Project Outreach

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.