Project Outreach

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 resistanceto 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.)