Craig Kennedy

A community-based approach to evaluation of health outcomes and costs for telepsychiatry in a rural population: preliminary results.

A pilot trial was established to support visiting psychiatric services and local public and private practitioners through the use of videoconferencing. The purpose of the trial was to determine whether people in the community received better health-care with telemedicine. A community-based approach was used to evaluate health outcomes, costs, utilization, accessibility, quality and needs for such services in a rural community in Queensland. Over a two-year period data were collected from 124 subjects who met the criteria of having a mental health problem or mental disorder. Nine further subjects refused to participate in the study. Only 32 subjects used videoconferencing to receive mental health services. Preliminary results did not show any significant improvements in wellbeing or quality of life, although the time span was relatively short. However, the results confirmed that the people were no worse off from a consumer or a practitioner perspective from using videoconferencing. Most consumers found that videoconferencing with a psychiatrist moderately or greatly helped them in managing their treatment, with 98% of them preferring to be offered videoconferencing in combination with local services. Overall, videoconferencing is a crucial part of enhancing psychiatry services in rural areas. However, it is not necessarily cost-effective for all consumers, general practitioners, psychiatrists, or the public mental health service.

The effectiveness of telepsychiatry measured using the Health of the Nation Outcome Scale and the Mental Health Inventory

In a telepsychiatry project in rural Queensland, data were collected from 124 patients attending hospital and general practice facilities for mental health-care and then again at follow-up one year later. Thirty-two of the patients were dealt with using telepsychiatry. Two health status scales were used to measure effectiveness: the Health of the Nation Outcome Scale (HoNOS), administered by the practitioners; and the Mental Health Inventory (MHI), which was self-administered by the patients. There was a significant difference between the initial assessment and follow-up groups on most subscales of the HoNOS, but no significant difference between the face-to-face and telepsychiatry groups. Similarly, the MHI results showed a significant difference on all subscales between the initial assessment and follow-up groups, but no significant difference between the face-to-face and telepsychiatry groups. Individuals who used and did not use telepsychiatry all had improved health outcome scores on the HoNOS and MHI during the study period. Telepsychiatry was as effective as face-to-face care.

Videoconferencing in the Queensland health service.

Videoconferencing was introduced in the Queensland health service in 1995. By the end of 1999, there were more than 150 videoconferencing units in health facilities around the state. Six audits of videoconferencing usage were conducted using similar methodology at six-month intervals from November 1997 to May 2000. Between November 1997 and November 1999, the number of calls more than doubled, from 566 to 1378. Hours of usage almost trebled, from 671 to 1724. The average duration of calls remained similar, at about 1 h 12 min. The proportion of calls involving more than two sites (multipoint videoconferences) increased from 44% to 65%. The majority of the activity was for education (including training). Videoconferencing was also used for administration and clinical care. Mental health staff were the heaviest users, but use by health professionals from other specialty areas increased during the study period. The Queensland health service has realized a number of important benefits from telehealth.

Telemedicine techniques can be used to facilitate the conduct of multicentre trials

A multicentre randomized controlled trial was established in Pretoria, Bloemfontein and Edendale in South Africa, and coordinated from London. The purpose of the trial was to determine the efficacy of low-dose beta irradiation of glaucoma. Five communication modalities (telephone, fax, email, videoconferencing and face-to-face meetings) were examined in terms of their benefits in a multicentre trial. The eight stages of the multicentre trial examined were: set-up and training, recruitment, standardization, patient management, data transmission, update and data dissemination, clinical follow-up and monitoring, and publication. On four-point Likert scales for rating the usefulness of the communication modalities at each of the eight stages of the trial (from 0 = not useful to 3 = very useful; maximum score 24) the telephone was given a total score of 10, fax 9, email 13, videoconferencing 15 and face-to-face meetings 9. Telemedicine techniques offer considerable benefits in the coordination of multicentre trials by improving data collection, maintaining the efficacy and monitoring of trials, while potentially offering reduced costs in terms of travel and time. The realtime scrutiny of patient records helps to ensure data uniformity and completeness of data collection. Videoconferencing was most useful when considered as one of several communication tools that can be used to improve the effectiveness of a service or process.

Training for telemedicine

All technology requires training. Simply installing videoconferencing equipment in a hospital or health centre, and leaving the manufacturers manual nearby, is not sufficient to encourage or maintain its use for telemedicine. Presenting clinicians and other users with thick policy and procedure documents to be read and understood is also not helpful. Following initial awareness raising about telemedicine and its potential, staff must be properly trained: not just in how to turn on the equipment but in how to use it effectively for consultation, education and administrative purposes. Training needs to be continual, especially where staff turnover is high. It should be practical, pitched at different levels, incorporated into mainstream activities such as orientation courses and staff development days wherever possible, and supplemented with clear, straightforward protocols and user-friendly instruction manuals.

Subspecialty Adnexal Ophthalmological Examination Using Telemedicine

We studied the clinical outcome of examination of a group of patients with adnexal (eyelid and orbit) conditions. Seventeen patients with adnexal problems were assessed by an ophthalmologist at a distance using telemedicine, and then subsequently by an ophthalmologist in a face-to-face consultation. Measurements such as palpebral aperture, levator muscle function and eyelid skin crease position were recorded. The clinical outcomes from both consultations were recorded independently by the consultants and then compared. The study showed that certain adnexal conditions, such as congenital and involutional ptosis, could be accurately assessed using telemedicine, but that other conditions, such as socket problems in patients who had a previous enucleation or those with non-specific ocular pain with less clear-cut features, were better assessed in a face-to-face consultation. Overall, teleconsultations appeared to be suitable for the assessment of uncomplicated ptosis but not for less well defined conditions. Other factors, such as family dynamics and language problems, also limited the usefulness of the technique.

Outcomes of psychiatry services using videoconferencing

There is noroutine telepathologyactivity inHongKong. At theChineseUniversityof HongKong(CUHK) wehave experimentedwithsystems andmethods for telepathology. Wehavetestedaremote-controlledmicroscope.Wehavesent andreceivedpathologyconsultationsviaemail. InApril1998, westartedaseriesofteleconsultationsessionsusingISDNlines withpathologists at the People’s LiberationArmyGeneral Hospital inBeijing. Anagreement has beensignedbetween thepathologists of CUHKandtheBeijingMedical University withthe GoldenHealthProject of theMinistryof Healthof Chinatotest satellite transmission. Wearecurrentlyworking onthe compatibility of the satellite systems. While theremotelycontrolledmotorized microscope providedadequate instantaneous images, thesystemwas costlyand there was sluggishness inimagetransmission. The combinationof audioandvisual features inconsultationand discussionsessions was helpful inarrivingat thecorrect diagnoses. Transmissionat 384kbit/s was thebare minimum for histopathologyimages. Thestabilityof the ISDNlines was essential. Wearecontinuingtosearchfortheoptimumsystemandat same time trainingpathologists innewworkinghabits.

Article Commentary: Commentary

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