective as face-to-face psychiatry. Detailed clinical utilization data supports that belief. (See evaluation report).

Project Outreach also demonstrated that Telepsychiatry is a very time/cost effective delivery system especially with a shortage of psychiatrists and the "down-time" related to travel. Preliminary results have shown the cost per patient visit for telepsychiatry can be less than half the cost of northern fly in services. (To date, Dr O'Reilly's study has demonstrated a $477 cost/visit for face-to-face interviews versus a $231 cost/visit for telepsychiatry interviews. It is expected this research will be concluded and published in 2005 (see Appendix A).

The Future

Project Outreach has shown that telepsychiatry works well when services are coordinated and follow-up services are readily available. Project Outreach initiatives have now been incorporated into the regional telemedicine programs but telepsychiatry within that system will require ongoing funding to ensure that the delivery of psychiatric services to remote communities has a provincial telehealth policy in place to address guidelines with regard to psychiatric record keeping systems, the use of multidisciplinary teams, and a telecommunication system that has an open, secure and confidential network that respects the new privacy laws.

3.0 Achievements

3.1 Goals Reached

3.1.1 What elements in the originally approved work plan were achieved?

3.1.2 What were the contributing key factors?

3.1.3 What were the obstacles or challenges that had an impact on your achievements and how did you deal with them?

The Original Goals of the Project

• Construct and manage a telepsychiatry network that would establish and/or incubate 40 remote First Nations and municipal sites in Ontario.
  
  
  • This goal was exceeded. The project was instrumental in launching and/or incubating 72 sites over 12 months. In some cases, the project supplied televideo technology. In other cases, sites had televideo equipment, which was either sitting unused in storage, or was not being utilized for telepsychiatry, until CHIPP Project Outreach began providing assistance with regard to clinical applicability.
  • Building upon drive-in and fly-in, programs, the project strived to create a managerial infrastructure that would enable each Hub to carry on developing telepsychiatry after the project ended. The infrastructure integrated the Clinical, Administrative, and Technical components of health care delivery, and is referred to in this document as the CAT model. The model is clinically driven -- as was the project.
  • Success was achieved in spite of project challenges that included difficulties in coordinating individual First Nation communities and adjusting to a regional model, which emphasized the need for each region to work towards self-sufficiency. Project Outreach hoped that an "inter" regional mental health concept could help in "bridging the gap" by assisting communities with immediate psychiatric needs, followed by a capacity building initiative to support and sustain community mental health programs.
• Begin development of a module for an Electronic Health Record (EHR) software system that would support the specialized clinical, administrative, and technical needs of telepsychiatry. The module would be designed to integrate with EHR systems supporting other medical applications.
  
  
  • The project produced a needs analysis, a blue print, and a prototype design that can help guide future development plans. The project actively worked with the CHIPP Synapse project to further develop the technology. The value added by Project Outreach focuses on legal, privacy, security and confidentiality issues. Our Ottawa Hub played a lead role in coordinating a CHIPP Project Outreach/Synapse pilot at their Hub and established our Project Outreach web site. (Appendix B, Legal Issues in Telemedicine).
  • Many EHR software systems have been developed. Few, if any of the systems, are being used in any significant way for psychiatry because they fail to meet the particular needs of clinicians. The goal of the CHIPP Project Outreach team was to develop a system designed by clinicians, for clinicians. A prototype for POIS (Psychiatric Outreach Information System) was completed. Although successful in achieving their goals, the POIS "working group" had hoped to go further, but was limited by funding and a regional uncertainty with regard to standards. It is hoped that future funding will include further development of psychiatric record keeping systems (see Appendix B, Legal Issues in Telemedicine; Appendix C, POIS Project Report; and Appendix D, Information Privacy Survey).
• Develop and manage a set of community and home care education materials that would enable patients, their families, and their communities, to better understand the clinical and social causes of their medical problems, and proactively work with their care providers to deliver solutions. The resources could be delivered via the Web, Videotape, or Print.
  
  
  • Hub clinicians provided educational support and materials to patients and their families as needed.
  • Information sources included: a) materials developed by and/or already utilized by each hub, b) availability of outside information such as print and video material, c) provision of website information on request, d) materials developed by various professional organizations, and c) lectures/seminars given by project personnel. In the latter case, for example, the project's First Nations Co-ordinator, was invited by the Ontario Psychiatric Outreach Program to provide its members with a guest lecture on cultural sensitivity within First Nations communities. Educational materials were delivered as part of the clinical routine of health care workers interacting with one another and with patients.
  • A First Nation Help Desk with both T1 and satellite connectivity was set up on the Chippewa of the Thames First Nation Reserve and has provided a "workstation" that can now focus as a learning centre for FN communications in the Health sector. To this end, the Chippewa have laid the groundwork with the UWO MBA program to prepare a business plan for the centre at the conclusion of CHIPP funding.
  • A portion of our CHIPP Project Outreach outcome studies, included cost/ benefit Research headed by Dr O'Reilly who has provided us with a randomized controlled equivalence trial comparing the efficacy of psychiatric consultation and four-month follow-up provided via videoconferencing versus the same service provided by face-to-face consultation. The face-to-face costs consisted of: per Diem payments to the psychiatrists, airfare, hotel costs and local travel in Thunder Bay. The total for the 84 patients seen was $58,715 or $699 per patient seen. There were 39 follow-up visits in addition to the 84 initial assessments. Thus, the cost per visit was $477. The videoconferencing cost consisted of sessional fees for the psychiatrists, cost of maintaining the ISDN lines, long-distance charges and the cost of depreciation of the equipment. The total was $34,712 for the 79 patients seen. There were 71 follow-up sessions in the videoconferencing group. Thus, the cost of providing service using videoconferencing was $439 per patient or $231 per visit. Dr O'Reilly's results to date have far exceeded our cost difference expectations. Dr O'Reilly's study is on going and complete results are expected to be published in 2005. ( Abstract to date: see Appendix A, The costs of providing psychiatric consultation and follow-up in person versus via videoconference: The results of a randomized control trial).

Telepsychiatry was significantly less expensive than flying in psychiatrists to see patients in person (face to face). It should be noted that the cost difference in favour of telepsychiatry would have been far greater if the new IP network being installed by Smart Systems for Health (SSH) across Ontario had been fully operational to allow interoperability between regions.

3.2 Additional Successes

3.2.1 What elements were achieved beyond the originally approved work plan?

3.2.2 What were the contributing key factors?

• We had intended to show that waiting lists could be reduced to three weeks at a receiving site. In fact, we were able to show that waiting lists could be reduced to as little as one-week ­­ surpassing our expectations.
• Over 118 psychiatrists participated in CHIPP Project Outreach - surpassing our expectations.
• Our original plan called to connect 20 municipal sites and 20 First Nation sites, to four University Hubs. With the finalization of the NORTH Network agreement we were able to pave the way to connect to more than 60 Northern sites from the U of T Hub when the NORTH Network infrastructure was completed (including over 20 First Nation sites). In addition, we established the capacity to reach some 19 Eastern Ontario Network sites as well as some 40 South Western Ontario network sites. This ability to connect has provided a psychiatric delivery system that can be utilized by these three regional telemedicine networks.
• A key factor contributing to the project's success was the involvement of the chairs of the departments of psychiatry under the leadership of Dr. Persard, (Chair Dept of Psychiatry UWO). This, together with the OPOP (Ontario Psychiatric Outreach Programs) psychiatrists headed by Dr Hodges, allowed Project Outreach to work in collaboration with a current drive-in/fly-in delivery program and not be perceived as a separate entity (see Appendices E and F, The Ontario Psychiatric Outreach Programs (OPOP), exerts from Annual Reports 2000 and 2001 respectively).

3.3 Unreached Goals

3.3.1 What elements from the originally approved work plan were not accomplished or sustained?

3.3.2 What were the contributing key factors?

Our originally approved work plan contemplated that Project Outreach would work with the other Ontario CHIPP projects to deliver telepsychiatry as a "channel" of the other projects. As the project developed, the "regional" projects wished to develop their own telepsychiatry as part of their overall telemedicine package. The Ontario wide approach was perceived by the regions as conflicting with their clinical, administrative and technical approaches. This challenge was dealt with by working with the regions to help them address the special needs of mental health as they strive to provide psychiatric services without compromising patient care.

3.3.3 What were the obstacles and how did that impact on you not being able to accomplish your objectives?

1. The project was dependent on the IP telecommunication infrastructure that Smart Systems for Health (SSH) was building. Communication over the network would be free to the telepsychiatry sites. Development of the network required more time than promised. As an interim solution, the project paid the cost of connecting many sites via ISDN technology. Delays in the development of the SSH network: a) caused delays in the set-up of project sites, and b) caused the project to incur an unexpected telecommunications expense.
2. The Help Centre was incubated at the project's Head Offices. The intension was to migrate the Help Centre to the project offices at the Chippewa of the Thames by the third fiscal quarter. Implementation was delayed until the last quarter because of: a) unexpected delays by SSH in connecting the Chippewa offices to the network via IP technology, and b) difficulties in finding Chippewa of the Thames personnel who were approved for a capacity building program that we had made available.

3.4 Documents or Products Generated

While implementing your telehealth system or electronic health record solution you may have developed a number of useful tools or products.

The chart below lists some of the tools and products that you may have developed. If you have a document or product that does not appear please add it.

Please note that, as per the contribution agreement, Health Canada must receive a copy of any tools and products that were developed through CHIPP funding.

Document /Product Name	Available in Paper and/or Electronic Form	License Fee Required for use (Yes/No)	Previously Provided to Health Canada (Yes/No)	Appendix Name /Number
Template(s) for vendor RFP	Not applicable
Template(s) for vendor contract(s)	Not applicable
Template for Hub and Site Agreements	Electronic	No	No	Appendix G
User Guide(s) and/or Training Manual(s)
Privacy	Paper	No	No	Appendix H
Template(s) for equipment testing	Electronic	No	No	Not Applicable
Policy and Procedure Manual(s)
Privacy	Paper	No	No	Appendices D and H
Job Descriptions and/or recruitment material
Hospital employee manual and procedures	Paper	No	No	Responsibility of the HUB'S
Software Application(s), includes:
EHR application/POIS Project Report	Electronic	No	No	Appendix C
"Legal Issues in Telemedicine"	Paper	No	No	Appendix B
Telehealth scheduling software	Not applicable
Other	Not applicable
Standards, includes:
Data (includes minimal data sets)	Electronic	No	No	Appendices B and C
Image	Not applicable
Messaging	Not applicable
Network Utilization	Electronic/Paper	No	No	Appendix I
Clinical Training Protocols
Manuals and protocols established by individual Hub Hospitals and clinics	Electronic	No	No
Clinical Program Protocol(s)
Manuals and protocols established by individual Hub Hospitals and clinics	Telepsychiatry Guidelines and Procedures for Clinical Activities. University of Toronto Hub	No	No	Appendix J
Video Conference Protocols and Etiquette Guide	Electronic/Paper	No	No	Appendix H
Quality Assurance Procedures	Paper	No	No	Appendices B, D, H and J
Confidentiality and Privacy documents	Paper			Appendices B, D, H and J
Consent Forms
Forms and protocols established by individual Hub Hospitals and clinics		No	No
Sustainability Plan	Paper	No	Yes	The four HUB'S have assumed responsibility of sustaining the telepsychiatry model under the umbrella of OPOP (Ontario Psychiatric Outreach Programs) in conjunction with the University Outreach Programs.

4.0 Main Impact

Your project received CHIPP funding because of its expected impact on delivery of health care services. We would like to find out in your own words just what impact your project had. Some things to think about in responding to this section are:

• 4.1 What difference is your project making in your community or your region?
• 4.2 What difference is your project making to your patients, to health care professionals, or to your organization's management and structure?
• 4.3 What changes have you noted in the provision of services?
• 4.4 What findings from your project can potentially impact on the development of responsive health delivery policy and applied research agenda?

• Telepsychiatry complements, rather than competes with conventional face-to-face psychiatry and reduces the need for clinicians and patients to travel, to meet face-to-face. By reducing the need for travel, Project Outreach found that telepsychiatry:
  • provided a means of making a wider range of clinical specialties available to more patients and more communities,
  • increased the hours of treatment available,
  • increased the speed with which treatment could be provided,
  • increased the patients to be effectively treated in the community,
  • increased the number of patients that could be seen,
  • reduced the need for hospitalization,
  • shortened the time that patients must stay in hospital, and more.
• Better treatment was delivered more cost effectively than would otherwise have been possible by conventional face-to-face psychiatry alone.
• CHIPP Project Outreach began delivering treatment to patients immediately.
• Over 118 psychiatrists participated in CHIPP Project Outreach. Most of the psychiatrists were recruited, trained, and/or introduced to the field of telepsychiatry by the project.
• At mature sites, waiting lists were reduced to as little as a week.
• Telepsychiatry has helped to reduce the need to hospitalize patients through early intervention and has helped to provide needed follow-up services so patients can enjoy an earlier discharge back into the community. (See Evaluation Report page 45)
• In 12 months of operation, the project logged 3,920 patient interventions.
• Cumulatively, the Hubs logged 937.25 hours of equipment utilization. All telepsychiatry involves communication between at least two locations. That being the case, we can assume that the Sites also logged 937.25 hours of equipment utilization communicating with the Hubs. The total amount of equipment utilization is the sum of the Hub and Site time: 1,874 hours.
• As planned, the project head office ceased to serve as an agent for the development of telepsychiatry in Ontario on September 30, 2002. The Hubs assumed exclusive responsibility for that role in their respective regions. Equipment utilization immediately began to decline. CHIPP funding was a driving force for the development of telepsychiatry in Ontario. In the absence of a provincial telehealth policy and budget, some Hubs felt it necessary to temporarily curtail service. The province is expected to release its telepsychiatry policy and budget soon and have begun to provide some regional interim funding to keep telepsychiatry operational.
• The project tracked how psychiatrists and other health care workers allocated their time. The result was a rich data source, valuable for policy development and accountability purposes. In addition the role of each multidisciplinary team member was monitored and logged. The details are captured in the evaluation report. It should be noted that the multidisciplinary approach of Project Outreach contributed significantly to its success and part of Project Outreach's recommendation for telepsychiatry in the future.

4.1 Human Resources Impact

Please indicate what short and long-term impacts your project has had on human resources. Some things to think about are:

4.1.2 What new skills have staff/health care providers developed?

4.1.3 Are these skills transferable to other jobs or situations?

4.1.4 Has job satisfaction changed?

4.1.5 Has productivity changed?

4.1.6 Was there resistance to change?

• The project utilized the University System in conjunction with Tertiary Care and Schedule One Facilities that were connected to Community Clinics and provided an integrated, seamless approach. It is important to note that the project clearly demonstrated that remote communities can have access to specialty programs within psychiatry, via televideo, including the utilization of multidisciplinary teams, which are so necessary for best "follow-up" clinical practices.
• Telepsychiatry is developing in an evolutionary rather than a revolutionary manner. It is building on existing medical procedures and job skills. Some additional training and experience is required to: a) set up a telepsychiatry session, and b) conduct a telepsychiatry session. There is a predictable division of labour that mirrors existing clinical practices. Psychiatrists and other health care workers focus on learning how to use the technology to deliver service. Secretaries and technicians focus on learning how to make the technology reliable and available when required by psychiatrists and other health care workers.
• At each Hub, the project paid a "Hub Division Manager" to serve as the regional champion: to help identify sites, manage the setup of sites, manage the maintenance of sites, support the technical needs of clinicians, and more.

  Each Hub supplied two support personnel as a contribution-in-kind to the project: a) a "Hub Coordinator/Secretary", and b) a "Hub Technician". In most cases, the two roles were filled by multiple persons who worked for the project on a part-time basis. Collectively, they "created" two full-time team members who provided administrative and technical support to the division managers and clinicians of each Hub.

  Each of the Sites, of each Hub, contributed a "Site Coordinator" as a contribution-in-kind to the project. In most cases, this role was filled by multiple persons who worked for the project on a part-time basis.

  The Site Coordinator and the Hub Coordinator/Secretary performed similar roles. The roles differed in terms of the frequency and quantity with which a function might be performed. For example, Hub Coordinator/Secretaries would have spent far more time booking telepsychiatry sessions than their counterparts at the Sites, because they would have booked the sessions for multiple Sites connecting to clinicians at the Hub.

  A similar list of functions can be prepared for the Hub Technicians who received training in the nuances of the teleconferencing technology and guidelines (notably issues of privacy, confidentiality, and security). The Hub Technicians brought a wealth of information to the project regarding local area networks, wide area networks and other types of technology that the project needed to navigate, in order to deliver telepsychiatry.

  The project's utilization reports enabled us to track clinician time and equipment time. We attempted to use time sheets to quantify the amount of work performed by Hub Secretaries/Coordinators, the Site Coordinators, and the Hub Technicians. That approach proved impossible, for three reasons:

  • Recording the time of a large number of people, doing a large amount of multitasking, a few minutes or a few hours at a time per day, on a part-time basis -- was impractical.
  • Many hospitals and clinics are understaffed. Asking staff to complete yet another form was not well received. Enforcing the use of time sheets would have produced unreliable data and would have seriously jeopardized participation in the project.
  • Most hospitals and clinics keep generalized time sheets. They are not in the habit of recording time by task. Thus, it was not possible to record the time that administration and technical personnel allocated to Project Outreach on a multi tasking basis. The on-line clinicians time was recorded in the utilization sheets.

4.2 Privacy and Protection of Information

We would like you to provide information about what may have happened in the area of privacy and the protection of personal health information as a result of your project. Some things to think about are:

CHIPP Project Outreach improved the collection, use and disclosure standards for both live TeleVideo information and records of it. By its mandate, the project was not tasked to create electronic patient records but it was tasked to create a prototype and blueprint for future development. The combination of Clinical, Administrative and Technical input into the POIS report focused upon the elements that must be present for a good psychiatric patient record system. The guidelines developed by Virtual Professionals Inc. (the project's general contractor) and Management Science Associates Inc. -- and the training and practical use of the equipment -- enhanced the awareness and respect of all persons involved for privacy, security and quality of service and the need to have relevant information available before, during, and after each session (see Appendix B, Legal Issues in Telemedicine; Appendix C, POIS Project Report; and Appendix H, Security Guidelines for Video Conferencing Units and Associated Connections).

4.2.1 Have there been changes in the behaviour of health professionals/staff with respect to the protection of personal health information?

The project research indicates that all participants in the project expressed a high degree of satisfaction with the steps taken to protect information. By its very novelty, the bringing together of distant health-care workers and patients electronically raised the awareness of the need to protect both privacy and security of the live sessions and the records of them. The Project Director was relentless in leading the clinicians, administrators and technicians to make those standards become foundations of their work and they did so faithfully. While many questions came to the support center and the technical team to ensure that privacy and security standards were being met, we are not aware of a single breach occurring.

4.2.2 Have changes been made to your policies and procedures?

Yes. See Appendix H, Security Guidelines for Video Conferencing Units and Associated Connections.

4.2.3 Have you completed a Privacy Impact Assessment? If yes, what did it show? Did you change any policies or procedures as a result of the Privacy Impact Assessment?

Yes. The assessment contributed to the development of the project's Security Guidelines for Video Conferencing Units and Associated Connections (see Appendix H).

4.2.4 Did you participate in the CHIPP Privacy and Security Survey conducted in August 2002? If yes, have you implemented the recommendations provided to you?

Yes. See Appendix D (Information Privacy Survey).

Our team participated in the Information Privacy Survey for CHIPP, which was delivered on time together with a guideline for use of the TeleVideo equipment. The guideline was circulated to the hubs and sites (see Appendix H, Security Guidelines for Video Conferencing Units and Associated Connections).

Security improvements were required and installed to make the telepsychiatry network perform well. Electronic patient records did not exist to enhance the system, so protocols had to be established for secure delivery of hard copy records for the clinicians and the field workers to support the sessions. That organized delivery of critical information by hard copy has set the stage for it to be carefully replaced by electronic records. Rigid requirements were put in place for both privacy and security of the TeleVideo sessions and a healthy respect for privacy and security was instilled throughout the team of participants in the project.

The means for security were improved by ensuring that all the technical team understood fully the relevant law concerning privacy and security. Each site was installed and established to meet those strict guidelines. The support center circulated standards for TeleVideo sessions that emphasized both privacy and security. The Project Director worked closely with the clinical, administrative and technical committees to ensure that privacy and security standards were both understood and respected in all operational phases.

Training and the data collection process contributed significantly to staff awareness of the importance of confidentiality and privacy issues. The focus on a new delivery system and its accompanying training was an introduction to the efficient way that data could be recorded, and the responsibility of each team member for specific functions. This "team" awareness of responsibility directly impacted on information security and has paved the way for staff acceptance of a more electronically managed record keeping system.

4.2.5 Did you receive any patient views/concerns/compliments on the handling and use of their personal information?

When surveyed, patients expressed a very high degree of satisfaction:

1. 95 percent - "comfortable with service",
2. 93 percent - "able to communicate as in person",
3. 85 percent - "as beneficial as face-to-face", and
4. 99 percent - "would use the service again"
   n = 86 (a random survey.)

4.2.6 Did any of your privacy/confidentiality rules/guidelines help or hinder your health care providers (all staff) to provide patient service?

As this project was a clinically based project, the privacy/confidentiality rules or guidelines were definitely there to help the multidisciplinary team members, as it was second nature for them to follow specific guidelines when dealing with patient care.

4.2.7 Was patient privacy raised as an issue in any way during the trial?

Patient privacy was not a problem. The "CHIPP Privacy and Security Survey" contributed to the development of the project's Security Guidelines for Videoconferencing Units and Associated Connections (Appendix H) and POIS Project Report (Appendix C).

In addition, by its very novelty, the bringing together of distant health-care workers and patients electronically raised the awareness of the need to protect both privacy and security of the live sessions and the records of them. The Project Director was relentless in leading the clinicians, administrators and technicians to make those standards become foundations of their work and they did so faithfully. While many questions came to the support centre and the technical team to ensure that privacy and security standards were being met, we are not aware of a single breach occurring.

4.2.8 What tools were used for obtaining and managing patient consent (electronic/paper/combination)?

Project Outreach did not develop a patient consent form. The project relied on the standardized forms already in use at each Hub hospital and Clinic. The forms became a part of each patient's medical record.

4.2.9 Were there instances where patients refused consent and, if yes, what were the reasons given?

A patient could request NOT to use the televideo for their consultation, although these were very few. If a patient refused his/her consult, that patient would wait until the next available session to be seen face-to-face or they would be asked again at the next televideo conference if they felt more comfortable using the equipment. On various occasions the patient was ready to try again and would take the advantage of using the tele-screen for that days consult.

4.2.10 Will you be conducting regular Privacy Impact Assessments? If not done routinely, under what circumstances will revised Privacy Impact Assessments be conducted?

CHIPP Project Outreach entered its shutdown phase the end of September 2002. On-going assessment is now the responsibility of the four Hub hospitals.

4.2.11 Have you participated in discussions with representatives of provincial health info structure networks on privacy and protection of personal health information?

The lead applicant instructed Project Outreach management to leave any loose ends in the hands of SWOT -N (Video Care).

4.2.12 Do you feel your project has influenced privacy policy and process development in your jurisdiction? If yes, in what way?

Personal health information was transmitted under strict standards between the remote sites and the hubs on a need to know basis so the clinicians and the supporting health-care workers at each end were informed and ready for each session. All sites were operating under the strict hard copy guidelines of the Ministry of Health so the flow of that information complied strictly with those existing standards. The project was not missioned to deliver that information by a patient record system, so the foundation for that system had to be put in place by streamlining effective delivery of information critical for meaningful sessions and nothing else. It is a complement to the project that not one complaint arose during its operational phase alleging any breach of privacy or security.

Security improvements were required and installed to make the telepsychiatry network perform well. Electronic patient records did not exist to enhance the system, so protocols had to be established for secure delivery of hard copy records for the clinicians and the field workers to support the sessions. That organized delivery of critical information by hard copy has set the stage for it to be carefully replaced by electronic records. Rigid requirements were put in place for both privacy and security of the TeleVideo sessions and a healthy respect for privacy and security was instilled throughout the team of participants in the project.

The means for security were improved by ensuring that all the technical team understood fully the relevant law concerning privacy and security. Each site was installed and established to meet those strict guidelines. The support center circulated standards for TeleVideo sessions that emphasized both privacy and security. The Project Director worked closely with the clinical, administrative and technical committees to ensure that privacy and security standards were both understood and respected in all operational phases.

Training and the data collection process contributed significantly to staff awareness of the importance of confidentiality and privacy issues. The focus on a new delivery system and its accompanying training was an introduction to the efficient way that data could be recorded, and the responsibility of each team member for specific functions. This "team" awareness of responsibility directly impacted on information security and has paved the way for staff acceptance of a more electronically managed record keeping system.

4.3 Policy and Research Implications

What results do you feel can be used to influence key groups, based on the knowledge and experience gained by your project? Consider stakeholders such as government policy makers at the federal, provincial, and territorial levels; health planners; health administrators; and health, health care, and technology development researchers.

Please include your recommendations for next steps based on these major findings. For example, this could include privacy protection, supplier readiness, physician readiness, additional research, and potential pilot projects. Here is a suggested structure:

Major finding #1: (one paragraph)

• Policy implications;
• Applied research implications; and
• Recommendations for next steps.

Please create as many "Major finding" clusters as you need.

1. Too many isolated projects shrouded in secrecy.
   • Patient looses if we are not on the same team.
   • Spirit of collaboration needs to be improved.
2. "Regionalization" has been adopted by Ontario.
   • But we need an Ontario wide Telehealth policy to help coordinate the silos to improve quality of care through:
     • Accessibility.
     • Responsibility.
     • Accountability and to ensure an adequate funding process that is standardized.
3. CAT Model
   • Clinicians should drive health projects, with the assistance of Administrators and Technicians (the CAT model).
   • It works if you can get the "CATs" to click on the same mouse.
4. Telepsychiatry Fee Structure
   • Need formal approval to allow psychiatrists to "adopt" a community, and work with multidisciplinary teams to ensure the best quality of care (Sessionals).
   • Family Practitioner (AFP's) Fee for service, etc. should also be available but require government approval.
5. Confidentiality/Security/ Privacy
   • High priority issues that beg further development of a psychiatric record keeping system with its unique features.
6. Data Collection
   • Need a user-friendly data collection system that does not burden the "CATs".
7. Development of Telepsychiatry Sites
   • Learning curve. After "buy-in", it takes 6 to 12 months for a site to mature, to the point where it can effectively and efficiently deliver 3 or more hours of telepsychiatry per week.
8. Clinical Success
   • CHIPP Project Outreach successfully provided:
     • Committal forms preventing suicide.
     • ORB hearings (Ontario Review Board).
     • Psychotherapy (e.g.) PTSD.
     • Cognitive Behaviour Education.
     • Interpreter access.
     • Medication management (hospital prevent).
     • Lab management (hospital).
     • ACT Team management.
     • Management of hospital ward from community psychiatrist.
     • Family televisits (e.g.) Nova Scotia.
     • A decrease in waiting lists.
     • Demonstrable "cost of delivery" savings.
     • Increased access time to specialists.
     • Weekly follow-up visits.
9. First Nations
   • Over the next 2 years, 20+ First Nation sites will have access to mental health services from the University Hubs when needed (as per CHIPP Project Outreach and CHIPP North Network agreement).
   • Established a help/service center at the Chippewa of the Thames. Equipped with IP, ISDN, and satellite communication technology.
   • Begun liaison with institutes to address capacity building in the area of health care providers.
   • Provided Hubs with education, regarding working with First Nations.
10. Research

    A need to continue with research including:

    • The impact of telepsychiatry on "burnout" or isolation factors that contribute to a high turnover rate, especially considering the high level of care required.
    • The impact of training medical/students, residents and other clinical disciplines via telepsychiatry in remote communities and how this influences future recruiting and retention issues.
    • The use of "neuropsych" testing that requires a "spacial" component that can be addressed through 3D imaging.
    • The use of psychiatric assessment tools such as EEG (electroencephalogram) "hats" that could be easily used at a community site and read at a Hub site.
    • Further research on psychiatric record keeping as it relates to the many "FORMS," the many REVIEW BOARDS, the patient advocacy and rights advisory board, and the substitute decision makers.
    • An evaluation of telepsychiatry as it impacts on the delivery of forensic psychiatry and the court system.
    • The development of an electronic psychiatric record system that respects confidentiality, security and privacy issues and moves toward an easier document sharing protocol that improves accessibility without compromising patient care.
    • The development of telepsychiatry in the home care setting (eg) utilization of the PACT teams.
    • Working with Family Practitioners to further develop a "Shared Care" mental health delivery system utilizing the capabilities of telepsychiatry. (see Appendix K, CPA abstract Telepsychiatry-Moving Forward; and Appendix L, A Model for Telepsychiatry in a Shared Care Environment.)

5.0 The Future

What are your plans for maintaining or developing your project once CHIPP funding ends? If you have already prepared a sustainability plan, please attach it as an appendix.

The project set up the Hubs and their affiliated hospitals so they could carry on the delivery and development of telepsychiatry in Ontario after CHIPP funding and the project ended.

Whether CHIPP Project Outreach, as a project, should receive future funding from the provincial government and/or the federal government depends on the value attached to having an entity that can: a) successfully champion the growth of telehealth in Ontario, and b) collect utilization data that is necessary for service development and fiscal accountability.

Following are some questions to consider in developing a sustainability plan. They can help you whether you have developed a plan or have not yet begun.

5.1.1 What are the key barriers to ensuring your project is sustainable beyond the CHIPP funding period?

Project Outreach envisioned a provincial model with the intent of working with the provincial health care regional system to introduce an economical delivery system that would address access to mental health care issues in rural and First Nation communities without compromising the quality of care. From the outset Project Outreach met the challenges of community, regional/provincial and federal concerns in the delivery of health care and was able to make a significant contribution toward integrated solutions.

Project Outreach has shown that telepsychiatry works well when services are coordinated and follow-up services are readily available. Project Outreach initiatives have now been incorporated into the regional telemedicine programs but telepsychiatry within that system will require ongoing funding to ensure that the delivery of psychiatric services to remote communities has a provincial telehealth policy in place to address guidelines with regard to psychiatric record keeping systems, the use of multidisciplinary teams, and a telecommunication system that has an open, secure and confidential network that respects the new privacy laws.

5.1.2 Do you have funding for the next stage of your project? How will the project be funded?

5.1.3 Do you intend to expand your project? If so, can you provide Health Canada with an overview of your future plans?

5.1.4 If you are not planning an expansion, what are the key reasons for not proceeding?

Four of Ontario's teaching hospitals (Hubs) came under the umbrella of Project Outreach to greatly expand use of telepsychiatry in Ontario. Upon completion of the project, the four

HUB'S assumed responsibility of sustaining the telepsychiatry model under the umbrella of OPOP (Ontario Psychiatric Outreach Programs) in conjunction with the University Outreach Programs.

Much of the telepsychiatry activity was put on hold by the provincial government after CHIPP funding ended September 30, 2002. We hope that activity will increase after the implementation of Ontario's new Telehealth Budget. The provincial government has supplied interim funding for telemedicine but has earmarked little for telepsychiatry to date.

It could be argued that Ontario's medical Hubs (that is, medical schools and their affiliated hospitals) could fund telepsychiatry from the savings that would accrue from a decrease in the need for travel, and a reduction in the need for hospitalization. However, it is not the intent of Telepsychiatry to totally replace drive in/fly in service but to compliment them by providing adequate follow-up service with crisis intervention and medication management. Individual hospitals need multi year funding approval. Without such approval, diverting funds to telehealth could take away from another valuable medical program - in spite of the savings that would accrue to the healthcare system. Hubs and sites are waiting for the province to release its much anticipated policy and budget supporting telehealth so that any increase in utilization is not borne by a hospital without a dedicated line item.

CHIPP Project Outreach successfully laid the groundwork for an integrated telepsychiatry approach in Ontario. Continued success and growth will depend upon community needs and the ability of Federal, Provincial and local governments to approve protocol and provide funding.

5.1.5 In your planning, have you considered such matters as:

• Your ongoing vision and mission
• Governance and leadership
• Human resources needs
• Communications
• Needs of health care professionals
• Technical development plans
• Funding requirements
• Interoperability with other projects and systems

Yes. No funding, no service. Passed on to Regional groups as directed by the province.

In addition, we would be interested in your views on areas where additional pilot projects are needed.

6.0 Communications

Clearly, communications is important in generating support for projects -- support in the community and among other interested groups. What methods or tools did you use to communicate with your stakeholders? Please provide a copy of the documents you will list below as appendices.

Methods or Tools	Date	Targeted Audience	Documents or Presentations Produced	Appendix Name/Number
Conference
Telehealth Society of Canada (Toronto)	October 22 & 23, 2001	Canadian Telehealth Audience	Networking
Canadian Psychiatric Association (Montreal)	November 17 & 18, 2001	Psychiatrists	Power Point CHIPP launch and initial results presented to CPA- section on Telepsychiatry
Ontario Psychiatric Association (Toronto)	January 17, 18, 19, 2002	Psychiatrists
Think Tank on Telepsychiatry (University of Waterloo)	February 19, 2002	IT and legal personnel	Project Outreach power point presentation
Canadian Evaluation Society Conference (Halifax)	May 6 & 7, 2002	Evaluators	Project Outreach evaluation power point presentation
Meeting: Dr N Wyman	August 7, 2002	Dr N Wyman, Tim Patterson, First Nations	First Nation issues
CIHR - Institute of Neuroscience, Mental Health & Addiction First Annual Meeting (Montreal)	October 5 & 6, 2002	Researchers	Networking
CHIPP Ontario Workshop (Toronto)	October 9, 2002	Peers
Canadian Psychiatric Association Annual Meeting (Banff) 2002	November 2 & 3, 2002	Psychiatrists	Project Outreach power point presentation CHIPP Results CPA workshop
Canadian Psychiatric Association Annual Meeting (Halifax) 2003	October 31-November 2 2003	Psychiatrists	Co-chair section on Telepsychiatry Post CHIPP initiatives Power Point -- Shared Care and Use of Telepsychiatry	Appendices J and K
Media Events
Press Conference. Alan Rock announced CHIPP funding received by Project Outreach	April 27 2001	Ontario Health and FN dignitaries. Parkwood Hospital, London.
Publications
Project Newsletter	November 2001 December 2001 January 2002	CHIPP Projects general public. (until Web Site development was complete)
Book Chapter Publication	Copyright 2003	General Information	Chapter Telepsychiatry and e-Mental Health. Edited by Richard Wootton, Peter Yellowlees and Paul McLaren. South London and Maudsley NHS Trust. The Royal Society of Medicine Press Ltd.
Open House
Christmas party		Lead Applicant, Chippewa, local psychiatrists
End-of-project party		Lead Applicant, Chippewa, local psychiatrists
Marketing / Advertisement
Website (please provide the Website address) www.project-outreach.ca			The Project Outreach web site was built and managed at the Education and Technology Services, Royal Ottawa Health Care Group. The evaluation data was up dated monthly throughout the project and could be viewed on the website in the form of monthly graphs.

7.0 Other

Are there other thoughts or information you feel Health Canada and other possible readers should be aware of, such as, patient safety issues?

It is important to address risk management issues as they relate to the special needs of psychiatry, for example,

• a psychotic patient who escalates during the interview and requires assistance for control.
• a suicidal/homicidal patient who may require chemical restraints or seclusion and the accompanying need to be placed on a Form 1 (APA). This procedure may require assistance from either security or police depending on the location of the televideo unit. It should be noted that Project Outreach made every attempt to locate its teleconferencing units in a safe environment, to prevent incidents such as these from occurring (see Appendix H, Security Guidelines for Video Conferencing Units and Associated Connections).