MHWD Telepsychiatry Project 2004

• Overview
• Background
• The Process
• The Problems
• Cost Benefits
• Recommendations
• Conclusions
• References

Abstract
The MHWD Telepsychiatry Project was an initiative within the Mental Health Workforce Development (MHWD) Programme^{[ a ]} which aimed to enhance and encourage the use of video-conferencing within the mental health sector, for both clinical purposes and workforce development initiatives. In essence, the project re-launched video-conferencing within the sector to promote the use of such technology for identified service needs such as increased accessibility to specialist services, early identification and treatment of symptoms and increased opportunities for professional development. The objective of the project was to support the more effective use of existing equipment where possible and to provide the support required for current and future purchase and use of video-conferencing equipment in the mental health sector.

Health services use a number of "labels" to describe the use of telecommunications technology within the health care sector, eg, "Telehealth", "Telemedicine" and "Telepsychiatry". "Telehealth" is the term that describes the use of telecommunication technology as an enabling tool for delivery of healthcare services. "Telemedicine" and "Telepsychiatry" are both specialisations of "Telehealth". One may argue that "Telemedicine" subsumes "Telepsychiatry". However, "Telepsychiatry" is considered to cover more than just the "medicine" part and should be considered as a separate entity from "Telemedicine". These terms are not and should not be used interchangeably. This paper refers solely to the use of video-conferencing within the mental health sector to deliver and/or support health care services. "Video-conferencing" is the simultaneous transmission of both audio and video images between two or more sites in real time (live).

Background
The "MHWD Telepsychiatry Project Phase 3 (Delivery)" had its origins in a feasibility study, funded by District Health Boards New Zealand (DHBNZ), out of which came a "Strategic Plan for the use of Video-Conferencing in Mental Health" (January 2002). This strategic plan highlighted the viability of video-conferencing within the mental health sector, stating that a "well-developed and supported video-conferencing network will provide benefit to consumers, family/whanau/caregivers, and staff working within the Mental Health setting."

Within mental health care services, video-conferencing has been acknowledged as providing: ^{[ 1 ]}

• a tool to enable District Health Boards (DHBs)^{[ b ]} to provide clinical supervision for clinicians working in rural and remote areas, thereby potentially reducing the clinical risk that can be associated with a lack of clinical supervision
• access to clinical training and professional development through grand rounds, guest presenters and video-conferencing based training programmes, reducing the risk of clinicians not being kept up to date with developments within mental health specialties
• a means of supervising mental health services consumers when they return to a rural or remote area as part of the discharge management process. Video-conference links can provide access to a mental health specialist from a local community centre.
• access to peer review or second opinions for clinicians from rural or remote areas, reducing the risk associated with a single view of a consumer’s degree of wellness and, hence, ensuring the development of the most appropriate treatment plan.

While acknowledging the benefits of video-conferencing and the successful implementations that have occurred in New Zealand,^{[ 2 ]} the MHWD Project found that some implementations have not been sustained. One of the main reasons for the existence of telepsychiatry and/or the use of videoconferencing within the mental health sector is the perception that staff and patient time will be saved by holding case conferences and/or consultations remotely. This Project has found that very little information is being collected or is available retrospectively on the costs and or benefits of using videoconferencing within the mental health sector.

The Process
The MHWD Telepsychiatry Project was a national initiative. It provided a central infrastructure via a website with support at regional and local levels within the New Zealand DHB mental health sector made available through a regional co-ordinator for each of the four regions who was available for a period of time. The website www.mhwdtelepsychiatryproject.co.nz provided a national repository that offered information on clinical and organisational guidelines and clinical and technical standards for the use of video-conferencing along with training analysis guidelines, requirements for video-conference room set-up and news of what project meetings were occurring in each region.

New Zealand’s 21 DHBs were divided into four regions – Northern, Midland, Central and Southern. A key contact person per DHB was appointed for each of 16 participating DHBs, to assist with project communications and provide management and resource support for the regional co-ordinators. The regional co-ordinators were contracted part-time to the project for three months.

Communication and meetings throughout the project were facilitated through both the key contact people at each DHB and the appointed regional co-ordinators.

The Problems
The project attempted to address key problems identified in the DHBNZ Strategic Plan for Use of Video-Conferencing in Mental Health 2002^{[ 2 ]} that related to the operation and acceptance of video-conferencing in the mental health sector. The Project Goals pointed to the requirement for:

1. an acceptable [to consumers and mental health service providers] and accessible [to consumers and mental health service providers] videoconference network [infrastructure and service] 
2. a network that is cost-effective 
3. a network that is capable of taking advantage of new technological developments 
4. the need to use best practice standards 
5. the need to increase the capacity of the currently underutilised existing telepsychiatry network by facilitating the rollout of new videoconference sites and by better utilising existing sites 
6. the need to increase integration with other services, both regional and secondary
7. the need to establish the cost-benefits for using videoconferencing.

The project goals demanded a national solution.

The following are some of the issues summarised for each identified problem.

1. Acceptable and Accessible Network
The use of video-conferencing within the mental health sector is sporadic, being well utilised within some DHBs, within regions that need better access to clinicians and staff and, in some cases, for training purposes. There is some co-ordination of use at a regional level, where it is mainly used for specialist consultation, clinical review of inpatients, case presentations, speciality service meetings between DHBs and regionally for some non-clinical and workforce development co-ordinated activities.

There is, however, very little video-conferencing that is co-ordinated at a national level, although some national meetings allow attendance via video-conferencing. Reasons cited for not using video-conferencing include: the difficulty in co-ordinating sessions across a number of venues; lack of awareness of where units can be accessed for national meetings; large regions simply expecting smaller regions to travel to meetings and not considering alternatives; attendees from smaller regions wanting to have the option not to travel to meetings and use videoconferencing instead, but often not given a choice to do so.

A national directory of ISDN numbers, contact details of people who organise room bookings, and room locations goes someway to co-ordinating an ability to network nationally, to improve accessibility. The existing structure has a long way to go to be acceptable in terms of future technological possibilities.

2. Cost-Effective Network
A cost-effective video-conference network can be supported through a centrally managed infrastructure and administration, through which telecommunication and equipment contracts can be negotiated to maximise economies of scale. The South Island Shared Services Agency (SISSAL) / Canterbury DHB (CDHB) model is a good example of this. SISSAL and CDHB work together on behalf of the six DHBs in New Zealand’s South Island to provide a cost-effective solution for videoconferencing within the South Island health sector, by negotiating effective economies of scale for telecommunication contracts and equipment purchase.

3. Network Capability
IP-based video conferencing is emerging as a viable technology to replace ISDN-based videoconferencing technology. This, in turn, requires a networking infrastructure that is capable of meeting the expanding requirements in order to maximise the potential of the technology.

4. Best Practice Standards
There are examples of pilot projects set up to use video-conferencing within the mental health sector to benefit clinicians, staff, patients and patients’ families. Few conclusions can be drawn about best practice standards from any of these, however, as there has been little documented about the projects or their outcomes. The Draft New Zealand National Telepsychiatry Clinical Practice Protocols and Guidelines (0510) are providing some guidelines for best practice for the use of video-conferencing within the mental health sector.

The Canadian Framework of Guidelines,^{[ c ]} developed as a National Initiative for Telehealth (NIFTE) in Ottawa in September 2003, has been used within the MHWD Telepsychiatry Project to guide what could be adapted for the mental health sector within New Zealand.

The Canadian guidelines cover five key areas that an organisation is required to review in order to implement telehealth initiatives:

1. Clinical standards
2. Human resources
3. Organisational readiness
4. Organisational leadership
5. Technology and equipment.

Some DHBs already have guidelines for the use of video-conferencing in two of these areas: clinical standards and technology and equipment standards.

Clinical standards guidelines consist of polices outlining aspects of patient confidentiality and informed consent along with details of what videoconferencing can best be used for.

Technology and equipment protocols include procurement practices, security, and maintenance in relation to equipment supply, use and maintenance. These guidelines, however, are not standardised across the DHBs that use them.

There are no examples of organisational readiness, organisational leadership or human resource standards to be found as part of the MHWD Telepsychiatry Project.

Waikato DHB is now looking at developing an overall DHB strategy for telehealth, which will include the use of video-conferencing.

5. Increase Network Capacity
As part of reviewing the ability to increase the capacity of the existing video-conference network in order to encourage better utilisation of existing sites, the following were noted:

1. Many sites were using minimum effective bandwidth capacity of 128kbps, which is reasonable quality for video-conference meeting purposes but totally inadequate for virtual clinical assessment and consultation purposes. 386kpbs is the minimum bandwidth recommended for quality picture and sound for clinical purposes. Changes made to bandwidth accessed in response to this knowledge increased the quality of sound and picture at both end points. Similarly, variation in transmission points capability causes problems – if an end point has only 128 kbps capacity while the other end point has 384 kbps the quality of sound and picture would be very poor: transmission capacity defaults to the lowest capacity in this case. Some DHBs (Tairawhiti and Hawke’s Bay to Wairoa) were unable to achieve the required bandwidth. The line capacity of both DHBs was limited and outside their control. Bandwidth access is also a problem for parts of the South Island, notably the West Coast and parts of Otago and Southland.
2. Some video equipment was so old it was not capable of receiving high quality picture and sound, thus affecting the other end point. This is being addressed in several areas where video equipment is being updated and replaced.
3. Cost is an issue affecting some areas’ capacity. Line rental and call costs for 384 kbps ISDN are three times higher than charges for 128 kbps. However, the lack of availability of data beyond simple telecommunication billing costs, eg, to indicate what transmission capacity was being used, for what purpose, and what the related quality of transmission was, makes it difficult to fully evaluate the impact of cost.

In summary, any ability to increase the capacity of the existing ISDN network is completely dependent on the existing telecommunication line network.

There is no national IP-capable network for video-conferencing that has been set up yet for the mental health sector. There is also a need for a secured broad band network for health. The technology is available for such implementation. The ability for sections of the health sector to access a broadband network nationally, as has happened with Project PROBE for the education sector, would go a long way to improving network capacity. However, of course, this would still require a network to maximise this technology.

The recently released Draft Health Information Strategy for New Zealand (HIS-NZ)^{[ 3 ]} "provides a context to support New Zealand health and disability strategies to make innovative use of information to improve the health and independence of New Zealanders". It also incorporates the principles of the e-government and digital strategies and builds on previous national health information strategies.

One of the global trends in health information systems cited in the HIS-NZ draft is particularly relevant to telehealth, that of recognition of the need for connectivity: " a general drive toward connectivity and increasing demands for online access that requires greater bandwidth and adequate security. Increasingly vendors are offering innovative solutions and applications that are based on high bandwidth communications, eg, for sharing of images."

6. Increase Integration With Other Services
The project team reviewed the ability of the mental health sector to integrate with other video-conference services within the health sector, not only at a regional level but at a national level as well. This was considered in order to save costs and leverage off services should they already be there.

Only one national network for video-conferencing exists within the New Zealand health sector – Telepaeds. Telepaeds was set up by the New Zealand TelePaediatric Society (NZTS) to act as a direct telehealth solution for the paediatric community of New Zealand. It is possible the Telepaeds network could be integrated into any future mental health network, thus, moving towards a national video-conferencing system.

This possibility is being further researched as part of a national telehealth initiative (refer options A and B below).

Cost Benefits
One of the main reasons for the use of telepsychiatry and / or video-conferencing within the mental health sector is the perception that staff and patient time is being saved by holding case conferences and/or consultations remotely. An outcome of the MHWD Telepsychiatry Project is the discovery that very little information is or has been collected about the costs and/or benefits of using video-conferencing within the mental health sector. The only information available, in varying forms of accessibility, were call costs, frequency, length of call and where calls were made to – all taken from telecommunication billing data.

Often, the time and travel savings for people video-conferencing instead of having to travel to meetings or consultations are quoted as a cost benefit. No specific data have been generated to give these claims any validity.

Recommendations
Recommendations from the MHWD Telepsychiatry Project are split into two options.

Option A is aligned with the review of a national telehealth strategy for the health sector sponsored by the Ministry of Health.

Option B covers the recommendations put to the MHWD Steering Committee in November 2004, before the national telehealth inquiry was activated and indicates an autonomous approach for the mental health sector.

Option A
A Telehealth Working Group has been formed with interested stakeholders in telehealth to begin development of a pathway forward for the use of telehealth, including the development of options for models of service delivery, and a governance model for telehealth in New Zealand. Telecommunication solutions developed for the recommended options will need to account for sector-wide requirements including consideration of cost versus benefit and the future feasibility of any technology solutions. It is intended that this group will exist for no longer than 12 months, at the end of which time recommendations will be made.

Option B
The following recommendations were presented to the MHWD Programmes Steering Committee in November 2004. These recommendations were made with the aim of maintaining the outcomes and outputs of the MHWD Telepsychiatry Project by providing a mechanism from which to do this that was specific to the mental health sector.

MHWD Programmes Custodianship Role
It is recommended the MHWD Programmes undertake an ongoing custodian role to support the use of video-conferencing as a national workforce development tool within the mental health sector.

In order to sustain various outputs from this project, a mechanism should be instituted whereby progress and changes being made nationally can be monitored and information about what does and does not work well can be passed on to other areas of the mental health sector. Frequent feedback during the MHWD project was that regions are very interested in what other regions are doing in developing video-conferencing. The benefits from using video-conferencing are not just within each DHB catchment but within and between DHB regions and nationally. The use of video-conferencing within the mental health sector has been championed most where access to health care professionals and services are limited.

Summary of Possible Solutions
The following summary is set out in ascending order of the current ability to implement, 1 being the "easiest" solution and 3, 4 and 5 being developments requiring a national telehealth infrastructure.

1. A National Booking Mechanism and Centrally Managed Services
This could be scoped for mental health as soon as it has been decided how best to implement telehealth within the health sector at a national level.

With the rate and speed at which technology is developing today, a national network for video-conferencing within the mental health sector must be considered within a national framework so as not to reinvent the wheel or waste existing resources.

2. Contract For a Managed IP Service Through a "Telemedicine" Framework
An option for the mental health sector could be for Telepaeds / Telemedicine to provide a managed service for video-conferencing as part of the national strategy for telemedicine. To gain the maximum advantage of a managed service, the sector would need to develop a business case for providing such a service. The MHWD Programmes could facilitate the scoping and requirements of such a business case, should this option be chosen.

3. Clinical and Organisational Guidelines
The national telehealth initiative would make recommendations relating to how to support best practice using video-conferencing by updating and evaluating clinical and organisational guidelines on use of video-conferencing.

Draft clinical and organisational guidelines have been included in the MHWD Project Report. The use of video-conferencing is still evolving as a tool to support service delivery within the health sector, be it for clinical, educational, workforce development or administrative purposes. Guidelines relating to best practice for video-conferencing need to provide a baseline to support integration of this tool into service provision. This would require a reference group to review evaluate and update guideline recommendations on an annual basis, publishing these from a recognised source.

4. Video-conferencing Standards Framework
In order to provide a cost-effective telecommunications and maintenance support framework for video-conferencing, there needs to be a consistent video-conferencing standards framework providing a platform for negotiation. At present, most of the 60 units surveyed in this Project were using ISDN technology. Of these 60 units, 37 (62%) are IP capable but are not linked into a national network). Some regions use IP technology to link video-conferencing regionally, eg, in the central region, Capital and Coast DHB link with Taranaki DHB (within the mental health sector). This issue would be addressed as part of the national telehealth initiative.

5. Economies of Scale for Network and Equipment Purchase
In order to achieve telecommunication and/or equipment economies of scale, there needs to be a structure or vehicle to negotiate from. The South Island Shared Services Agency (SISSAL) / Canterbury DHB (CDHB) collaboration provides a model for such negotiations, negotiating on behalf of all six DHBs for the communication requirements of all sectors within that DHB.

Central Region’s Technical Advisory Services (TAS) has created a structure to negotiate for equipment purchase and maintenance contracts for video-conference units on behalf of the central region DHBs. At present 10 of the 16 DHBs participating in this project have separate telecommunication contracts.

This issue also would be addressed as part of the national telehealth initiative.

Conclusions
Providing a cost-effective network/infrastructure for a successful video-conferencing facility within the mental health sector, that is acceptable, accessible now, and future-proof, will require a nationally managed IP-network-based secured video-conferencing infrastructure. This would ensure the best utilisation of a cost-effective infrastructure by leveraging economies of scales to best advantage. This option would have to be part of the national strategic direction recommendations of the Telehealth working group for New Zealand.

A national governance structure would be the best platform for providing the strategic and operational direction towards supporting best practice standards for video-conferencing as a part of an overall telehealth initiative.

Best practice standards would need to address what constitutes a measurable outcome for service delivery and how best to generate the relevant data to measure these costs and benefits to service provision.

The national provision of any clinical and mental health care workforce development initiative using video-conferencing would require co-ordination at both regional and national levels. There are already structures supporting regional initiatives in place within the mental health sector, however, development at a national level would require a national mandate. It is hoped this would come out of the Ministry of Health’s new Telehealth Review.

References

1. DHBNZ. Strategic Plan for use of Video-Conferencing in Mental Health. Wellington: District Health Boards New Zealand, 2002.
2. Norris T, Kerr K. A review of telehealth and its relevance to New Zealand. 2004. ISBN 0-478-28229-X.
3. Ministry of Health. Draft Health Information Strategy for New Zealand. Version 1.5, 26 Nov 2004.

Footnotes