Project: Project Outreach

Canada Health Infostructure Partnerships Program

Synopsis

The objective of Project Outreach was to create a provincial teleheath model to better meet the needs for specialized mental health care in remote Ontario communities. The project employs televideo conferencing technology to connect four of Ontario's medical hubs to sites in their jurisdictions. Initially, the project set out to construct and manage a telepsychiatry network that would serve 20 First Nations sites and 20 municipal sites in Ontario.

Within 12 months, the project was instrumental in launching and/or incubating over 72 telepsychiatry sites - some of these from scratch, some that were already using telehealth but not for telepsychiatry, and others with equipment in storage but unused until the Project began providing training and implementation assistance. Unfortunately, due to the lack of infrastructure, only six First Nations communities were connected.

The project originally planned to develop a prototype and blueprint for future development of an electronic health records (EHR) to support the specialized clinical, technical and managerial/administrative needs of telepsychiatry. However, in partnership with another CHIPP funded project, SYNAPSE, Project Outreach pilot tested their E.H.R. model, and this is now being used in the Royal Ottawa Hub site.

Outcomes

Project Outreach demonstrated conclusively that telepsychiatry:

• provided a means of making a wider range of clinical specialties available to more patients and more communities in a more timely fashion (At mature sites, waiting lists were reduced to as little as a week);
• increased the hours of treatment available;
• increased the speed with which treatment could be provided;
• increased the number of patients to be effectively treated in the community;
• increased the number of patients that could be seen;
• reduced the need for hospitalization; and
• shortened patients' hospital stays.

Better treatment was delivered more cost effectively than would have been possible with conventional face-to-face psychiatry alone.

Most of the 118 psychiatrists who participated in CHIPP Project Outreach were recruited, trained, and/or introduced to the field of telepsychiatry by the project.

Upon project completion, the Hubs assumed exclusive responsibility for the development of telepsychiatry in Ontario in their respective regions.

Policy Implications

The project tracked how psychiatrists and other health care workers allocated their time, which has left as a legacy a rich data source, valuable for policy development and accountability purposes. In, addition the role of each multidisciplinary team member was monitored and logged.

"Regionalization" has been adopted by Ontario,but an Ontario-wide Telehealth policy is needed to help breakdown the silos, ensure coordination, and improve quality of care through:

• accessibility;
• responsibility; and
• accountability and to ensure an adequate funding process that is standardized.

Formal approval is needed 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.

Confidentiality/Security/ Privacy are high priority issues that beg further development of a psychiatric record keeping system with its unique features.

Research Implications

There is a need to continued research on:

• The impact of telepsychiatry on "burnout" or isolation factors that contribute to a high turnover rate in rural and remote areas, especially considering the high level of care required for patients with psychiatric illnesses;
• 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 "spatial" 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 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; and
• A user-friendly data collection system is needed that does not burden the clinicians, Administrators and technicians (CATs).

Lessons Learned

Project Outreach reported multiple lessons learned; an excerpt follows.

• Clinicians should drive health projects, with the assistance of Administrators and Technicians (the CAT model);
• The governance structure of the project was too diversified and geographically dispersed, with too many committees and too many decision makers. A more clear-cut governance structure is recommended, through an OPOP type (Ontario Psychiatric Outreach Program), loosely knit organization;
• Highly interrelated functions (notably Finance and Accounting) should not be separated. Greater efficiency would have been achieved and more multi-tasking would have been feasible if all personnel had been consolidated in one location;
• Psychiatric patients may have different responses to and needs from telehealth. For instance, there is a requirement for stricter legal requirements regarding privacy and confidentiality and a need to create a balanced system that centralizes control of reliability, security, and cost, and decentralizes data storage to protect privacy when developing the psychiatric module for EHR systems; and
• One must allow for a learning/adoption curve in Telepsychiatry Sites. After "buy-in", it takes 6 to 12 months for a site to mature, to the point where it can effectively and efficiently deliver three or more hours of telepsychiatry per week.

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. Telepsychiatry will require ongoing funding to ensure continueddelivery of psychiatric services to remote communities. Also required is a provincial telehealth policy to address guidelines with regard to psychiatric record keeping systems, and the use of multidisciplinary teams. Telepsychiatry will also need a telecommunication system that has an open, secure and confidential network that respects the new privacy laws.

Project Outreach began liaison with institutes to address capacity building in the area of First Nations health care providers. This needs to continue.

Appendix A: Documents or Products Generated

Template for Hub and Site Agreements

User Guide(s) and/or Training Manual(s)

• Privacy

Template(s) for equipment testing

Policy and Procedure Manual(s)

• Privacy

Job Descriptions and/or recruitment material

• Hospital employee manual and procedures

Software Application(s), including:

• EHR application/POIS Project Report
• "Legal Issues in Telemedicine"

Standards, includes

• Data (includes minimal data sets)
• Network Utilization

Clinical Training Protocols:

• Manuals and protocols established by individual Hub Hospitals and clinics

Video Conference Protocols and Etiquette Guide

Quality Assurance Procedures

Confidentiality and Privacy documents

Consent Forms

• Forms and protocols established by individual Hub Hospitals and clinics

Sustainability Plan

For additional information, please contact:

Dr. Robbie Campbell at Robbie.Campbell@sjhc.london.on.ca or at 519-858-5085