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Klinik, Diagnostik, Therapie und Rehabilitation
Organ der Österreichischen Gesellschaft
für Psychiatrie und Psychotherapie
http://www.oegpp.at
Regularly listed in Current Contents / Clinical Practice
and EMBASE/Excerpta Medica
e-Ment@l He@lth
Challenges
for the Future
18/S2
Dustri-Verlag Dr. Karl Feistle
http://www.dustri.de
ISSN 0948-6259
Volume 18
Number S2 – 2004
Editorial
e-Mental Health: Challenges
for the Future
M. F. Cabrera
Reviews
The Future of Telepsychiatry
in Europe
P. McLaren
Telepsychiatry and e-Mental
Health: Electronic Telecommunication in Psychiatry
H. Sulzenbacher, A. H. Bullinger,
T. Senn, E. Bekiaris, U. Meise
Original Papers
On the Integration of Telepsychiatry Services in European Remote
Areas: the ISLANDS Project Case
Study
M. F. Cabrera, M. T. Arredondo,
M. Rodriguez, E. Bekiaris
57
Klinik, Diagnostik, Therapie und
Rehabilitation
Organ der
Österreichischen Gesellschaft für
Psychiatrie und Psychotherapie
59
S2
04
64
74
Services and Architecture for the
ISLANDS System: Toward a
Modular Non-Conventional Telepsychiatry System
A. Amditis, Z. Lentziou, M. Panou,
A. H. Bullinger, E. Bekiaris
79
Towards the Development of Tools
for Remote Interventions
M. Panou, E. Bekiaris, A. Amditis
89
The ISLANDS Treatment Scenarios
and Service Batches
A. H. Bullinger, T. Senn, E.
Bekiaris, U. Meise, R. Mager,
F. Müller-Spahn, H. Sulzenbacher
93
Process Quality Analysis of Telepsychiatry: Contributions of Statistical Control Process and Critical
Pathway Analysis
C. De Las Cuevas, J. Artiles
100
I
Reports
Ethical Conduct within the
ISLANDS Project
T. Senn, H. Sulzenbacher, U. Meise,
K. Estoppey, R. Mager, F. MüllerSpahn, A. H. Bullinger
106
Rehabilitation
Potential Constraints and Obstacles
relevant to the Introduction of
e-Mental Health and Telepsychiatry
U. Meise, H. Sulzenbacher,
A. H. Bullinger
109
Some Considerations about the Concept of Presence in Telepsychiatry
C. De las Cuevas, J. L. González
de Rivera
112
The Telemed Project (RACE-Project R 1086): Lessions learned for
Telepsychiatry from the first EU
funded Telemedicine Project
P. McLaren, A. Charles-Nicolas
116
Perspectives of Communication
Technology in Psychiatry: The
ISLANDS Project in Greece
A. Politis, A. Pehlivanidis, A. Amditis, Z. Lentziou, † M. Markidis, G.
Trikkas, A. Rabavilas
123
History of Telepsychiatry in the
Czech Republic
P. Doubek, A. Kott, J. Raboch
127
Telemedicine in French Guyana
T. Le Guen, N. Poirot,
O. Tournebize, A. Guell
131
Bookreview
Telepsychiatry and e-Mental Health
R. Wootton, P. Yellowlees,
P. McLaren
Guest Editors
Maria Fernanda Cabrera, Madrid
Evangelos Bekiaris, Thessaloniki
Alex H. Bullinger, Basel
Maria Theresa Arredondo, Madrid
Angelos Amditis, Athens
Hubert Sulzenbacher, Innsbruck
Organ der
S2
04
111
II
Zeitungsgründer
Franz Gerstenbrand, Innsbruck
Hartmann Hinterhuber, Innsbruck
Kornelius Kryspin-Exner †
Herausgeber
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Herausgeber
Ullrich Meise, Innsbruck
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Sylvia Holter, Wien
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Rehabilitation
Organ der
http://www.oegpp.at
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Wilhelm Wolf, Wien
Herausgeber
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Neuropsychiatrie, Volume 18, S 2, 2004, page 57-58
Editorial
e-Mental Health:
Challenges for the Future
Maria Fernanda Cabrera
Telecommunication Engineering School, Technical University of Madrid
ISLANDS Project Coordinator
Since the development of methods for electronic communication,
clinicians have been using information and communication technologies
in healthcare. However, rapid and farreaching technological advances are
changing the ways in which people
relate, communicate and live. Technologies that were barely used ten
years ago, such as the Internet, email, and videoconferencing are
becoming familiar methods for diagnosis, therapy, education and training. This is producing a promising
field – e-mental health – whose focus
is the use of communication and
information technologies to improve
the mental health care processes.
This area has developed rapidly,
accumulating knowledge and proposing innovative affirmations. This is a
multidisciplinary field that requires
the cooperation among different professions: psychiatrists of different
specialties at one end, and software
programmers, designers and computer engineers at the other. The results
of this collaboration are represented
by the ISLANDS project partners in
the present compilation of papers.
The first paper in this issue is a
discussion of the future of telepsychiatry in Europe by McLaren that examines different aspects of this discipline. His paper outlines the main
challenges for public mental health
services in Europe. In order to make a
positive impact with the use of telepsychiatry in e-mental health, it will
need to demonstrate how it can help
service planners and providers to
address accessibility, user empower-
ment and competent service in the
point of need.
In the second article, Sulzenbacher et al. describe the use of electronic telecommunication in psychiatry.
After a defination of the terms ‘telepsychiatry’ and ‘e-health’ and a short
presentation of basic of electronic
telecommunications the current psychiatric utilisation of the telephone,
videoconferencing, and the Internet is
described.
The third paper, by Cabrera et al.,
is an attempt to develop and comprehend the potential of e-mental health
through the presentation of the
ISLANDS project whose specific
goal is to develop services to provide
modular, non conventional, remote
psychiatric and psychotherapeutic
assistance for remote areas.
In the next paper, Amditis et al.
describe the architecture and components of the telepsychiatry platform
planned for this project. The result is
based on the analysis of the state of
the art telemedicine systems, as well
as, in the extensive compilation of the
different kind of available technologies.
Next, Panou et al. discuss on the
need of computer based tools to support Web and teleconference based
interventions. The paper presents the
preliminary tools that are being developed within the framework of the
ISLANDS project.
After that, Bullinger et al. present
the ISLANDS scenarios and service
batches. The treatment scenarios consist in the specification of nine categories which address the needs of
possible users in the psychiatric and
psychotherapeutic field. According to
different mental health problems
(phobia, depression, alcohol-related
disorder and psychotic disturbances)
each category comprises modules to
help users suffering from or concerned with this problem.
The next paper, reports on the
results of a new process quality
analysis in a telepsychiatry routine
service. In it, De las Cuevas and
Artiles, provide the methods and the
statistical analysis of a one year teleconsultation psychiatric service in the
Canary Islands. Results showed that
the continuous quality improvement
approach diminished the working
time and increased the productivity of
a telepsychiatry service.
The next paper indicates the general ethical principles that apply to the
ISLANDS project research. In it,
Senn et al give the general ethics related to research with humans and research involving testing and assessment, that concerns the proposed
screening, counselling and treatment
services provided in the context of
this project.
Meise et al. report on the potential
constraints and obstacles relevant to
the introduction of e-mental health.
The main restrictions identified and
analysed in the paper fall into five
categories: human, ethical, legal,
business and technological.
In their contribution, De las Cuevas and González examine the concept of presence in telepsychiatry.
Their report outlines the relevance of
the recent context created by the new
e-Mental Health: Challenges for the Future
communication technologies and the
novel patient-practitioner relationships.
The next article, by McLaren and
Charles-Nicolas, is concerned with
the first EU funded telepsychiatry
project, the Telemed Project (RACEProject R 1068). The paper reviews
the technical and organisational background to Telemed and summarizes
key results.
Following this, a paper by Politis
et al., reports on the perspectives of
using communication technologies
applied to psychiatry in Greece. It is
thought that the implementation of
telepsychiatry is not only bounded to
therapy or consultation, but also to the
education of the healthcare providers.
Authors concluded that the application
of these methods clearly depend on a
careful structural planning.
After that, a report by Doubek et
al. concerns the history of telephone
help lines in Czech Republic and
gives future possibilities of telepsychiatry in this European Region. The
paper describes different help lines
available that cover different operation modalities: independent organisation, outpatient clinic and inpatient
clinic.
Finally, Le Guen et al. present in
their paper the six month follow-up
results of an experimentation protocol of teleconsultation per satellite in
French Guyana. The results reveal
that, in spite of the extreme operational difficulties this geographical area,
it is possible to deploy a telemedicine
58
network in truly isolated sites and follow pre-established protocols. Teleconsultation is a reliable and useful
medical practice, reasonable in terms
of cost and technically controlled.
All in all, the current special edition contributes significantly to the
cumulative knowledge of emerging
e-mental health. The writings in this
journal are evidence of a scientific
reality today, specifically, what many
psychologist of psychiatrist once considered futuristic therapy is now clinical actuality. The future is present,
at least in the human mind.
Neuropsychiatrie, Volume 18, S 2, 2004, page 59-6318–125
Review
The Future of Telepsychiatry in Europe
Paul McLaren
The Priory Ticehurst House and
South London & Maudsley NHS Trust, London
Key words
Telepsychiatry, Videoconferencing, Mental
health, tertiary and secondary Services
The Future of Telepsychiatry in
Europe
This paper will discuss the future
of Telepsychiatry in Europe. Telepsychiatry has been researched for
over 50 years but has still to make a
significant impact on service delivery. Costs are falling and access to the
technology increasing and Telepsychiatry has the potential to deliver
culturally competent and effective
mental health services in a market
which spans the new European Community.
Introduction
Telepsychiaty has been defined by
Wootton, Yellowlees & McLaren
[20] as the, ‘Delivery of health care
and the exchange of health care
information for the purposes of providing psychiatric services across
distances’. It is not new. The earliest
reports in the literature were from
Nebraska in the late 1950’s, when
Wittson & Dutton [19] reported on
the use of a closed circuit television
system operating over a microwave
link to connect the Academic Department of Psychiatry at the University
of Nebraska with a state psychiatric
institution 100 km away. The aim of
this research group was to improve
the communication between an isolated struggling institution and an academic centre and thereby raise clinical standards in the institution. Subsequent Telepsychiatry research has run
in the same groove. Since its inception, it as been promoted as a potential solution to or the inequalities in
mental health service provision produced by geography and market forces. The combination of an advanced
telecommunications infrastructure,
low population density and unequal
distribution of medical resources was
offered as the recipe for successful
Telemedicine in general and Telepsychiatry in particular. These factors
occur where the bulk of Telepsychiatry research has been reported in
Australia, Canada and the western
United States. More recent developments have focussed on improving
communication between primary and
secondary health services [6] and between elements in increasingly distributed and fragmented community
teams [14].
Telepsychiatry in Europe
The research reported in this supplement on the ISLANDS project
represents an important extension of
Telepsychiatry experience in Europe.
It will generate valuable information
on the generalizability of the results
of earlier studies. This is not the first
project to look at the use of Telepsychiatry to enhance mental health services to the periphery of the Europe-
an Union (EU). Tertiary services have
been piloted from the South London
& Maudsley NHS Trust in London to
the Channel island of Jersey [5]. Goncalves [4] described a Telepsychiatry
component in a telemedicine link between Lisbon and the Azores. Mannion et al [8] in Ireland reported on a
link established between a hospital on
the mainland and the island of Inishmore, off the west coast of Galway.
Frier [1] et al. reported on the use of
videoconferencing in a psychology
Service in the Highlands of Scotland,
an area which has one of the lowest
population densities in the EU. This
service operated over 200 km between Inverness and the Isle of Skye,
using BT VC 7000 videoconferencing units connected by ISDN at
128 kbits/s. Twenty-seven adults and
seven children were treated with
Cognitive Behavioural Therapy
(CBT) by videoconferencing. Most
service users complained of poor
sound and picture quality, but were
still satisfied with the consultation .
These results highlighted important
issues for future developments such
as the challenge of balancing the
costs of high quality video imaging
against economic feasibility and
sustainability in what may be low
volume services.
Mielonen et al [11] reported on
the use of videoconferencing in Oulu
in Finland, where videoconferencing
at 384 kbits/s was used for family therapy, occupational counselling, clinical consultation and teaching. In 1996
videoconferencing was used in this
area for a total of 249 hours, which
increased to 434 hours in 1997.
During 1997, 45% of the time was
used for teaching, 26% for occupational counselling, consultations and
therapies, 23% for training and 6%
for administration.
This same group [12] reported on
the use of videoconferencing for
discharge planning from a mental
health unit. The majority of participants stated that they would prefer to
have their next meeting by videoconference. The most common reasons
given were the reduced need for
travelling and the ease and speed of
the consultations. An economic analysis showed that at a volume of
50 care planning consultations per
year, the videoconferencing alternative is about FM 2340 cheaper than
conventional meetings and the municipality would save about FM
117,000 by using the medium. Six
hours of travelling time could be used
for other purposes when the meeting
was held by videoconferencing.
The future of mental
health care in Europe
The main challenges for public
mental health services in Europe are
accessibility, user empowerment and
getting culturally competent services
to the point of need in a timely
fashion. If Telepsychiatry is to make a
positive impact, on mental health
then it will need to demonstrate how
it can help service planners and providers address these challenges. There is little in the literature to support
claims that it can do this. Most research in the field has been technology
driven rather than being proposed as a
solution to a service need [13]. Telepsychiatry will not make a poor service provider effective or a failing service efficient but it could be a powerful tool for opening up the mental
health care market in Europe and
giving consumers greater choice as to
where they get their care. The migration of elders from north to south and
60
the anticipated migration of labour
from east to west will generate increasing demand for international mental health care within the EU.
The treatment of mentally disordered offenders is another major challenge with which Telepsychiatry may
assist [22].
Most Telepsychiatry services have
been performed in real time, as ‘live
links’. A trend in other areas of Telemedicine has been the development of
store and forward services, for example in Teledermatology. In these services a clinical history and still image
are captured at a remote site and sent
by electronic mail to a specialist for an
opinion. It is difficult to envisage the
drivers which would lead to the development of store-and-forward clinical
Telepsychiatry. Further opinions could
be sought in current services through
sending video clips on DVD’s or videotapes but this is employed only in
exceptional circumstances. Watching
the tape will give the expert less information than a face-to-face interview
and will be as time consuming. Storeand forward Telepsychiatry may
become a tool for professional supervision A consultation can be recorded
digitally, stored as a record and transmitted to a remote supervisor for
viewing and commenting. The Tromso group [3] reported the use of videoconferencing for psychotherapy
supervision using 384 kbits/s ISDN
(Integrated Service Digital Network)
connections. Trainees had five faceto-face sessions, alternating weekly
with videoconferencing. The quality
of supervision could be satisfactorily
maintained by videoconferencing, for
up to half of the 70 hours required for
training. A precondition for this estimate was that the supervision dyad
should meet face-to-face and establish
a relationship characterised by mutual
trust and respect. Major concerns
reported by the participants were the
loss of non-verbal cues and the effects
this had on spontaneity, the expression of personal emotional material,
and the experience of social and emotional presence.
Telepsychiatry consultations can
be routinely recorded in digital format and monitored remotely. This
may become a key element in the clinical mental health record, offering
protection to the consumer against
abuse and the professional protection
against malicious allegations. In a
Telepsychiatry consultation the power in the encounter is tipped towards
the service user, relative to the faceto-face condition. They are seen
closer to or in their own home, not in
the professionals office in an intimidating institution.
Communications technology has
crept into many areas of mental
health care delivery without research
or clinical champions. The telephone
is often used by professionals to follow up patients with whom they have
a therapeutic relationship. This has
rarely been formalised but where it
has, it has been deemed advantageous. Simon et al [18] reported a randomised controlled trial of a system
for giving General Practitioners feedback on prescribing to depressed
patients versus feedback on prescribing plus care management including
systematic follow up by telephone.
The care management with telephone
follow up significantly improved
clinical outcomes in this depressed
sample. Telephone help lines, such as
the Samaritans, over which users
disclose painful or intimate personal
details, to people they may never
meet are hugely popular. The telephone offers a combination of accessibility, anonymity and confidentiality
which may make it a suitable tool for
psychotherapy [7].
The educational and informationgathering components of the cognitive behavioural therapies (CBT) are
ideally suited to computerization. The
building blocks of the therapeutic
relationship, which are central to all
therapies, are still poorly understood
and still too nebulous to digitize. This
may lead to the development of
hybrid models of CBT with the information-gathering, self-monitoring
and educational components delive-
McLaren
red by information technology while
the therapist focuses on live sessions,
face-to-face or by videoconferencing.
This will allow the total time in therapy for service users to be increased,
while the therapist’s time is reduced
and better focused. The efficiency
and effectiveness of the psychotherapies could be improved and if the
relationship component is delivered
by communications technology then
access will be improved and costs to
service users reduced.
The delivery of psychotherapy by
such systems should not be seen as a
threat to existing service providers.
Attempts should be made to integrate
the technology into other service delivery models.
Most professional and service
users who have been asked, have
found Telepsychiatry services acceptable [2, 13, 14, 15]. They like the
increased access and the choice that
they have via such services, and it has
been suggested that they also like to
have the ability, if they wish, to
‘switch off’ the practitioner. It has
been suggested that some service
users may prefer being assessed or
treated electronically, namely those
patients who are paranoid or avoidant.. The potential of Telepsychiatry
to improve access for those with
severe and enduring mental illnesses
needs particular attention.
The legal and ethical
framework
There have been many concerns
expressed about the risks to safety
and security of personal data when
information technology is used. These concerns tend to be magnified by
the idea that information is transmitted over distance. In an early phase of
the Telemed project ( see McLaren &
Charles-Nicholas in this supplement)
when the LCVC was installed in a
room on a ward, the research team
were asked to remove a computer
with a camera mounted on top even
61
though it was obviously unplugged
from the mains and the telephone
line, because visiting professionals
were concerned that it posed a risk to
confidentiality. Such prejudices are
less common as experience with
information and communication
technology grows but there is still a
need for professional education on
the technology. This is often overlooked in technology driven projects.
Factors influencing
technology adoption
Key issues in technology adoption have been described by Rogers
[16]. He hypothesised that about
5–10% of any population were ‘early
adopters’ of the new technology and
in Telepsychiatry, it is these individuals who are still setting the pace.
Rogers also hypothesized that
70–80% of providers will adopt if
there is evidence to support its adoption. Rogers’ final group were the
remaining 10–15% of any population
who are described as ‘laggards’. This
group is the last to change. The
evidence base for Telepsychiatry
needs to be further strengthened to
generate the critical mass of adopters
required to make it economical. The
ISLANDS programme will provide
valuable information in this respect.
Younger mental health professionals
are coming through with much stronger information technology skills and
are much more aware of the power of
information and communication
technology to enhance efficiency at
work. This will lead to further innovation, more rapid adoption and ultimately improve the provision of mental health services.
Key issues for the future developments of Telepsychiatry health services are licensure, registration and
professional insurance within countries and across national, regional or
international boundaries. Changes to
legislative frameworks tend to be reactive, following changes in practice.
Recognition that adequate assessments can be made by videoconferencing for the purposes of compulsory
treatment will be an important developments. So also will the development and adoption of national and
international guidelines to ensure that
the increased access offered by Telepsychiatry does not result in harm.
A further challenge is remuneration for Telepsychiatry consultations.
Governments have been slow to
remunerate doctors for providing services via videoconferencing, although this does now happen in the
USA. Other health systems have only
allowed payment for videoconferencing when it is undertaken as part of
the clinician’s daily work, as in the
case of public sector health systems
in Australia, the United Kingdom and
Canada. There has not, however, been
acceptance by governments of payments for videoconferencing in the
same manner as face-to-face services.
Payments for email and telephony
services are unusual. There are some
health sectors in the USA that will
pay for short email medical consultations, although not usually in mental
health.
A factor which has inhibited the
development of sustainable funding
systems for Telepsychiatry services is
that the costs of setting up go to the
service provider and most of the cost
savings go to the patient in terms of
reduced travel and opportunity costs.
The provider has to offer the same
amount of professional time in direct
contact with the service user. Possible
areas where costs may be saved for
the provider are in terms of reduced
downtime from professional staff travelling. It has been assumed that
Telepsychiatry services and videoconferencing interactions are inferior
to face-to-face, because they are mediated and communication is lost due
to the limitation of channels by the
medium [17]. There is no body of evidence to support this in clinical use. It
is possible that for some tasks videoconferencing is a superior medium
and it may be that a premium should
be charged for remote services. Cost
savings and convenience accrue to
the service user.
Telepsychiatry in future will probably use Internet Protocols in a broadband environment, and the speed of
implementation will depend in part on
the rate of broadband roll out. This is
less of a problem in public sector services, where fibre optic networks are
increasingly being deployed, but will
remain difficult in terms of making
the last connection into the home. The
further development of broadband
networks will undoubtedly accelerate
the use of Telepsychiatry.
The commercial potential of Telepsychiatry has yet to be realised in the
private health care market. Significant adoption of digital technology
has taken place in the banking and
entertainment sectors and these will
be the drivers for getting broadbandlinks into the home. Partnerships
between health care providers and
telecommunications providers will be
required before significant roll out
can take place.
Further research
There is a need to strengthen the
evidence base for Telepsychiatry.
Most of the published research is on
pilot projects with limited information on sampling, statistical power
and image parameters. Getting funding for trials with sufficient power to
demonstrate clinical effectiveness in
a range of disorders and settings has
proved difficult. There is also a need
for meaningful economic evaluations. Some qualitative research has
been reported. May, et al ( 9) reported
on a Telepsychiatry referral service
for patients being treated by GPs for
anxiety and depression, using the British Telecom VS1 desktop videophone over 128 kbits/s. Twenty-two
patients and thirteen doctors were
interviewed after a video-link consultation. Twenty-two patients and thirteen professionals were studied.
62
Professionals stated that they did not
see a need for videoconferencing
where accessibility is not a problem.
The most important problem identified was the extent to which communication skills needed to be adjusted
to meet the demands of the medium.
In a further analysis [10], it was
reported that the use of videoconferencing in this way threatened professional nursing constructs about the
nature and practice of therapeutic
relationships.
An additional complication for
research is the rapid development of
the technology. In the two to three
years that it takes to complete a clinical trial the specification of the equipment tested is likely to become obsolete. It is likely, however, that Telepsychiatry services will become increasingly cost effective on the
broadband Internet [21]. Much more
could be gained from Telepsychiatry
research if smaller projects could be
combined to improve statistical power and reduce administrative costs.
The ISLANDS project will stimulate
international collaboration and further multicentre research.
Relatively little is known about
the significance of image parameters
in videoconferencing for clinical processes. Videoocnferencing equipment with a broad range of specification has been used in published research. The bandwidth is usually quoted, but not the picture parameters
and it is these that matter more to the
clinician and the patient. The experiences of communicating over a
videophone connected by the telephone network and a rollabout videoconferencing unit connected by a
high capacity digital line are very different. High specification equipment
costs more to buy and costs more to
connect. It produces a better quality
image but what quality of image is
good enough for which task? Basic
information on the relationship between image parameters, such as definition, colour scale, frame rate and
image size, and clinical outcomes is
still lacking. Microanalysis of media-
ted interactions has the potential to
reassure professionals as to the ways
in which the process is changed in
clinically significant ways.
Conclusion
Psychiatrists using videoconferencing have had issues with picture
resolution and video frame rate. GPs,
nurses, clinical psychologists and
social workers provide the bulk of
mental health services. Their role in
Telepsychiatry service provision has,
been one of supporting the patients. If
Telepsychiatry is to make a real
impact on service provision it will
need to be embraced by the bulk of
professionals providing services ,nursing and social workers and be seen to
facilitate the development of their
professional roles.
A key research question to be
asked in community mental health
care is which communications medium is most appropriate for which
task . More research is required to
analyse the costs and benefits of
using the telephone, videoconferencing, email, the post and face-to-face
communication for core clinical
tasks. There is a need for international
standards of service delivery in Telepsychiatry.
Telepsychiatry has been piloted in
a wide range of geographical locations and service models. Service
user responses have been generally,
but not uniformly positive and these
responses need further clarification.
Professionals have embraced videoconferencing for supervision, education and administration, but are still
wary of using it for communicating
with service users for clinical tasks.
This wariness may owe more to prejudice and professional defensiveness, than objective assessment. The
costs of kit and communication links
have limited the diffusion of such
applications to areas with low population density, where economic benefits are obvious. Costs of both are
McLaren
falling rapidly and the readiness with
which service users, even while suffering from acute and severe mental
illness, adapt to clinical consultations
by videoconferencing, suggests that
this mode of service delivery could
become commonplace, both for
accessing scare national and international tertiary expertise and for improving communication between elements in distributed urban community services. Mental health services are
facing growing demands and struggle
to deliver effective treatments in sufficient quantity. Efficient communication between service elements and
getting effective treatment to service
users in a timely fashion are two of
the major challenges facing mental
health services this century. Telepsychiatry has been shown to have the
potential to improve both. Within two
decades videoconferencing could be
the preferred medium for contact
between professionals and mental
health service users in Europe.
63
[7]
[8]
[9]
[10]
[11]
[12]
[13]
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;6; (suppl 1) 93-95
Dr. Paul McLaren
Honorary Consultant Psychiatrist
South London & Maudsley NHS Trust
62, Speedwell Street
Deptford
London SE 8 4 AT
Email: PMcl639251@aol.com
and
Medical Director
The Priory Ticehurst House
Ticehurst, Wadhurst
East Sussex TN5 7HU
United Kingdom
Review
Telepsychiatry and e-Mental Health:
Electronic Telecommunication in Psychiatry
Hubert Sulzenbacher1, Alex H. Bullinger2, Thomas Senn2, Evangelos Bekiaris3
and Ullrich Meise1
1
Center for Online Mental Health, Dept. of Psychiatry, Medical University Innsbruck
2
Center of Applied Technologies in Mental Health, Dept. of Psychiatry, University Basel
3
Center for Research and Technology Hellas, Hellenic Institute of Transport, Thessaloniki
Key words
Telepsychiatry, e-Mental Health, Telephone, Videoconferencing, Internet
Telepsychiatry and e-Mental
Health: Electronic Telecommunication in Psychiatry
The terms Telepsychiatry and
E-Mental Health describe the use of
telecommunications media in psychiatry. Telepsychiatry is mostly used in
connection with psychiatric videoconferencing, while the term E-Mental Health is related rather to the Internet. Communication media with a
wide range of possibilities for use in
psychiatry are the telephone, videoconferencing, and the Internet. The
telephone is a well-tried medium in
emergency medicine and crisis intervention, but rarely usable for psychiatric diagnosis because of the lack of
visual information. Videoconferencing, on the other hand, offers the
reliability of psychiatric face-to-face
diagnosis, if the transmission speed is
fast enough. So far, because of high
technical and financial requirements,
videoconferencing has been used
mainly under very distinctive geographical and economic circumstances.
Via web sites, chat rooms, message
boards or e-mail, the Internet facilitates a variety of communication possibilities in psychiatry. Although one
can hardly doubt that presently the
potential of electronic telecommunications is not exploited fully, the
obstacles and limits in all their technical, organisational, political, geo-
graphical, economic, linguistic, ethical-juridical, social, and medical
aspects have to be considered.
prehensive definition is presented
below:
Telemedicine is defined as the
delivery of health care and sharing of
medical knowledge over a distance
using telecommunications systems.
[101]
Introduction
Definitions
When assessing the quality of
health-care systems, general access to
medical care is undoubtedly a key
criterion. As it is more difficult to
achieve adequate access to healthcare for people living in rural areas
than for those in urban environments,
the improvement of medical care in
remote regions has to be seen as a
major task for every health-care
system. The most obvious solution
for this problem is increased settlement of physicians and establishment
of hospitals, but as this is expected to
reach its economic limits soon because of insufficient utilisation, other
solutions have to be found.
Certainly the use of telemedicine
can reduce the problem of inadequate
health-care in remote areas. Through
telemedicine, medicine by distance, it
is possible to save time and money for
patients and therapists, as only the
medically relevant information between those involved and not the individuals themselves has to be transferred. Although the term 'telemedicine'
has been defined frequently, most
definitions differ just marginally. As
an example S.W. Strode’s very com-
Telemedicine is not an invention
of the electronic age, but the development of electronic communication
media has increased the speed of
information transfer so much, that the
use of telemedicine could now be
acceptable from an economic, but
also an ethical view. As on the one
hand medicine over large distances is
currently only efficiently realisable
through electronic media and as on
the other one of the most important
benefits of electronic communication
media probably lies in overcoming
geographical barriers, the terms 'telemedicine' and 'e(lectronic)-health' are
inseparably connected.
The term 'e-health', which was
developed recently in analogy with
terms like 'e-commerce' or 'e-business' focuses on the electronic transmission of medical information.
Comparing it with 'telemedicine', J.
Mitchell gave the following definition of 'e-health':
E-health is […] a term which describes the increasing use of electronic
communication and information
technology in the health sector. Telemedicine is the term used to describe
the use of telecommunication for the
provision of medical services to
distant locations. E-health is a more
general term that describes the use of
Sulzenbacher, Bullinger, Senn, Bekiaris, Meise
both telecommunication and information technologies for the delivery
of health services both at a distance
and locally. Hence, e-health is an
umbrella term that encompasses telemedicine and telehealth. [83]
conferencing and the Internet, is neither categorised as 'telepsychiatry' nor
'e-mental health', if rigid definitions
are used.
From the psychiatric viewpoint
both definitions are problematic, due
to the way electronic telecommunications became involved in psychiatry
historically. The term 'telepsychiatry'
was first used for interactive videoconferencing in psychiatry [31] in
1973 and since then both terms have
been used synonymously. Although
there have been repeated attempts to
define 'telepsychiatry' in a broad sense similar to 'Telemedicine', colloquially but also in scientific literature
the term is used almost exclusively
for psychiatric interactive videoconferencing. A. Buist et al. expressed
this usage explicitly:
Telepsychiatry is a specialist form
of telemedicine in which videoconferencing is used by psychiatric practitioners to communicate with other
mental health service providers and
with patients. [15]
Basics of electronic telecommunication
And also the term 'e-health' is not
usually used in the comprehensive
sense suggested in the definition
above. G. Eysenbach gave a definition which considered the term’s
Internet origin:
e-health is an emerging field in
the intersection of medical informatics, public health and business,
referring to health services and information delivered or enhanced
through the Internet and related technologies. [37]
This conceptual vagueness was
the reason we chose to use both
terms, 'telepsychiatry' and 'e-mental
health', in this article as the psychiatric use of all important telecommunication media will be presented. The
compromise made here is clear when
we consider that the telephone, the
most important communication medium in psychiatry, alongside video-
Each communication medium can
be characterised by several technical
parameters which determine its possible uses. In this chapter some important parameters will be described with
regard to the most common electronic
media and their use in psychiatry.
65
in post-discharge care.
Still pictures: These can be transmitted via television, web sites or
e-mail. Telemedical transfer of still
pictures is used primarily in radiology, pathology and dermatology for
diagnostic purposes. With the increasing diffusion of the Internet new
uses, such as medical education, have
recently emerged [28], although in
psychiatry there are hardly any possibilities to exploit these.
Audio-visual data: Such information can be transmitted via television,
web sites or e-mail. In psychiatry
audio-visual data transfer is used for
diagnosis and psychotherapy, but also
in supervision, psychiatric education
and administration.
Type of information transferred
Physiological data: The monitoring of physiological functions over a
distance is called 'telemetry'. Telemetry was probably first used by NASA
for terrestrial surveillance of astronauts' blood pressure, respiration and
body temperature [112]. More recently this technology was used for
instance for ECG-monitoring [87],
electro-physiological observance of
mountaineers [50, 88] and divers
[60], and SIDS-risk infants [4]. From
the psychiatric view, the possible uses
seem to be limited.
Written text: The classical form of
storing information and the most
important form of communication in
science. Although each optical communication medium is able to transmit written texts, for this sort of information transfer mostly web sites,
message boards, chat rooms, and
e-mail are used. In psychiatry written
text is used for general information
transfer and education, but also for
psychotherapy.
Spoken text: is mostly transmitted
via radio and telephone, but is also
transferable through web sites and
e-mail. In psychiatrie telecommunications spoken text is used mostly for
organisational and administrative
purposes, in emergency medicine and
crisis intervention, and occasionally
Direction of information transfer
Unidirectional information transfer enables the transmission of data in
only one direction, from one defined
transmitter to one or more defined
receivers. This form of data transfer is
used in radio and television broadcasts and on simple non-interaktive
web sites. In psychiatry unidirectional data transfer can be used for
transmitting general information and
psychiatric education.
Bi-directional information transfer: Here the position of transmitters
and receivers changes during the
communication. Such an interactive
form of communication is made possible by telephone, videoconferencing and e-mail. As bi-directional
data transfer allows information exchange between two people, psychiatric diagnosis, counselling and psychotherapy is possible.
Multidirectional
information
transfer: This form allows more than
two people to communicate with each
other. Every participant can act as
transmitter as well as receiver. Multidirectional telecommunication occurs
in audio- and videoconferences and
Internet, mediated in message boards
and chatrooms. This form of information transfer allows discussions and
Telepsychiatry and e-Mental Health: Electronic Telecommunication in Psychiatry
exchange of ideas between more or
less selected groups of communication partners.
Synchronicity
Synchronous communication demands simultaneous attention of all
communication partners. Radio and
television broadcasting, telephone,
real-time-videoconferencing, and Internet chat rooms are based on this
form of communication. Synchronicity allows immediate interaction of
communication partners, as required
for instance in crisis intervention and
diagnostic interviews.
Asynchronous communication:
The transmitted information is stored
and available for the receiver when
needed. This form of communication
is used in telephone mailboxes, storeand-forward videoconferencing and
in various Internet-mediated technologies like e-mail, web sites, and message boards. Asynchronous communication is used for example in organisation and administration, education and discussions.
Communication Media
in Telepsychiatry and
E-Mental Health
In terms of their use for psychiatric purposes telephone, videoconferencing and Internet play a prominent
role. These three communication
media can be used for psychiatry in a
number of ways: for education,
exchange of ideas, diagnosis, therapy,
organisation and administration as
well as for crisis intervention and
psychiatric emergencies. The utilisation of these media in psychiatry is
described below.
Certainly there is a multitude of
other widespread communication
media, but there is comparatively
limited use for any these in psychiatry. As a result, just a few sporadic
articles on the use of these media in
psychiatry have been published, for
instance about television spots within
the Anti-Stigma campaign of the
World Psychiatric Association [94] or
about the diagnostic reliability of the
fax [10]. Because of their restricted
psychiatric use, a description of these
communication media has been
excluded in this article.
Telephone
Overview
The first telecommunication
medium, electromagnetic telegraphy,
was already developed in the first half
of the 19th century. Telegraphy allowed asynchronous bi-directional
transmission of written information,
however, efficient utilisation was
restricted by technical inadequacies:
First the text which was to be transferred had to be encoded into a (developed by S.F.B. Morse in its original
form) binary sign system, and after
transmission the receiver had to decode the text. For this en-/decryption
specialists skilled in the use of the
Morse-alphabet were required, who
were placed at telegraphy offices. So
not only was the use of the new
communication medium restricted
mainly to larger communities, furthermore it was very expensive.
Compared with telegraphy the
telephone, for which A.G. Bell received the patent in the year 1876, had the
advantage that no encoding and decoding of the transmitted text was required. As the users of the new medium
were not dependent on en-/ decryption
specialists, the telephone could be
installed directly at the users' homes.
Furthermore the telephone allowed the
communication partners a synchronous bi-directional interaction, by
which direct conversations over large
distances were made possible. As a
result, it is no surprise that the new
medium spread rapidly: In 1922, the
year Bell died, 14 Million telephone
lines were registered in the USA alone.
66
Very soon these new communication possibilities were also used in
medicine. The fast and uncomplicated information exchange via telephone allowed its use in organisation
and administration as well as in emergency medicine and crisis intervention. Until today the telephone has
been an indispensable part of these
medical fields.
Given the telephone's omnipresence and manifold usability, there is
a surprising shortage of scientific literature on its medical use. This shortage is alarming mainly in terms of
psychiatry, as here, more than in any
other field of medicine, quality and
therapeutic success are based to a
similar extent on verbal interaction, a
form of interaction which can easily
be carried out over the telephone.
Utilisation in psychiatry
Psychiatric diagnosis by telephone is problematic: The reliability of
telephone based diagnoses is partially
– dependent upon the disorder in
question – lower than in face-to-face
interviews [91]. However, psychiatric
screening by means of standardised
screening instruments, for which a
lower diagnostic reliability is acceptable, is feasible by telephone [8].
Compared with its limited diagnostic possibilities, the telephone
has a great potential in view of postdischarge care. With medical aftercare by telephone, it is possible to
reduce the dosage of prescribed
medication, the accumulated costs,
and the frequency and duration of
further hospital admissions [96, 108].
While the telephone's possibilities
have been little used in psychiatric
after-care so far, the telephone has
been serving for decades in psychiatric crisis intervention as an inestimable – often underestimated – tool.
Since the first telephone helpline was
established in London in 1953, an
extensive network of telephone crisis
intervention has developed [30]. Furthermore informal crisis intervention
is probably offered by most psychia-
tric divisions and outpatients departments. A certain suicide preventive
effect of telephone crisis intervention
could be proved [27].
The telephone is the most important communication medium in
rescue services and an essential component of practices and hospitals. On
average, a physician spends approximately one whole workday per month
with phone calls [40].
Moreover the telephone has been
playing a significant role in synchronous forms of telemedicine, and was
consequently esteemed as "the most
important part of telemedicine" [58]
and as "the most basic unit of a telemedicine equipment" [112]. Despite
the fact that in scientific literature the
telephone has been neglected in
favour of the more spectacular videoconferencing, it should be examined
whether, considering the video quality achievable, this method really adds
anything compared with a simple
telephone connection, particularly if
no broadband connection is available
[100].
Videoconferencing
Overview
Videoconferences were used in
psychiatry for the first time in the
1950’s, when C. Wittson established
an interactive audio-video link between the Nebraska Psychiatric Institute in Omaha and the Norfolk State
Hospital, 180 km away. Already in
this early period a broad spectrum of
uses was found such as psychiatric
education [110], group therapy [111],
and psychiatric consultation [11].
In the year 1973 the term 'telepsychiatry' was coined for psychiatric
videoconferences [31] and, although
until today videoconferencing has
been used in nearly all medical fields,
psychiatry frequently was seen as
'native application' of interactive
telemedicine by means of videoconferencing [3].
Although videoconferencing is
usable as an asynchronous communication medium too, it is used in
psychiatry almost exclusively as a
synchronous bi- or multidirectional
communication medium. So, similar
to the telephone, an immediate interaction between all communication
partners is possible. But the additional transmission of visual information provides the important advantage
of a better diagnostic reliability compared with the telephone. If a sufficient quality of picture and sound can
be guaranteed, videoconferencing is
able to achieve the diagnostic reliability of a face-to-face interview
[6, 35].
However, the quality of the transferred audio-visual information
depends on the transmission speed. If
a transmission speed of 384 kbit/s or
faster is available, highly reliable
psychiatric diagnosis is possible;
lower transmission speed reduces the
diagnostic reliability [113, 115]. This
means that videoconferencing, if it
should be used for diagnosis, requires
high acquisition costs as well as high
operating expenses. These high costs
are probably the main reason why so
far psychiatric videoconferencing
could only be practised under very
specific circumstances: As an integrated routine service, videoconferencing exists presently almost exclusively in rich developed countries with
large sparsely inhabited regions
which are therefore difficult to provide for medically.
The high costs of interactive television have caused a second important difference compared with the
telephone: As such a system is hardly
affordable for private households,
potential users usually cannot be contacted at their homes. Although in
some Telemedical projects videoconferencing systems were installed
directly at the users' homes [85, 106],
the services were usually – and as
routine services exclusively – installed in public institutions. Of course
the possibilities for use of such office/hospital-based telemedicine differ
very much from home-based teleme-
67
dicine [53], as it is made possible
through the telephone or the Internet.
Psychiatric videoconferencing
has always been seen as a chance to
improve mental healthcare in remote
areas. However, because of high costs
such systems have succeeded mainly
in rich countries with sparsely populated remote areas, such as Australia
[15, 21, 24, 29, 45, 52, 73, 104],
Canada [48, 105], the USA [14, 36,
46], or the Scandinavian states [33,
43, 82]. Several projects were concerned with the problematic situation of
psychiatric healthcare on smaller
islands [26, 49, 76, 98]. As problems
of mental healthcare also occur in big
cities, some inner-city projects have
also been set up [13, 78].
The possibility of performing
psychiatric and psychological diagnosis via videoconferencing was
used quite often in recent years, and
for most mental disorders. Usually
the diagnoses are based on psychiatric interviews, occasionally using
standardised tests which have been
adapted to the requirements of the
medium [9, 16, 84, 116].
Continuing psychiatric care after
the first diagnostic interview has been
offered rather rarely: Considering the
high prevalence of chronic and recurring mental disorders, various studies
enumerate surprisingly low numbers
of follow-up sessions [64, 97, 105].
Videoconferencing has not only
been used as a communication tool
between patients and experts, but also
for the exchange of information between therapists, education, administration, supervision and training [43,
54, 62, 64, 73, 89]. Psychologists and
psychiatrists, nursing staff, social
workers or occupational therapists
participated in such sessions [15, 33].
Numerous studies showed high
satisfaction among patients and therapists [15, 26, 34, 57, 67, 81, 84, 90,
98, 109]. The reservations, mostly
among therapists, can probably be
explained with frequently occurring
technical problems [42, 43, 51, 65,
75, 79, 84, 99].
Although usually in psychiatric
videoconferencing modern high-tech
equipment is used, the interaction
itself is rather traditional: Because of
the concentration on diagnosis and
therapy, normally only patients and
therapists participate in videoconferencing sessions. Apart from parents
in child-psychiatric projects [34, 35,
67], the patients' relatives are rarely
involved. Consequently the socialpsychiatric demand for integration of
family members in the therapeutic
process hardly seems to be realisable
with interactive television.
Half century ago, when videoconferencing was used in psychiatry for
the first time, many people expected a
great success of the new communication medium. Instead a slow and hesitating development took place.
Depending upon various geographical, technical and economic circumstances, psychiatric videoconferencing has only succeeded in a few
regions. However, the increasing diffusion of webcam and broadbandInternet could well lead to a fundamental change in this situation in the
near future.
Internet
Overview
The idea of the Internet was conceived not later than 1962 when
J.C.R. Licklider published his description of a "galactic network": a
global network of connected computers, each computer able to send and
receive data and programmes to and
from all others. The first data transfer
over a large distance took place in
1965 [71]. Beginning in 1969, a
scientific department of the US-Ministry of Defence developed a network
between originally just four university computers: the Arpanet. This was
presented to the public successfully
in 1972 and already had forty connected computers [114].
Although the foundations for
computer networks were set up, the
enormous diffusion of the Internet
could not have happened without the
development of the Personal Computer. The first stages of development
date from the sixties, while the great
breakthrough took place in the late
1970’s. Until then mainly large
university computers were connected
in the network, after a huge new
market emerged with new interests
and demands (simple performance,
appealing design, entertainment
programmes).
In the following years the number
of computers connected with the network doubled nearly once a year and,
although the speed of the spread
slowed down recently, the Internet is
the fastest expanding technology in
history. However, the spread of the
Internet is extremely uneven: While
in many developed countries the
Internet is used at least occasionally
by more than half of the population,
in some of the poorest countries not
even one in a thousand has Internet
access [22]. All in all men use the
Internet more frequently, but health
websites are visited more often by
females; the typical Internet user is
comparatively young, lives in an
urban environment and has an above
average income and education [41,
72, 95].
The Internet is the most complex
communication medium ever developed. It allows the transfer of most different information in uni-, bi- and
multidirectional ways, synchronous
as well as asynchronous. Websites,
message boards, chat rooms, webcams, file sharing programmes,
e-mail and mailing lists are such different forms of information transfer
that in fact each of these can be seen
as a communication medium sui
generis. In this article, however, the
Internet is presented as a composite,
as normal Internet access allows the
user to employ all those single media
and to decide, to which degree and to
which purpose those media will be
used.
68
The World Wide Web offers an
immense and continually increasing
amount of information. It has been
estimated that there are approximately 100,000 websites dealing with
health questions [39], from which a
considerable segment is concerned
with mental health. These websites
are offered by a wide variety of owners: organisations operating worldwide as well as national, regional and
local psychiatric institutions, and also
individuals such as patients, their
families and therapists. Consequently
the information offered is impressively diverse: Descriptions of mental
disorders are available as well as
information on psychiatric stigma,
legal questions and presentations of
personal experiences of patients and
their relatives. The search for relevant
information can be facilitated by
categorised link lists [12, 74]. Frequently the quality of Internet information has been doubted, and some
scientific articles indicate that a certain scepticism towards medical
information on the Internet seems to
be reasonable [5, 68]. Nevertheless, a
systematic search for harm caused
through inadequate Internet information brought very few definite results
[23].
Although in principle psycho-diagnosis via the Internet is possible, the
diagnostic reliability can be too low,
if inadequate bandwidth is used
[115]. In view of the Internet's continuously increasing transmission
speed, however, it is to be anticipated
that this could be overcome in the
near future. No reliability problems
caused by low bandwidth exist for
psychiatric screening: Psychiatric
screening is a form of provisional
diagnosis by means of standardised
screening tools, which indicates a
certain likelihood for the presence or
absence of a mental disorder. It has a
significantly lower reliability than a
diagnostic interview [107]. Psychiatric screening is able to make people
afflicted aware of their possible men-
tal disorder. The Internet currently
offers such tests for various frequent
mental disorders, for instance for
alcohol-related disorders [56, 63],
anxiety disorders [1, 77], or depressive disorders [25, 86].
The fact that the Internet is also
usable for therapeutic purposes is little known, although for psycho-therapeutic methods it is absolutely feasible. There are several websites which
offer CBT programmes, some of
them with integrated diagnosis and
outcome testing by means of screening instruments [17, 18, 47]. Beside
such fully-automatic therapy programmes, the Internet also offers
individual psychotherapy. Here the
communication between client and
therapist usually takes place via email or in a private chat room [2].
Formally standardised psychotherapy
over e-mail is also available [59, 69].
The chances of success for Internetbased psychotherapy have been
assessed very differently. Undoubtedly patient selection, which is not easy
to make over the net, is of great
significance here [19, 20, 70].
Although synchronous multidirectional telecommunication in the
form of telephone and videoconferencing already existed before the development of the Internet, the widespread use of this form of telecommunication did not start before the invention of the Internet chat room. The
asynchronous multidirectional telecommunication of Internet message
boards is an entirely new form of telecommunication, made possible first
by the Internet. Currently multidirectional telecommunication is used primarily by patients and their families
and allows exchange of ideas, talking
about personal experiences and mutual support; psychiatric message
boards are usually moderated to prevent personal injuries or suicide propaganda of participants [66, 103].
The various forms of communication, which are offered by the present
Internet, can be used for psychiatry in
a wide variety of ways, and millions
of people are able to participate.
However, it has to be considered that
even more potential users are excluded from Internet access because of
economic, social and even medical
reasons. So it is one of the most
important technical and political
challenges of our time to enable as
many people as possible to access the
probably most important communication medium of the future.
Discussion
After the separate presentation of
the telephone, videoconferencing and
Internet in the previous section, in
this final part some aspects of psychiatric telecommunication will be
explored, which are significant for all
these communication media.
Technical aspects and network
architecture
Although a separate description
of those telecommunication media
which play an important role in psychiatry was preferred in this article, it
has to be emphasised that current farreaching technical developments are
leading to increasing convergence in
the possibilities of telecommunication media. Webcams, Internet-telephone or picture-telephone are presently still new and little used forms of
data transfer, but it is certainly imaginable that these media will be a common part of everyday communication
in a few years, as, for example, the
mobile phone and the SMS are already today.
It should be noted, however, the
possibilities of a telecommunication
medium do not only depend on its
technical parameters, but also on the
structure of the network used.
Psychiatric videoconferencing is
mostly used to improve the situation
of mental healthcare in remote rural
regions. Typically small regionally
connected networks are used. Videoconferencing is currently a very
expensive form of telecommunica-
69
tion, and therefore the carriers are
dependent upon financial support
from the local, regional, or national
government. It is not surprising therefore, that videoconferencing services
are typically orientated towards political borders and that transnational
projects are rare [92]. This orientation
is the reason that language barriers
play a more important role only in
multiethnic societies.
The Internet on the other hand is
hardly influenced by political boundaries: The Internet offers worldwide access to websites and e-mail
addressees. While videoconferencing
services are mainly installed in rural
areas, in terms of the Internet the
inhabitants of such remote regions
are disadvantaged compared with
people living in urban environments
[72]. Even though for the Internet
political borders don't play a particularly significant role, there is still one
important limitation for Internet
access: Language boundaries can hinder the access to relevant information, particularly if the user does not
master the predominant English language [102].
The system architecture of the
telephone network stands between
videoconferencing and Internet: On
the one hand the telephone allows
one, at least theoretically, to get in
contact with other people connected
with the telephone network worldwide; so the communication is similar to the Internet and restricted
mainly through language barriers,
less through political structures. On
the other hand different charges for
calls at home and abroad cause a political influence, too.
Home-based telemedicine &
office-/hospital-based telemedicine
With regard to the psychiatric usability of different communication
media, one must distinguish between
home-based telemedicine and office-/
hospital-based telemedicine [53].
While in the first form the telecommunication system is available for the
user directly at his home, the second
form requires the user to move to an
institution in which the system is
installed.
Office-/hospital-based telemedicine is mainly used just to speed up
the information transfer between physicians for diagnostic purposes. It is
presently the most important function
of telecommunication in radiology,
pathology and dermatology, for
example. In psychiatry office-/hospital-based telemedicine is practised
mostly as psychiatric videoconferencing.
Home-based telemedicine allows
the user to communicate directly at
his/her home. For this form of telecommunication mostly the telephone
and Internet are used.
Ethical aspects
In connection with medical telecommunication there are various
ethical-juridical questions. Some of
the most important problems are
discussed below. Ethical guidelines
for the use of telecommunication in
medicine were proposed, for instance
by eHealth Ethics Initiative [32],
Health on the Net Foundation [55],
and MEDEM & eRisk Working
Group for Healthcare [80].
Anonymity: This telecommunication problem has been known about
the telephone for a long time. However, whether the principle only to give
personal information about patients
to definitely identified people is
obeyed consistently may be doubted.
For patients, anonymity is mostly
problematic in view of the Internet.
So frequently the carriers of websites
and their medical qualification are
insufficiently specified or not specified at all [61]. Particularly for significant interaction like psychiatric diagnosis or psychotherapy via telecommunication, it must be guaranteed
that all relevant information about the
therapist's person and qualification
are open to the patient. However, in
other situations anonymity is not just
acceptable, but moreover desirable:
Undoubtedly the success of crisis
intervention via telephone is at least
partially caused through the callers'
possibility to stay anonymous. The
situation is similar in Internet chat
rooms and message boards. Even for
carriers of websites, in some cases the
wish for anonymity has to be accepted, for instance, for patients suffering from a mental disorders and for
their family members [93].
Confidentiality and data security:
Although these issues play an important role in the personal interaction
between patient and therapist too, the
use of telecommunication requires
particular attention. Before the exchange of confidential information, it
has to be assured that the data is not
available to anyone except the designated addressee. Stored data also
has to be protected against unauthorised access.
Crisis intervention: If patient and
therapist use telecommunication
media, it should be clarified already
before a possible emergency situation, which intervention possibilities
are open to the therapist. In a crisis
situation the therapist should be able
to contact an emergency service near
the patient's residence immediately.
70
And finally psychiatric illness is
able to restrict the use of telecommunication: Dementia, substance abuse,
depressive episodes or schizophrenic
psychoses can affect the acting, thinking and feeling so much, that the use
of a telecommunication medium becomes absolutely impossible. And so
finally psychiatric disorders set the
limits of telepsychiatry and e-mental
health and determine their role: as a
worthwhile complement to the personal communication between patients,
relatives and therapists – but not as its
substitute.
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Original
On the Integration of Telepsychiatry Services in
European Remote Areas: the ISLANDS Project
Case Study
María Fernanda Cabrera1, María Teresa Arredondo1,
María Rodríguez1 and Evangelos Bekiaris2
Telecommunication Engineering School, Technical University of Madrid
1
2
Key words
Telepsychiatry, system architekture
On the Integration of Telepsychiatry Services in European Remote Areas: the ISLANDS Project
Case Study
There are some regions in the
European Union – predominantly
islands – with particular characteristics, which are responsible for their
being behind the average socio-economic development in Europe. They
have an economic as well as medical
logistic disadvantage. They are remotely located with a lack of access to
modern healthcare facilities, especially psychiatric and cognitive-behavioral therapies. As a consequence,
quality of life of patients living in these areas is impaired. Since anxiety,
depression or other mental health
disorders cause progressive vocational, emotional and even physical
impairment of individual functioning,
the ability to participate in societal
activities and to support economic
development of the living area is altered. Studies assessing the possibilities of positively influencing economic and mental health problems in
remote European areas are lacking.
Facing this reality, the European
Union has funded ISLANDS (Integrated System for Long Distance
Psychiatric Assistance and Non-conventional Distributed Health Services), a Quality of Life (QoL) project.
ISLANDS joins research groups
(UPM, ICCS, COAT-Basel, University of Innsbruck, Charles University of
Prague), companies and industry
(Fundación Vodafone, TRUTh, Interaxon, MMU), and end users (Servicio
Canario de la Salud, University
Hospital Fort-de-France, Eginition
Hospital) to build a platform aimed to
deliver long distance psychiatric services.
In this paper, several aspects related to the aforementioned problems
are analyzed and a real case study,
drawn from ISLANDS project, is
presented.
Introduction
The need for health services rises
because of the ageing in Europe as
well as in other industrialized
regions, and because of the citizens’
health services quality expectancies.
Demographic factors and technological progress lead to higher costs for
health services [6]. But at the same
time, there is a need in reducing those
costs because of lower public budgets. Consequently, it is very important to use all possible resources to
bring together divergent interests.
In the European Union (EU), different types of healthcare (HC)
systems exist in the various member
states and sometimes they differ even
from region to region. Europe’s long
history of regional autonomy, strong
national feelings, and heavily defended borders may well account for the
diversity of such HC systems. This
leads to non homogeneous medical
treatments over the European territory that limits, to some extend, the free
circulation of citizens. The problem
of people medical disadvantage is of
greater relevance in the numerous
islands within the EU.
Epidemiological data suggest that
anxiety disorders (post traumatic
stress disorders (PTSD), agoraphobia
and other phobias, etc.), depression,
drug addiction and psychosomatic
disorders (tinnitus, eating disorders,
and chronic pain syndromes) often
occur in any population. Those disorders have an important impact on
societal development and economic
aspects.
The socio-economic development
of the European regions lying remote
from the main stream can be stimulated by reducing the impact of mental
health problems. Their empowerment
will lead to more autonomy, can
lower the necessity of financial support from the European Union and is
able to improve quality of life in
remote regions.
The use of telemedicine is
undoubtedly increasing across de
world, but it is still proving difficult
to embed firmly within normal clinical practice [5]. However, one of the
best ways of addressing the problem
of medical disadvantage of people
living in rural and remote regions is
the use of modern tools and aids to
overcome practical obstacles and to
disseminate mental health tools to
those remote populations, offering a
significant chance for health services
and quality of life improvement [1].
On the basis of the before mentioned conditions, the objective of the
last generation EU Fifth Framework
Cabrera, Arredondo, Rodriguez, Bekiaris
Programme
funded
project
ISLANDS [4] is to develop services
to provide modular, non-conventional, remote psychiatric and psychotherapeutic assistance for remote areas. By these means quality of life of
the users, quality of mental health
care and the economic strength of the
region should improve and overweight the costs of implementation
and service support. This project will
try to reduce inequalities in mental
health services and status among
European regions.
Methods
The project started with a literature review of the state of the art on
remote therapeutic psychiatric and
psychotherapeutic
interventions,
complemented by field work with the
realization of questionnaires to
patients, families and doctors, and an
international workshop, to result in
appropriate service delivery scenarios. In total, 164 questionnaires were
filled in: 71 by patients, 59 by informal careers and 34 by medical professionals from Austria, Czech Republic, France, Greece, and Spain.
The scenarios specified, the different user group needs and the epidemiological findings led to the definition of different remote service categories (diagnosis, counseling and therapy) for patients, informal careers and
professionals, as well as an overall service layout. These services are supported by interactive and user-friendly
tools for service content presentation,
namely: an interactive web chat tool, a
database of reference case studies, an
expert tool for therapy guidance, a tool
for service confidentiality, and the
necessary communication tools and
service delivery platforms.
All the above developments (content, tools, and delivery platforms)
are integrated into modular service
typologies, taking into account relevant security, legal and ethical issues.
The proposed services will be
75
tested in three pilot sites: the French
Oversea Departments, the Greek
Southern Sporades and the Spanish
western Canary Islands. At first sight
there are some similarities between
these sites, but in fact the differences
outweigh. The pilots are part of three
different countries, and three different languages are spoken. Besides, a
different historical and cultural background has led to different social,
economical, political, and medical
structures. These locations represent
different service combinations, geographical regions and support needs
(but with homogenous user groups),
using a common set of evaluation
parameters and data processing tools.
The cost effectiveness of each
proposed services and tools are being
analyzed. The guidelines on appropriate service provision will be formulated and the recommendations for supporting policy interventions will be
issued.
As pilot application fields, five
typical case studies of psychological
problems have been selected that can
be found quite often in normal populations and are of specific interest:
• Post-traumatic stress disorder.
• Agoraphobia.
• Depression.
• Problems of alcohol abuse and
concurrent violence in families.
• Psychotic disorders.
All cases are applicable in all
three pilot sites to evaluate the proposed therapeutic content and tools
under different geographical and
environmental conditions.
Results
The ISLANDS project belongs to
the last generation of the QoL projects, and it started operating at the
beginning of 2003. The main goal of
ISLANDS, which has been proposed
by the relevant partners, is to develop
remote services in diagnosing, counseling and treatment of psychological
disorders. The project will establish
appropriate content and service provision media in a comprehensive,
modular, and integrative framework
for remote patients, relatives/informal cares and professionals, making
use of innovative computerized tools
with multimedia and multilingual
user interfaces, to offer these services
in an optimal way.
The main outcome will be an adequate treatment of psychological problems in terms of quality assistance
delivery for the patients, as well as
support for the family and the local
medical practitioners. Each of the
ISLANDS sites involves a target
population of more that 100.000 citizens, and each of them will aim to
integrate the developed services. The
following sections describe the required functional and technological
infrastructure.
A) System architecture
The platform is composed of:
• Remote services in diagnosing,
counseling and treatment of
psychological disorders [2].
• Computerized tools with multimedia and multilingual user interfaces.
• A distributed tele-psychiatry platform, which allows transfer of critical parameters in a secure medical telecare network among
patients, their family members
and stationary centers, enabling
virtual telepresence, remote
monitoring and teleconsultation
with medical experts, irrespective
of location limitations.
In order to offer these services and
tools, the architecture developed for
such platform is based on the provision of a Multi-Access Server (MAS)
that comprises full range of widely
accepted information technologies
offering to the users a universal, easy
to use, on-line and cost-effective
access to the provided services. The
MAS allows users to access remotely
regardless of the access terminal they
choose. The integrated platform will
embed several technical implementations to permit the access to the wide
On the Integration of Telepsychiatry Services in European Remote Areas: the ISLANDS Project Case Study
76
Figure 1. ISLANDS architecture
range of services for patients, professionals and family members already
mentioned.
The architecture is open and
distributed, able to integrate different
functional modules from different
developments using heterogeneous
software and hardware solutions. It
allows each clinical site to configure
the number of services they want to
offer to their own users depending on
the local healthcare organization. In
addition, the ISLANDS architecture
facilitates the integration of existing
applications that could be adapted.
The architecture (see figure 1)
allows the interoperability of different modules that perform the functionality of the ISLANDS services in
a distributed way. The general components are:
• The Knowledge Management
Organizer (KMO). This is the central
element of the platform in charge of
coordinating the interoperability between the agents integrated into the
system. The KMO receives a message from each agent whenever an
event happens and checks which is
the next action to be done and the
agent that should perform it. Afterwards, the KMO sends a message to
the final agent containing the information to perform the action.
• The ISLANDS agents. These are
Web Services (3) that have to collaborate to guarantee a homogeneous
access of the users to the services. They
are divided into two different categories: Communication Servers (CS) and
Application Servers (AS). Each CS is
in charge of managing the communication process between the platform and
one specific user terminal. They have
the responsibility of performing the
security policies for user access control, data confidentiality and data integrity during data transfers. Each AS is
in charge of performing the kind of
data analysis that requires the presentation of the results accessible from different user terminals.
• The ISLANDS database. The
information that has to be shared to
allow the interoperability between all
the agents and applications is classified according to its nature: user’s
information, profiles, medical data
and treatments, centers of excellence,
access rights and reference cases.
• The user applications. These are
the software modules that allow the
user to interact with the system and
access to the available services.
• The user terminals to access the
system.
The telecommunication infrastructure is a state of the art one, calling for no further research, being the
main added value the integration of
already validated solutions.
Security is also a critical aspect
that has been taken into account due to
the nature of the managed information.
Mechanisms for authentication, confidentiality, data integrity and access
control are being implemented.
Cabrera, Arredondo, Rodriguez, Bekiaris
77
SERVICES AND SCENARIOS DESCRIPTION
Type of content
PATIENT
Screening
Psycho-education,
counseling
PROFESSIONAL
NFORMAL CARER
Guided therapy
Help in screening for a
disorder in a friend, partner, family member, etc.
Psycho-education,
counseling
Guided advice
Major chapters
• Anxiety symptoms
• Depressive symptoms
• Alcohol abuse
• Psychoticdisorders
• Anxiety in general
• PTSD
• Depression in general
• Alcohol
• Self-exposure in anxiety disorders through
professional guidance
• PTSD therapy through standard writing
• Self-management techniques in depression
• Motivational therapy in alcohol abuse /
dependence
• Alcohol abuse
• PTSD
• Depression in general
• Alcohol
• Helping others in self-exposure in anxiety
disorders
• PTSD therapy through standard writing
• Helping others in self-management techni
ques in depression
• How to support someone in motivational
therapy in alcohol abuse/dependence
Supervision and advice in
screening
• Post-traumatic stress disorder
• Agoraphobia and other phobias
Supervision and advice in
psycho-education, counseling • Depression
• Alcohol abuse
Supervision and advice in • Psychoticdisorders
treatment
REQUIREMENTS DEFINITION
Data
Data urgency Telecommunicatio
transmitted
n Services
Text
Low
SMS, WAP, chat,
e-mail
Text
Low
SMS, WAP, chat,
e-mail
Text, speech,
conferencing
High
Text
Low
SMS, WAP, chat,
e-mail
Text, speech
Low
Speech, SMS, WAP,
chat, e-mail, MMS,
conferencing
Text, speech,
video
High
Speech, chat, e-mail,
MMS, videoconferencing
Text, speech,
video
Intermediate
Text, speech,
video
Intermediate
Speech, chat, e-mail, SMS,
MMS, videoconferencing
Text, speech,
video
High
Speech, chat, e-mail, SMS,
MMS, WAP PUSH,
videoconferencing
SMS, WAP, chat,
e-mail, MMS,
speech,
conferencing.
Speech, chat, e-mail,
SMS, MMS, WAP PUSH,
videoconferencing
Table 1: Service layout and requirements definition
B) Service layout
The service delivery is based
upon a multi-screening and a multistep approach addressed to three target groups: patients, family members
and local professionals. Three service
batches are discerned, according to
the user group to whom they should
benefit, as shown in table 1. As described in the table, the first column
identifies the service content for each
of the end users. The second column
relates the type of services with the
different type of content. The third
one shows the type of the information
transmitted.
The various services to the
patients, their families and the local
professionals, although reliable as
stand-alone, are planned to be also
offered in coordination.
C) Tools and media
The need to offer generic, easy to
use and low cost remote services has
lead to the choice of a web portal as
the basic service delivery platform. It
includes a user-friendly interface and
navigation tools, which can be personalized according to level of services
and patient types. The overall design
principle is the integration of specific
interactive and situational information with standardized and validated
neuropsychological assessment tools,
leading to specific pathways of handling the respective situation, delivering the appropriate sessions and in
general managing the service.
In order to deliver the web-based
interventions and evaluate their progress, a set of computer assessment
and training tests have been designed.
An automatic system has been developed, which analyze the user’s answers, compute scale scores, compare
them with the inclusion cut-off scores
On the Integration of Telepsychiatry Services in European Remote Areas: the ISLANDS Project Case Study
and inform the participants if they are
accepted.
A database of case studies has
been defined. It contains a description
of the existing remote treatments and
tools, and a collection of particular
cases. Its structure is behind the web
platform and can be accessed by normal web browsers, being compatible
with various computer types.
D) Communication framework
The communication systems
employed for each service use alternative and redundant means to guarantee global coverage at the best
cost-efficiency ratio. Although the
relevant telecommunication framework is state of the art, its integration
and use pose a number of challenges,
such as:
• proper communication signal
operation and transfer in remote areas
with poor telecommunications infrastructure;
• real time transmission of potentially high data content (e.g. physiological signals or images), with the
current limitations of browser interfaces and network communications;
• seamless and reliable communication, when transferring from one
medium (e.g. Web) to another (i.e.
satellite communication);
• service cost viability, since satellite communications especially are
still quite expensive.
The above issues are gathered in
table 1 where the last two columns
represent the communication technologies proposed in relation to the
importance and urgency of the transmitted data.
Discussion
The project seeks wide user
acceptance of the defined remote
psychological support services, from
all user types (patients, families and
local professionals). The support of
services for the family and the local
professionals is proposed to avoid
any negative influence on their part of
the patients’ (remote) therapy and, on
the other hand, to further supplement
it by consulting also the patient’s relatives and medical doctor accordingly.
The development of a knowledgebased expert tool to guide the relevant
services application aims to avert
erroneous application of such services, by inexperienced medical personnel or the users themselves and
their relatives.
The psychotherapeutic services
differ to a high extent in the various
European areas. Also the role of the
family and the local doctor is much
more important in Southern than in
Northern Europe. In order to be able
to support a Europe-wide service network, that will be able to be integrated in the medical and psychological
support services of different countries
and cultures, ISLANDS targets a
modular service, that will be offered
and validated in three different sites,
that follow completely different service provision formats. In addition, as
they are applied to distant and remote
populations of islands, the local cultural specificities are also taken into
account. The adaptation of these services to such a wide cultural and
organizational spectrum will make
the service content and media open
enough for pan-European adoption.
78
diagnostic, counseling and therapy
purposes. Each of these components
is being successful and will continue.
The project will, it is hoped, provide
leadership, enhance information
about mental health problems, and
undertake research in cost-effective
policies to improve the mental disorders addressed.
Acknowledgements: We are grateful for the valuable contribution of
the ISLANDS project consortium to
this work. This project is partially
funded by the EU Quality of Life Programme.
References
[1]
Barry DK: Web Services and ServiceOriented Architectures. San Francisco,
Elsevier Science 2003
[2]
Burnett KF, Magel PE, Harrington S,
Taylor CB: Computer-assisted behavioral health counseling for high school
students. Journal of Counseling Psychology, 1999; 36: 1-5
[3]
Council of Europe. Demographic Year
Book. 2001
[4]
European Commission, Quality of Life,
ISLANDS: Integrated System for Long
Distance Psychiatric Assistance and
Non-conventional Distributed Health
Services,
Project
QLG5-CT-2002-
01637. 2003
[5]
Hawker F, Kavanagh S, Yellowlees P,
Kalucy RS: Telepsychiatry in South
Conclusions
Australia. Journal of Telemedicine and
Telecare 1998; 4: 187-194
The potential benefits of telepsychiatry, especially for European
remote areas, are considerable. Telepsychiatry has the capacity to enhance, support and increase the efficiency of mental health services; reduce
inequalities of access to health services and information for individuals
and communities, particularly in rural
and remote locations; and support,
educate and train isolated health practitioners where they live and work.
Over the past 12 months, the
ISLANDS consortium has focused in
the development of feasible tools for
[6]
Wootton R, Yellowlees P, McLaren P:
Telepsychiatry and e-mental Health.
Royal Society of Medicine Press Ltd,
2003
Maria Fernanda Cabrera PhD
ETSI Telecommunicación
Ciudad Universitaria
28040 Madrid, Spain
E-mail: chiqui@gbt.tfo.up
Original
Services and Architecture for the ISLANDS
System: Towards a Modular Non-Conventional
Telepsychiatry System
Angelos Amditis1, Zoitsa Lentziou1, Maria Panou2, Alex H. Bullinger3
and Evangelos Bekiaris4
1
Institute of Communication and Computer Systems, Athens
2
Trans European Consulting Unit of Thessaloniki, Thessaloniki
3
4
Key words
Telepsychiatry,
services,
architecture,
system, screening, diagnosing, therapy,
ISLANDS system along with the components description will be presented
and thoroughly analysed in this paper.
e-mental health, technology
Services and Architecture for the
ISLANDS system: Towards a
Modular Non-Conventional Telepsychiatry System
Quality of life of patients living in
remote areas is impaired. Since anxiety,
depression, substance use disorders or
other mental health disorders cause
progressive vocational, emotional and
even physical impairment of individual
functioning, the ability to participate in
societal activities and/or to support economic development of the living area is
altered. Modern technologies, such as
the Internet, the telephone, the videoconference and other kind of communications, software tools, multimedia training packages, can provide feasible
tools for diagnosis, counseling and therapy. In this paper the services that will
be delivered to the three different target
groups (i.e. professionals, patients and
their informal carers) within the
ISLANDS will be discussed. Patients,
their families and professionals will be
able to interact with each other in different ways. Mobile phones, web-based
coaching, newsgroups, chats, video
conferences and many other devices
can support the communication between the three aforementioned groups,
e.g. to find support and help in screening and diagnosing a patient [1]. Therefore, the architecture of the
Introduction
Telemedicine has been applied
nowadays in practically every area of
the clinical medicine as well as medical education. However, although
telemedicine is represented in the
vast majority of medical advances
and specialties, the stages of development and maturity vary significantly
from specialty to specialty. The following table (table 1) presents a number of telemedicine applications in
relation to the level of maturity.
Maturity depends on several factors, including the quantity and quality of research that has taken place for
the specific application, the degree to
which the application has been accepted by the professionals, and the
development of standards and protocols for this application. Other parameters that are related to the developing field of telemedicine applications are namely technical feasibility,
diagnostic accuracy, sensitivity, specificity, clinical outcome, and cost
effectiveness. Taking a look at table
1, it is obvious that teleradiology and
telepathology are on a high rank on
the maturity scale when evaluated on
the basis of the attributes listed above.
Radiology
Mature
Pathology
Psychiatry
Cardiology
Maturing
Dermatology
Ophthalmology
Surgery
Pediatrics
Emerging
Emergency medicine
Rare Diseases
Table 1: Telemedicine applications categorised by the level of maturity [2].
In contrast, telemedicine has only
recently been applied in other cases
such as in surgery, pediatrics, and rare
diseases. This is reasonable to an
extent, since the difficulties that arise
in the second case are more complex.
Maturing clinical applications
include telepsychiatry, teledermatology, telecardiology, and teleophthalmology, as issued in Table 1, since
there has been held a primitive research and development work in these
specialties. The most recent evidence,
however, do not indicate the acceptance of the relevant technology in
the aforementioned applications. This
situation results partly from the undeveloped national and international
standards for technology and clinical
protocols. Specifically, telepsychiatry
has primarily been realized through
videoconference and similar technology [2, 3]. Even at an early stage,
there were challenging experiments
Services and Architecture for the ISLANDS System: Towards a Modular Non-Conventional Telepsychiatry System
in the field of psychiatric teleconsultation in Boston, Massachusetts, and
Omaha, Nebraska, that proved the
clinical efficiency of telepsychiatry.
Today, telepsychiatry is one of the
most frequently used clinical applications of telemedicine, and it is estimated that more than 12,000 telepsychiatric consults are conducted annually
in the United States. Moreover, research in this field has illustrated a high
degree of accordance between telepsychiatric and traditional in-person
consults regarding the clinical assessment [2].
Similar to other clinical applications, cost analyses in telepsychiatry
suggest that large amounts of money
have been invested to the maturing
field of e-mental health. This percentaService
No
End User
II
Patient
III
IV
V
Informal
Carer
Type of content
• Alcohol abuse
Psychoeducation, • Schizophrenia
counseling • Depression in general
• Alcohol
• Self-exposure in anxiety disorders
through professional guidance
• Schizophrenia therapy
through standard writing (exposure
Guided
and cognitive restructuring)
therapy
• Self-management techniques in
depression
• Motivational Therapy in
alcohol abuse / dependence
Help in scree- • Anxiety symptoms
ning for a
• Alcohol abuse
disorder
Psychoeducation, • Schizophrenia
counseling • Depression in general
• Alcohol
• Helping others in self-exposure
in anxiety disorders
• Schizophrenia therapy through
standard writing (how to support
Guided advice for therapy someone)
• Helping others in self-management
techniques in depression
• How to support someone in Motiva
tional Therapy in alcohol abuse /
dependence
Screening
I
VI
Service
Type
ge is bound to increase in the following years, since the cost of telepsychiatric equipment is continuously
declining. What is more, research and
study on the acceptance of and satisfaction with telepsychiatry systems
suggest that both patients and providers are content with this type of delivering psychiatric facilities. It is common knowledge that acceptance is closely associated with frequency of use.
Therefore, enhancing the interaction
with this kind of technology will result
in the users’ wider acceptance [2].
The ISLANDS project aims at
developing services to provide modular, non-conventional, remote psychiatric and psychotherapeutic assistance for people who live in remote areas. Therefore, in the following units
80
the services and the architecture of
the ISLANDS system will be thoroughly analysed. This paper is organized as follows: the following section is an analysis to the services that
will be delivered through the
ISLANDS project to the three target
groups namely the general practitioners, the patients and their carers. The
next section provides details concerning the design of the ISLANDS
system architecture. In this section,
except for describing the different
components that compose the system,
the state of the art technology for conducting and establishing e-mental
health sessions is also presented.
Finally, the main concerns and obstacles along with the conclusions are
being put forward.
Data transmitted
Data urgency
Service
(high, intermediate, low) frequency
Text
Low
Daily
Text
Low
Daily
Text, speech,
conferencing
High
Daily
Text
Low
Daily
Text, speech
Low
Daily
Text, speech,
video (films,
conferencing)
High
Daily
Amditis, Lentziou, Panou, Bullinger, Bekiaris
Service
No
VII
VIII
IX
End User
Type of content
Service
Type
Supervision
and advice in
screening
Supervision
and advice in
psychoProfessional
education,
counseling
Supervision
and advice in
treatment
81
Data transmitted
Text, speech,
video (films,
conferencing)
• schizophrenia
• agoraphobia and other phobias
• depression
• alcohol abuse
Data urgency
Service
(high, intermediate, low) frequency
Intermediate
Daily
Text, speech,
video (films,
conferencing)
Intermediate
Daily
Text, speech,
video (films,
conferencing)
High
Daily
Table 2: The three different batches of services that the ISLANDS project aims to deliver
Data transmitted
Importance
Recommended technology
Text
Low
Mail
Text, Speech
Low
Mail, telephone
Text, Speech, Conferencing
High
Videoconference/
computer conference
Text, Speech, Video (films, conferencing)
Intermediate/High
Videoconference/
Computer conference
Table 3: The recommended technology in relation to the different services
Services
The ISLANDS project aims to the
The ISLANDS project aims to
address four different mental health
problems, namely schizophrenia,
depression, phobia and (ab-)use of
alcohol through the use of electronic
means. For each of the aforementioned categories a series of modules
will be set and integrated in order to
help users suffering from or concerned with this problem.
Mainly, there are three types of
services (i.e. screening, counselling
and therapy) that will be delivered to
the three different types of end users.
This means that substantially the
ISLANDS project aims at providing
nine different services for the users
(i.e. professionals, patients and their
informal carers). For instance, the
screening service has different meaning for each user; for the patient it
means that he will have the chance to
be diagnosed, while for their family
members it means that he will receive
support and help in screening and for
the professionals that he will accept
supervision in screening. These are
analytically presented below.
As described in the following
table, three service batches are discerned for the benefit of the three different end users as indicated by the
three different shadings in the colour
of the table along with the second
column (namely the general practitioners, the patients and their carers). In
the third column the type of service is
identified for each one of the end
users (i.e. screening, counseling and
therapy for the three aforementioned
target groups). In the forth column the
type of content that corresponds to
the different type of services are presented. For instance, screening a
patient within the ISLANDS project
involves examining a person for
anxiety symptoms, depressive symp-
toms and alcohol abuse. The sixth
column shows the urgency (namely
high, intermediate or low) in the
transmission of the required data in
relation to the type of service while
the previous column identifies which
format (i.e. text, speech, conference,
and video) of the transmitted data can
cover the relevant need. This means
that dependent on the importance and
the urgency in the transmission of the
medical data the technology that will
be used is defined. For example, a
low importance service delivery can
be supported by text, whereas the
most urgent cases require the transmission of video (audio and visual
contact). This issue will be discussed
analytically in the following section.
Finally, in the last column the required frequency of the delivered service
is described and defined as daily, since it is crucial for a psychiatrist to
have a daily contact with his patients
or other professionals. What is more,
patients with mental disorders
demand a frequent diagnosing and
treatment. In order to sum up all the
above mentioned technologies in
comparison to the importance of the
transmitted data, a supplementary
table is being put forward: As described in this table an incident with low
importance (e.g. following up a
patient’s condition after he/she has
been diagnosed and treated) can be
conducted via mail, since the required
amount of information can be delivered by transmitting a written text. The
same rationale corresponds to the
need of high importance data transfer.
Further details on the usage of each
above mentioned technology (namely
mail, telephone, videoconference and
computer conferencing) are provided
in the last section of this paper. Following, an elaborate description of the
ISLANDS system is being given.
Architecture of the
ISLANDS system
Building such a complicated
system that will be able to combine
the delivery of nine different services
to three different target groups and at
the same time be compatible with the
standards and the situation that exists
in three different European areas
(Spain, Greece and France) is a time
consuming and intricate task. For this
reason, a thorough analysis regarding
the specifications and the requirements of the various components and
the peripheral devices of the overall
system is needed. This analysis leads
to an elaborated design of the proposed system for the ISLANDS project,
the description of which is extensively presented in the following lines.
Primarily, the architecture of the
ISLANDS system takes the following
parameters into account:
• The various current technical
ways of establishing e-mental health
and their requirements in relation to
the existing equipment in the area of
telemedicine in general.
• Cost efficiency issues.
• Liability.
• Risk analysis.
• Security issues and confidentiality for the safety of the users.
Additionally, the ISLANDS
system will be able to integrate different functional modules from different development using heterogeneous software and hardware solutions
and it will allow each clinical site to
configure the number of services they
want to offer to their own users in
dependence to the local Health Care
Organisation.
The ISLANDS system will support both home based and
office/hospital based infrastructure
for the delivery of the various services. The difference between these two
infrastructures is that the hospital
based technology supports one information channel, is handled mainly
through videoconferencing, is used
for diagnosis and therapy and does
not demand the presence of family
members or other informal carers of
the patient. In this case the costs are
paid by the provider. In the following
picture the general concept of the
hospital based e-mental health is
presented:
It is obvious from this figure that
there is a psychiatric hospital (or a
private clinic of a psychiatrist) in the
Figure 1: Hospital based telepsychiatry
82
area and this clinic is directly connected through one communication
channel to the general hospital, where not only the patient but also the
general practitioner can be guided
and consulted on how to handle a problem. This is an ideal solution for those who despite the fact that they are
not close to a psychiatric clinic, they
live near a general hospital and therefore the travel time and related issues
are no hindrance.
On the other hand, the home
based technology supports many
information channels, is used for education and information purposes and
is handled through telephone and
Internet. In this case the technology is
usually paid by the user. The picture
that follows illustrates the idea of the
home based e-mental health.
This picture conveys the idea that
the psychiatric clinic or the psychiatrist connects directly to each one of
the end users. This means that that the
patient, for instance, does not have to
travel to the nearest hospital in order
to be treated, since he/she can be diagnosed and treated whilst in his/her
home. In this case, the user overcomes the travel expenses and other
relevant problems that moving to
another place may mean. However,
he/she must be able to cover the
expenses for the purchase and the
Figure 2: Home based telepsychiatry
Figure 3: The general architecture of the ISLAND system
maintenance of the telecommunicating equipment.
The ISLANDS system is liable to
support both ways of telepsychiatry
(home and hospital based). The basic
concept is that the ISLANDS system
will primarily consist of the ISLANDS
Multi-Access Server (IMAS). This
server will comprise a wide range of
information technologies and will
offer to the users the opportunity to
have a universal, user friendly and
cost-effective access to the ISLANDS
services. The idea is that the IMAS
will allow users to access the remote
services whatever access terminal
(namely phone device, PDA, PC, laptop or digital TV) they choose (or
combination of them). In the following picture the aforementioned
view is presented:
As it is shown in this picture any
user can have access to the IMAS
regardless of whether he is using
GPRS, telephone connection, ISDN
lines, Internet connection or some
83
kind of videoconferencing system in
order to gain the required information
from the ISLANDS system. The
require information will actually be
stored in a database. Further information about this subject will be given to
the following section.
This means that, the integrated
platform will embed several technical
implementations to allow the access
to the above mentioned range of services (namely screening, counseling
and therapy) for patients, professionals and family members.
The architecture will be flexible
so as to be able to integrate different
functional modules from different
development using heterogeneous
software and hardware solutions. The
three different pilot sites namely the
Eginition Hospital (Greece), the Servicio Canario De La Salud (Canary
Islands-Spain) and the University
Hospital Fort-de-France (MartiniqueFrance) have already a certain equipment at their disposal for handling
some kind of communication with
those patients who live in remote areas. Therefore, it is crucial that the
ISLANDS system will be designed in
a way that will allow the integration
as well as the extension of the functions of the existing components in
these three European areas. In this
way, each pilot site will have the possibility to define the number of services that it will offer to its users
(according to their needs that are
strongly related to the location’s special characteristics) in dependence to
the local Health Care Organisation.
Therefore, the design of the architecture of the ISLANDS system was
conceived so as to allow the interoperability of different modules that perform the functionality of the
ISLANDS services in a distributed
way, as thoroughly discussed earlier.
The ISLANDS center will comprise
the following components:
• The Knowledge Management
Organiser (KMO), which is responsible for handling and operating all the
incoming and outcoming data.
• The ISLANDS agents. Some of
the ISLANDS agents are in charge of
communications with the different
user terminals integrated within the
ISLANDS centre (named communication server agents) and other agents
are in charge of data analysis and processing (named Application Server
Agents). The number of agents that
will comprise the ISLANDS centre
will depend on the kind and number
of terminals that each one of the three
pilot sites will already have at their
disposal.
• The ISLANDS database, which
will have a user-friendly and modular
interface and a multi-criteria search
engine, to be useful to the whole range of potential users. The access
rights will differ for each user group.
Therefore, only medical doctors will
have access to the reference cases, so
as to prevent other users from making
wrong assumptions for their own
case. However, everyone will have
access to the included lists of available treatment, tools and Centres of
Excellence at worldwide scale.
• The various user terminals.
The following figure describes
the functionality of the different
agents and generally illustrates the
operation of the ISLANDS system. In
this picture two different ways of
accessing the ISLANDS center are
presented:
• Using high computing power
through ISDN or PTSN connection.
In this case the user is connected via
the web browser to the ISLANDS
server by making an XML, HTTP,
HTTPS request (URL). The server
gives an HTTP response (HTML) to
the user.
• Using low computing power
through wireless network such as
GPRS, GSM connection etc. In this
case the user sends a WSP request
(URL) to the ISLANDS center, which
is converted into an HTTP request
(WML) by the WAP Gateway Proxy,
in order to gain access to the
ISLANDS server. The server provides the user with an HTTP response
84
Figure 4: Initial approach of the ISLANDS system architecture
which is accordingly converted into a
WSP response.
In both cases the user can have
access to the ISLANDS services and,
thus, be consulted on-line from the
project’s web portal. In this way the
user will have the opportunity to find
all the required information for screening, counselling and treating people
with mental disorders, help their
families to be able to support them
and give the professionals the necessary tools to cope with a similar situation.
Telepsychiatry and e-mental
health in general can be accomplished using various technologies. A
number of services can be delivered
through a web portal (such as access
to a database of case studies). However, the ISLANDS project aims at
providing additional services as well
to the end users. Among the most
important and useful ones are those
that can be handled through the common technologies, such as the telephone, the Internet, the Computer
conferencing and the videoconferencing. Following more information
about the aforementioned technologies are presented analytically [4]:
Telephone
This type of connection will be
applied to services I,II, IV and V (as
indicated in table 1) where the importance of the data transfer is low and
the communication between the doctor and the patient or the informal
carer can be held through speech.
Additionally, the telephone has the
advantage of being interactive and
therefore can be extremely useful in
cases of emergency such as a crisis
incident.
The telephone is a common, but
underrated, communication technology. Despite the availability of a variety of sophisticated systems that can
support telemedicine applications
such as conference calls, voice mail,
good quality global audio connections and other forms, the plain old
telephone system is the first line of
defense for handling clinical operations. Unfortunately, this kind of
communication lacks in visual contact and the patient’s rehabilitation
consultations often require visual
feedback before an informed decision
can be made. However, as already
mentioned above the telephone can
be essentially useful in crisis situations) [3].
Regarding the technical characteristics the telephone provides optimal
function in many cases. In other
cases, noise in long-distance telephone lines can cause the system to frequently lose the connection. The telephone usually comprises the following features:
• Supports home-based e-mental
health.
• Has a low cost regarding installation, equipment and maintenance
issues.
• The installation is usually paid
by the user.
program, transfer data files between
sites and some kind of conversation
namely chat [5, 14].
The number of functions available on a system depends on the computer hardware and software. Almost
all desktop conferencing solutions
can display still images, receive audio
and live-video, provide a share work
space, and allow you to type messages between sites. Let’s have a closer
look at these conferencing features.
Internet – Mail
Desktop / Computer
Conferencing
Recent technological advancements in computer graphics, engineering, video production, and Internet
communications can be used to provide visual feedback and multimedia
clinical interactions. Computer
systems that provide these features
are often referred to as computer conferencing systems or desktop conferencing systems.
Personal computer-based conferencing systems are the most cost
effective way of sharing video and
audio information between sites.
Even the lowest cost, new, personal
computers are capable of handling
live video and sharing software applications. In fact, the main limitation
for desktop conferencing is the telecommunication line capacity – not
the capabilities of the computer
system. Desktop computer conferencing systems should handle most of
the tasks associated with a remote
consultation; however, high-end
video conferencing systems are currently required to display full-screen,
television like, video.
Most desktop conferencing products have the same basic function
set; such as show live video from the
other site, capture and display still
images, annotate images on a shared
work space, jointly use a computer
applied to services II and V where the
importance of the data transfer is low
and what is usually required is the
exchange of text between the professional (doctor) and the patient or
informal carer. Internet and specifically email can be used for the cases
of screening a patient or helping in
screening a patient’s condition. In no
case, can this type of connection be
used for diagnosing or therapy purposes.
Emails do not interrupt research
meetings or patient consultations.
They do not need an immediate reaction as a phonecall does, even for
extremely incidents that do not require direct and immediate treatment.
Emails can cope with a prompt type
of communication with no interruption at all. It is mainly for informatory purposes, such as notifying the
doctor about the patient’s condition
or requesting advice from a professional on how to proceed with a specific problem. Email content can be
noted without having to reply immediately, something which is very useful in cases where thinking time, or
communication with someone else
before replying, is worthwhile. Additionally, putting together an email
gives many more potentials for prioritising, both information and
demands for input. Most email
systems have the ability to send a
report if there is a problem delivering
85
the message, and can be configured
by sending a reply confirming that the
message has been opened [6, 16].
When it comes to conferencing
through Internet several issues are
raised. One of the main factors that
affect communication system performance is the type of connection that
exists among the computers. A local
call to an Internet provider can result
in a more reliable connection since
data lines for Internet traffic are often
better than long-distance telephone
lines. People with a faster Internet
connection can take advantage of the
better performance while still being
able to connect to people with a slower communication link. An Internet
connection also has the advantages of
allowing multipoint conferencing
(i.e. more than two people participating in the meeting) [7, 8].
Generally, the use of the Internet
technology comprise the following
features [9, 15]:
• It is mostly store-and-forward.
• It has usually low quality while
transmitting videos.
• It is easy to access and use.
• It is mainly home-based.
• The costs either for installing or
for using it are medium.
• The installation is usually paid
by the user.
Videoconference
applied to services III, VI, VII and IV
where the importance of the data
transfer is intermediate or high and
there is a very urgent need for the
exchange of text, speech and video.
These cases aim mostly at helping the
professional to handle a situation and
include giving advice in screening/
diagnosing a patient, counseling and
giving therapy/treatment according to
the patient’s condition.
There are mainly three types of
videoconferencing [3]:
Person to Person: This is the simplest form of conference where two
computers connect directly with each
other using a specific conferencing
software. All that one has to do is type
in the IP address of the person or class
he would like to connect with for a
conference. Much the same way one
would dial up a friend on the phone.
Group Conference: This is where
many people can participate and collaborate. To do this, each person or
class has to connect to a site that is
running a specific software. The connection is made by typing in the IP
address of that software. The software receives everything that is transmitted by the group and then transmits it to the others in the group
Broadcast: This is way of conferencing is much like television. One
computer which is running a particular software transmits audio and
video to all those who are connected.
Generally, the use of the videoconferencing technology comprise
the following characteristics:
• It is singularly interactive, which
means that the psychiatrist can have a
direct contact with the patient and the
person who is responsible for looking
after him.
• It allows both document and
record sharing and thus can be used
not only for cases where the visual
contact is important but also for cases
where the exchange of files (i.e.
medical records) is crucial.
• It can provide visual connection
to the patient.
• In many cases it results in poor
quality of the picture on the screen due
to different ways of transmition.
• It is usually office/hospitalbased.
• The cost for the purchase and the
installation of the equipment is often
rather high.
• The installation is paid by the
provider.
where it is very difficult to reach
otherwise, such as countries where
telecommunications are unavailable
or unreliable. The M4 service is optimized to work with the Integrated
Services Digital Network (ISDN)
available in many countries providing
high-speed data connectivity at 64
kbps from the individual mobile
satellite terminal linked through the
ISDN to the final destination.
Through an ISDN connection the
inherent problems of analog circuitswitched data transmission are avoided and at the same time much higher
data throughput is achieved. Surely,
the possibility of analogue connection through the INMARSAT satellite
still exists. In short, Inmarsat-M4 service extends a company's (or a hospital’s in our case) WAN (wide area network) via satellite to the world's most
remote regions, allowing worldwide
accessibility.
In figure 5 the overall connection
of a remote area with a psychiatric
clinic (or the psychiatric department
of a general hospital) through the
INMARSAT satellite is analytically
presented. This figure is taken as an
example from Following, a description of the various components that
are necessary to manage the communication takes place.
The satellite is actually responsi-
ble for connecting the Hospital with
the remote area. The terabit network
router (TNR), which intermediates
between the hospital and the local
server, achieves terabit-level aggregate routing capacity in a carrier-class
system. It distributes the path of pakkets between large numbers of routing engines connected via a distributed, linearly scalable switch fabric. It
can house 16 K processing nodes in
64 open racks arranged in four rows
to achieve an aggregate routing capacity of 2.4 Tb/s. The local Lotus server has the capability to connect
through ISDN or Internet or even
through an analogue network to another Lotus server and retrieve information from it.
The TT-3080A Messenger is a
suitable for a portable high-speed
data terminal, which enables fast
worldwide communication. The 64
kbps bandwidth of the TT-3080A
Messenger and the ISDN interface
makes it possible to browse on the
Internet, connect to the Local or Wide
Area Network, transfer large files,
transmit real time and store and forward video conferencing, send pictures and images and broadcast quality
voice. This can be accomplished relatively easy by plug and play applications, which are easily connected to
the Messenger.
Satellite
Infosat’s Inmarsat M4 service
extends the functionality to places
86
Figure 5: Overall connection through the INMARSAT satellite
A portable station is needed in
order to manage the communication
with the remote hospital. This station
has to fulfill some requirements such
as to be a lightweight and easy-to-carry terminal and to give the users the
opportunity to get high-speed data
services and PSTN (public switched
telephone network) quality voice
connectivity.
Concerns and obstacles:
Issues to be taken into
account
There are multiple and various
constraints and obstacles related to
the introduction of e-mental health
into the remote areas of Europe,
which have to be taken into consideration while setting up an e-mental
health support system [10]. While the
introduction of e-health is not recent,
since its implementation has started
many years ago, e-mental health is
still in an early stage of its evolution.
This means that there are various
restrictions and practical problems
that arise from the establishment of emental health sessions. Namely, there
are constraints related to the installation of the relevant equipment, the
cost-effectiveness, the reliability of
the system while transmitting the
data, the e-mental health acceptance
not only by the average people but
also by the professionals, the need for
telepsychiatry in the specific pilot
sites along with the assessment of the
potentials and advantages that come
from its use and the different needs
that the different target groups have.
Above all however, the national and
international legal, ethical and organizational framework should be ensured. All the aforementioned ideas will
be thoroughly explained in the following lines.
As resulted from the aforementioned topics, the existing equipment in
terms not only of hardware, but also
of software, predefines the structure
and the design of a telepsychiatry
system. Therefore, it is extremely
important to conduct a survey on the
state of the art on the relevant technology, before building the architecture
of telepsychiatry system. The problems that are raised and that have to
be discussed and solved, to an extend,
before designing the system architecture are delays in the transaction of
data due to the bad networking connections and generally inefficiencies
in the functionality of the telecommunication systems, inadequate existing
applications in the telemedicine area
that could be used as term of reference, lack of existing relevant telecommunication infrastructure and user
friendly interfaces and nihility of
tele-support systems flexible enough
to cover the various needs and features of the different end users.
Additionally, there are issues related to the installation of the telematic
equipment that have to be taken into
account. Setting up and installing a
system like this in remote areas and
specifically in unapproachable
islands is a complicated and at the
same time challenging subject, which
however provokes a number of problems. Most of the pilot sites within
the ISLANDS project are areas that
can only be accessed by boat, which
makes the installation of the relevant
system even more demanding and
rough. What is more, the various geographical scenarios and characteristics of the different areas pose a lot
of problems that have to be thoroughly examined before purchasing the
different components and constructing the telepsychiatry system.
Moreover, there are cost related
issues that have to be taken into consideration [11]. An appealing and
attractive system has to be cost effective, which mainly means that it will
provide the users with services that in
comparison to face-to-face psychiatry will be economically preferable.
As already examined and experienced by one of the ISLANDS pilot
sites (i.e. the French Pilot in Martinique), the cost of a tele-consultation by
INMARSAT M4 satellite today is 78
87
€ (53 € for only communication
costs). The relevant cost through
ISDN or PTSN connection is much
lower, depending on the national price list. In Greece the relevant cost is
approximately 0.50 euros/minute for
distant phone calls (without including
a monthly fee of 5 euros). For wireless telephony (e.g. PDAs, cellular
phones etc) this price is 0.10
euros/minute (without including a
monthly fee of 7.50 euros) on average. Of course, in the aforementioned
cases one has to add the expenses for
the purchase of the equipment, its
installation and its maintenance. For
videoconferencing systems these
expenses are extremely high and cannot be paid by the patient. However,
even in this case the expenses are outbalanced from the face-to-face sessions between the psychiatry and
people who leave in remote places,
since then travel expenses are high
enough and must also be encountered. What still has to be examined is
who will have to pay for the equipment i.e. the patients and their families or the hospital and the Health
Ministry and the related public sectors?
Regarding the Human related
issues that were previously mentioned, statistically, patients appear willing to accept e-psychiatry, after
having used a telepsychiatry or relevant system [12]. However, the professionals (in our case the psychologists/psychiatrists or the general practitioners) are reluctant to accept the
introduction of the concept of e-mental health. Their concerns focus mainly on the ethical issues having to do
with the medical data security and
confidentiality and the fact of receiving hardly any compensation for the
effort they devote to their work
through the tele-appointments. Surely, a significant part of their resistance
to the e-mental health applications
occurs due to their inability to confront with the new rules and generally to their inflexibility to comply with
the technological evolution, which in
many cases corresponds to time con-
suming training lessons [10, 13].
Thus, a telepsychiatry system should
be designed in a way to attract mostly
the professionals’ interest more than
alluring the patients or their carers.
Finally, the ethical, legal and
organisational framework that was
mentioned in the first paragraph of
this section involves issues related to
the security and the confidentiality of
the medical records and data in general, the policy and the strategy that
will be followed and that in many
telehealth applications it is not well
defined, the insurance conditions
towards the safeguarding of the
patients rights in case that the telesessions do not result in the desired
outcome, the legal consolidation of
the professionals that will be using
the telepsychiatry systems and finally
issues that deal with the financial
matters, such as the high cost of the
relevant equipment.
tions have been given regarding the
various ways of establishing e-mental
health. Finally, an extensive reference
has been given to the different kind of
technology, namely the Internet, the
telephone, the videoconference and
the computer conference.
In the short-term future the work
will be centered on examining the
various users’ needs and characteristics within the different pilot sites
and defining the different key actors’
role towards the design of a modular
and flexible telepsychiatry support
system. A risk analysis study and an
analysis of the security-related issues
will also take place towards the development of the system. Finally, the
communication services definition
and requirements, the access services
specifications and the geographical
scenarios will be thoroughly analysed
and described.
[8]
[9]
[10]
[11]
[12]
[13]
[14]
References
[15]
[1]
[16]
Conclusions
The establishment of psychiatry
sessions through the use of electronic
means, such as e-mail, Internet, telephone, videoconference and other
technologies is a complicated task,
since it raises many questions regarding its feasibility and faces many
problems that have mainly to do with
the users’ needs and acceptance and
several technological constraints and
barriers. Issues related to legal and
ethical matters come also in light. It is
very crucial that all the aforementioned parameters be well studied and
defined before building the architecture of the ISLANDS system.
The discussion was focused on
giving information about the services
that will be delivered to the end users
through the ISLANDS project and
providing details concerning the description of the architecture of the
ISLANDS system. The state of the art
of the telemedicine applications was
analytically presented and many solu-
[2]
[3]
[4]
[5]
[6]
[7]
Using Communication Technology to
Enhance Rehabilitation Services, A
Solution Oriented Manual, Edward
Lemaire, PhD Institute for Rehabilitation Research and Development, Terry
Fox Mobile Clinic, The Rehabilitation
Centre, Ottawa, Ontario, Canada
State-of-the-Art Telemedicine/Telehealth: An International Perspective,
RASHID L. BASHSHUR, Ph.D.,
SALAH H. MANDIL, Ph.D. and
GARY W. SHANNON, Ph.D.
Wittson, Cecil L, and Benschotter, RA:
Two-way television: Helping the medical center reach out. Am J Psychiatry
1972;129:136–139.
Yellowlees P. The use of telemedicine to
perform psychiatric assessments under
the Mental Health Act. J Telemed Telecare 1997;3:224–226.
Dongier M, Tempier R, LalinecMichaud M, et al. Telepsychiatry: Psychiatric consultation through two-way
television: a controlled study. Can J
Psych 1986;31:32–34.
Houston MS, Myers JD, Levens SP,
McEvoy T, Smith SA, Khandheria BK,
Shen WK, Torchia ME, Berry DJ. Clinical consultations using store-and-forward telemedicine technology. Mayo
Clin Proc 1999;74: 764–769.
Grigsby B, Brown N. Report on US telemedicine activity. Am Telemedicine
Service Provider 1999.
88
Kennedy C, Yellowlees P. A community
based approach to evaluation of health
outcomes and costs for telepsychiatry in
a rural population: preliminary results. J
Telemed Telecare 2000;6:S1:155–157.
Evolution Of Telehealth To Ehealth And
Onto The Internet Why It Must Happen!
Linda Weaver, P.Eng., M.B.A, F.E.I.C,
C.C.E Chief Technical Officer, TecKnowledge Healthcare Systems, Inc.
Deliverable 1.2: “Treatment scenarios
and preliminary specifications” of the
ISLANDS project, A. Bullinger, K.
Estoppey, M. Kottlow, C. De las Cuevas
Castresana, U. Meise, H. Sulzenbacher,
P. Doubek, A. Kott, A. Charles Nicolas,
M. Michalon, N. Ballon.
Trott P, Blignault I. Cost evaluation of a
telepsychiatry service in northern
Queensland. J Telemed Telecare 1998;
4: 66–8.
Zarate CA Jr., Weinstock L, Cukor P,
Morabito C, Leahy L, Burns C, Baer L.
Applicability of telemedicine for assessing patients with schizophrenia:
Acceptance and reliability. J Clin Psychiatry 1997;58: 22–25
Mielonen ML, Ohinmaa A, Moring J,
Isohanni M. The use of videoconferencing for telepsychiatry in Finland. J
Telemed Telecare 1998;4:125–131.
http://www.rcpsych.ac.uk/college/
sig/comp/docs/connectJune02.pdf
http://www.rcpsych.ac.uk/college/
sig/comp/docs/connectMay03.pdf
http://www.coh.uq.edu.au/coh/ resources/reports/Email%20Guidelines.pdf
Dr. Angelos Amditis
Institute of Cummunication and
Computer Systems
Irron Polytechniou 9, Str.
15773, Athens
Greece
e-mail: angelos@esd.ece.ntua.gr
Original
Towards the Development of Tools for Remote
Interventions
Maria Panou1, Evangelos Bekiaris2 and Angelos Amditis3
TransEuropean Consulting Unit of Thessaloniki, Thessaloniki
1
Center of Research and Technology Hellas, Hellenic Institute of Transport, Thessaloniki
2
3
Key words
expert tool, database, case studies, PC
tests, interventions.
Towards the Development of
Tools for Remote Interventions
In this paper the need for computer-based tools to support web and
teleconference-based interventions is
presented, followed by the short specification of three such tools, namely
PC-based assessment and training
tests, a case studies database and a
knowledge-based expert tool. These
tools are appropriate for professional
assistance of patients with light
degree psychiatric disorders (anxiety,
depression, etc.). Specifically for the
database, the content, search criteria,
data collection forms and fields are
explained. Also, the concept and procedure to develop the knowledgebased tool is analysed. Finally, the
paper presents in a schematic diagram format the interrelated use of
these tools, for the operation of the
remote intervention, including diagnosis, counseling and therapy.
Introduction
Studies have shown feasibility of
telehealth for mental health in general. Specifically, a research in Maniwaki, Canada aimed to compare the
effectiveness of a validated treatment
delivered through videoconference
and in face to face. Results revealed
that telepsychotherapy seems as
effective as face to face for panic
disorder with agoraphobia and for
cognitive-behaviour therapy. Also, it
is possible to build an excellent therapeutic alliance in videoconference
[1].
tools, case studies database and
expert tool.
Tools for remote
interventions
Therefore, tools to support telepsychotherapy are needed, such as
the computerized ones developed
within ISLANDS project and described.
The users of the tools are divided
in two groups:
- Informal Assistant or Patient
(IAP);
- Professional Assistant (PA).
Islands project
As informal assistants, members
of the family of the patient may be
considered, while professional assistants are the psychologists or other
experts.
Some regions in the European
Union are behind the average socioeconomic development of Europe.
They are in remote areas, where with
a lack of access to modern health care
facilities, especially psychiatric and
cognitive-behavioural therapies are
lacking. Furthermore, epidemiological data suggest that anxiety disorders, depression, drug addiction and
psychosomatic disorders often occur
in any population.
ISLANDS is a EU co-funded project, encompassing 12 partners form
12 European countries, including
experts in expert tools development,
remote clinics, and communication
media providers. The project aims to
cover the gap of healthcare in the area
of psychiatry in remote areas, through
the development of remote services
in diagnosis, counselling and treatment of relevant disorders. One of its
main objectives and innovations is
the development of computerised
tools, i.e. assessment and training
As it is expected, different user
types will not have access to the same
tools, in order not to allow patients or
their family members make wrong
transfers and extrapolations to their
own case. Below follows the description and architecture of assessment
and training tools, the database of
case studies and the expert tool being
developed within ISLANDS.
Computer assessment
and training tools
A set of computer assessment and
training tests will be designed, to
deliver the web-based interventions
and evaluate their progress. The overall design principle will be the integration of specific interactive and
situational information with standardised and validated assessment tools,
leading to specific pathways of hand-
Towards the Development of Tools for Remote Interventions
90
ling the respective situation, delivering the appropriate sessions and in
general managing the service. The
specific psychological test modules
of these PC-based tools will, in terms
of content, mirror the standardised
paper and pencil tools and will deliver the service content established
within ISLANDS. Also, PC-based
tests for the assessment of burden,
workload, anxiety/ stress as well as
emotional feelings of the patient or
his/her relatives and their support,
will be realised.
The content of these tests will be
the following:
- Problem type screening.
- Remote diagnosis service
content.
- Remote counseling service
content.
- Remote therapy service content.
- Integrated remote intervention
content.
- Tests for assessment of burden,
workload, anxiety/stress and
emotional feelings.
Furthermore, the ISLANDS web
portal has been developed with a
user-friendly interface (also appropriate for people without good PC
knowledge and expertise) and navigation tools. Currently, the development work is focused on the inclusion
of different UI’s to support different
levels of services and categories of
users (i.e. different patient types,
family members, local doctors). Both
password and security software and
public domain areas and chat forums
are foreseen.
Finally, an automatic system will
be developed, to analyse the user’s
answers, calculate their scores, compare them with the inclusion cut-off
scores and inform the participants if
they are accepted. This will continue
to monitor their progress and will
report it to their carers.
Figure 1: ISLANDS services diagram.
Figure 2: Start page of the database.
-
Case studies database
It is about an on-line database,
accessible via the project web site.
This database is under development,
encompassing a userfriendly and
modular interface and a multi-criteria
search engine, to be useful to the PA.
A search engine software is included,
allowing the user to search the database by selecting a specific keyword
from a predefined list.
-
The database includes:
Description of existing and new
assessment/training interventions.
-
Description of tools to deliver
those interventions (especially the
ones to be developed within
ISLANDS) and a short Manual
for them.
Use cases.
Centres of Excellence.
The role of the database in the
complete services concept of ISLANDS is depicted in the following
scheme (in the diagram, it is also clear how the expert system is involved
– see next section) (Figure 1).
Thus, the Personal Assistant will
have to login (emphasis is given to
the security of the system) and if
accepted by the system, he/she will be
Panou, Bekiaris, Amditis
91
and pencil, PC-based database of test
cases) and treatment assessment indicators, that he/she may not be able to
coordinate and use optimally. Thus,
the existing knowledge, as well as the
one accumulated during project pilots
by patients experts, will be formulated in a set of knowledge-based rules
and later in software program, in
order to be and included in an expert
system, that will support and guide
the carer.
Figure 3: Centres of excellence ‘results’ user interface.
The reason that an expert tool is
useful, especially in the area of medicine, is that it can support the local
and maybe nonspecialised psychologist and can compose the knowledge
and experience of more than one
experts, offering better reliability [3].
Furthermore, such a system can provide the explanation for its decision,
offering to the user an understanding
and resolving possible questions.
The expert system will be constituted by a team of programs that can
be separated in three categories:
• the core,
• the interconnection and,
• a set of support programs.
Figure 4: Graphical presentation of the structure of the ISLANDS expert system.
able to access the following areas:
- expert tool;
- database of patients and PA data;
- discussion forum for PA only;
-
discussion forum for IAP;
diagnosis;
counselling;
therapy;
case studies.
The introductory user interface of
the database is shown below (Figure 2):
After selecting one of the four
possible fields, the user has access to
the ‘search’ page of the selected field,
or he/she can view all entries in this
field. Then, the ‘result’ page appears
with available information. The following figure shows the result page for
the field ‘Centres of Excellence’
(Figure 3).
At the end of the project, the data
base will be available in three
languages (English, French and German).
Knowledge-based expert
tool
One of the major project risks is to
offer to the expert an abundance of
communication media (i.e. voice and
face-to-face contact) tools (i.e. paper
The structure of the ISLANDS
expert tool is shown in the diagram of
Figure 4 [2].
The core of the Expert System
constitutes of the knowledge base and
the inference engine. The knowledge
base stores facts (data, information)
and rules regarding the knowledge’s
field of a specific particular disorder
that it will help in the proposition of a
specific treatment and use of certain
tool(s). The inference engine deals
with the solution of the problem and
constitutes of various subsystems.
This engine is in charge of the
management and the knowledge control that is found stored both in the
knowledge base and in the working
memory of the program, aiming at the
configuration of conclusions. Its
main parts are the interpreter and the
scheduler. The interpreter deals with
Towards the Development of Tools for Remote Interventions
the implementation of selected
actions applying in the knowledge
base corresponding rules, aiming at
the production of knowledge. The
scheduler is the sub program in charge of deciding the strategy for the
control of the system. It deals with the
observation of the order of implementation of ac-tions and calculates
the results of the application rules,
based on determined priorities given
or other criteria (a list that contains
their rules to be executed).
The interconnection with the user
implements the communi-cation between the user and the system. The
data is imported to the system based
on questions and answers from the
system to the user, i.e. questions
about the symptoms of the patient and
the result of specific tools that the
patients have been examined with, as
paper&pencil tests, PC-based tests,
etc. Also, information may be acquired through specific databases of
patients data and progress status. All
these are called the ‘Support tools’.
The communication is implemented
through the use of a friendly graphical user interfaces.
The successive stages of the development of the ISLANDS ex-pert
system is given below [4]:
1. Analysis and determination of
the main parameters of the problem.
2. Knowledge Acquisition.
- Knowledge Elicitation.
- Knowledge of Analysis.
3. System Design.
4. Implementation.
- Prototype development (knowledge verification from the
specialist).
- Debugging.
5. System final validation.
- Validation by the developer.
- Users Evaluation (during the
project pilots).
6. Final system optimisation.
For the expert tool to be developed , a list of actions has to be realised in advance, namely:
- definition of the intervention
success criteria and subcriteria
(per intervention phase);
- definition of the intervention
phases for each service;
- definition of thresholds for the
above criteria;
- specification of measurements
of those criteria;
- correlation of each intervention
with relevant reference case from
the case studies database;
- correlation of this intervention
with any other relevant one (i.e.
check if also the relatives of the
patient or his/her local doctor are
using the relevant services of
ISLANDS and synchronisation /
correlation of those services and
their out-comes);
- application of best practice and
knowledge-based rules for the
intervention, from a group of
selected experts of the Partners.
92
design of the tools may be indicated
and appropriate modifications will be
realised for their optimisation.
References
[1]
[2]
[3]
[4]
ISLANDS 1st International workshop,
Stephan Bouchard presentation, Prague,
September 2003.
John Durkin, “Expert Systems Design
and Develop-ment”, Prentice Hall International, inc 1994, USA.
Vasiliki Dimitroula, “Expert system for
the diagnosis of eye diseases”, Master
dissertation, December 2000, Thessaloniki, Greece.
Donald A. Waterman, “A Guide to
Expert Systems”, 1986.
Dr. Evangelos Bekiaris
Posidonos 17,
17455 Athens,
Greece
E-Mail: abek@certh.gr
The above expert tool will be
firstly developed, based upon the current level of knowledge and then it
will evolve with the project. Of course it is not aimed to substitute the
carer or even totally guide each type
of service, but only to assist the carer
in managing the service progress and
monitor key service assessment parameters and milestones.
Conclusions
All the tools described above will
be validated in three countries, namely
France, Greece and Spain, with 70
patients, 35 family members and 7
local doctors in each one and an equal
number of persons to act as the control
group. The selected users will suffering from the following disorders:
- psychotic disorders,
- agoraphobia and other phobias,
- depression, and
- alcohol abuse.
Based on the results, some problematic areas on the functionality or the
Original
The ISLANDS Treatment Scenarios and
Service Batches
Alex H. Bullinger1, Thomas Senn1, Evangelos Bekiaris2, Ullrich Meise3,
Ralph Mager1, Franz Müller-Spahn1 and Hubert Sulzenbacher3
1
2
3
Center for Online Mental Health, Dept. of Psychiatry, Medical University Innsbruck
Key words
Introduction
eMentalHealth, eHealth, telepsychiatry,
telemedicine
The ISLANDS Treatment Scenarios and Service Batches
Traditional eHealth applications
followed the classic top-down approach: from medical authority to the
patient. With the Internet coming into
the equation, patients gained immediate access to global medical databases and information sources. Consequently, patients are taking more interest in and more responsibility for
their health-related decisions while
relying less upon individual medical
professionals.
Also mental health patients are
increasingly presenting themselves
for diagnostic advice or even treatment, sometimes literally armed with
information they found in web-based
sources. Furthermore, patients as well
as their significant others are also helping themselves and each other, with
or without the involvement of professionals.
The ISLANDS project is directly
aimed at providing relevant tests and
tools for these mental health patients,
together with experts’ knowledge,
diagnostical and supervisional expertise for professionals working with
these patients.
As patients do change, so will
professionals have to change further.
They will need to become more specialized and learn to accommodate
their newly empowered patients, rather than expecting to be the unquestioned expert.
The ISLANDS project forms a
part of the field of eMentalHealth,
which itself is embedded in the rather
wide field of eHealth.
The technical term “eHealth”
refers to all forms of electronic
healthcare delivered over the internet
(e-mail, chat room and interactive
websites), through the telephone, by
television and videoconferencing, fax
and message boards, ranging from
informational, educational and commercial products to direct services
offered by professionals, non-professionals, business or consumers themselves. With telemetry even the monitoring of physiological functions
(blood pressure, respiration, and body
temperature) has become possible.
Telemedical transfer of images (teleradiology, telepathology, teledermatology) has as a purpose for medical
data interpretation and diagnosis.
Furthermore, the development of new
technologies within the last years led
to some new fields of application as,
for example, medical education [1].
A central focus of eHealth is the
development of low-cost and convenient supportive communities that
focus on a wide range of issues [2].
People can anonymously join a sizeable online community to share personal information to a depth that is
unprecedented in the face-to-face
world.
Some websites provide virtual
communities, chat rooms for personal
issues and discussion hours with professionals. Behavioural and lifestyle
recommendations are available from
a number of public websites such as
http://www.realage.com.
While the “first generation” of
eHealth applications primarily offered information and support, at present increased access to practitioners
and direct service delivery is offered
[3, 4, 5].
Internet-based technologies are
now converging with satellite and
cable television for full interactive
broadcast capabilities delivered
through one, seamless technology.
Professionals and patients are able to
interact over the Internet in a secured
environment. With continued improvement in security and quality of
healthcare websites, consumers and
practitioners were able to increasingly rely upon eHealth to provide
accurate clinical data and support.
EMentalHealth is not only one of
the main applications of eHealth [6],
but moreover, one of its most successful applications [7, 8]. It mostly
consists of diagnosis, screening,
counselling, consultation, education
and therapy through telephone, videoconferencing and internet-based
eMentalHealth.
Specialized groups offer support
for almost every type of mental disorder (e.g. trichotillomania) or life circumstance (such as divorce), as well
as support for friends and family [9].
Behavioural healthcare practitioners are already using computers to
take histories, fine-tune diagnoses,
monitor progress, and maintain therapeutic contact through email. The
Internet is used as a virtual office to
provide interactive consultations [10].
EHealth is including more and
more interactive services and the virtual office will become an integral
part of psychiatric practice.
The aim of the ISLANDS project,
concerning eMentalHealth, is to create and distribute services that add
value to the field of eHealth, especially the delivery of resources that support the development and management of psychiatric services for
remote locations and the various user
communities of users targeted by the
project.
These services are foreseen to
provide modular, non-conventional,
remote psychiatric and psychotherapeutic assistance for remote areas. By
these means quality of life of the
users, quality of mental health care
and the economic strength of the
region should improve and overweight the costs of implementation
and service support by far. The project will reduce inequalities in mental
health services and status among
European regions.
Description of the ISLANDS
service batches
The treatment scenarios consist in
the specification of nine categories
which will address the needs of possible users in the psychiatric and/or
psychotherapeutic field (see next
table):
According to different mental
health problems (phobia, depression,
alcohol-related disorders and psychotic disturbances) each category will
comprise modules to help users suffering from or concerned with this problem. Within this paper the numbering of Table 1 will be followed to
facilitate for the reader orientation
and oversight within the various service batches (Figure 1 shows).
The general scheme of the treatment modules foreseen for the
ISLANDS project.
94
User
Diagnosis
Counselling
Therapy
Patients
Service No. I
Service No. II
Service No. III
Informal carers / Service No. IV
Service No. V
Service No. VI
family Seeking… Information on… Information on… Information on…
Professionals
Seeking….
Service No. VII
Expert opinion
on…
Service No. VIII
Supervision on…
Service No. IX
Expert opinion
and/or supervision
on….
Table 1: Mapping of ISLANDS user groups and service levels
Figure1: General Scheme of ISLANDS Treatment Modules
Login, access and use rights
To give a thorough description of
this scheme, we will start with the
box on the left upper corner: As soon
as an unknown user tries to log into
the ISLANDS system, an automated
screening process will start. This
screening will be unspecific and serve as an identifying process with
respect to the unknown user. Next to
all personal unique identifiers (name,
date of birth, residence, etc.) clarification will be sought to the essential
question, whether the unknown user
seeks access to the system as patient,
as informal carer or as professional.
As eMentalHealth applications hold
most sensitive data, the information
given by an unknown user will have
to be validated by the administration
of the ISLANDS services system
prior to the assignment of specific
access rights to the then known user.
These specific access rights will
always be restrictive in part, as for
example a patient has no business of
scanning the information given in the
supervision submodule of the
ISLANDS services and vice versa.
As soon as a known user identifies
her-/himself via a pre-assigned login
procedure, this user will undergo specific screening in case of first login
into the system or in case progression
tests are due. Afterwards the user will
be re-directed to the respective submodule (therapy, counselling or
supervision).
Bullinger, Senn, Bekiaris, Meise, Mager, Müller-Spahn, Sulzenbacher
In a sense the user forum is an
exception to this re-direction process,
as this will be an exchange forum
mainly for the users themselves. In
this forum different user groups
might meet each other. In order to
prevent spreading of unwanted knowledge (for example information on
deadly eatable substances exchanged
between highly depressed and potentially suicidal users) as well as guarantee adherence to netiquette this
forum will be moderated via the
ISLANDS expert pool.
The ISLANDS Experts Pool will
feed in knowledge into the therapy
module, the counselling module and
the supervision module. The Experts
Pool will also moderate the user
forum, as mentioned above. In addition to that, the ISLANDS experts
will have the right to interact directly
with the ISLANDS database on two
different levels:
• Write data on themselves (fields
of expertise, etc.) and users they
take care of
• Read data stored in the database
- In clear text (open) data related
to users they take care of
- Anonymised data related to all
other users
Description of Service Batches
The numbering of the service batches follows the numbers given in
table 1.
A variety of these service batches
in terms of content deals with specific
information and psychoeducational
materials rather than with direct and
specific advice for the respective
user. Within the ISLANDS project
these information-based service batches will be pooled into an Information Library: All materials dealing
with mental-health – related information as well as with psychoeducational material in a more narrow sense
goes into this library. If a user of the
ISLANDS services requires access to
service batches IV to VI (services for
informal carers and/or family members) she or he will be directed to this
Information Library where the desired information can be looked up via
decision trees as well as via search
options comparable to those known
from web-based search engines. In
addition to that pre-categorized links
to further information on the respective subject in question will be offered.
Another subset of service batches
(concerning the batches VII to IX,
services of professionals) can be set
aside separately insofar as these services have to be real-time and require
a individual counterpart at the respective ISLANDS center of excellence.
A professional seeking help with diagnostic or therapeutic problems,
requiring supervision in a therapeutical or counselling setting can not be
pointed to a referenced article or a
mere database entry. These service
batches therefore have to be capable
of multimedia streams over the internet (audio and video).
The service batches I to III, dealing with patients directly, have to be
described individually:
Service batch I: Diagnosis
for patients
For diagnostic purposes disorderspecific as well as disorder-unspecific screening and testing instruments
are needed.
Disorder-specific screening instruments
Basically most disorder-specific
self-report screening instruments
show similar strengths and weaknesses: They are usable for both screening and outcome measurement; they
show an overemphasis on so-called
core symptoms of the respective
disorder while underweighting the
more atypical symptoms of the
respective condition.
95
As disorder-specific self-report
screening measure for depression we
recommend the BDI, alternatively
also the CES-D or the Zung SDS
could be used.
We suggest using the AUDIT as
disorder-specific screening instrument for alcohol-related disorders,
which can be used as a clinicianadministered or a self-report test; if
the test is clinician-administered, an
optional clinical screening procedure
containing a physical examination, a
blood test, and two questions about
traumatic injury can be added. The
AUDIT is able to identify harmful or
hazardous alcohol consumption, is
highly correlated with other selfreports of alcohol problems, such as
the MAST, and also significantly correlated with biological indices. An
AUDIT cut-off of 11 or higher
(recommended by WHO) yielded
sensitivity and specificity scores for a
DSM-III alcohol-related disorder
assessed by the DIS of 0.84 and 0.71,
respectively; a cut-off of 13 or higher
yielded a sensitivity and specificity of
0.70 and 0.78, respectively, which
may be better for screening purposes.
We recommend using the BAI as
a reliable and well-validated measure
of somatic anxiety symptoms found
across the anxiety disorders and also
in depression. It is a short, self-administered scale and is simply scored.
The BAI is well suited for monitoring
change with treatment. Because it is
easy to administer and because data
on non-clinical individuals are available, the BAI may be a useful screening tool for unselected individuals in
a general medical setting. Its simplicity also supports its potential as an
administrative tool for documenting
the performance of health care delivery systems in treating anxiety. –
However, it is important to note that
the BAI does not assess worry, a key
symptom of generalized anxiety
disorder, nor does it focus on other
DSM-IV symptoms of generalized
anxiety disorder, such as difficulty
with concentrating, irritability, or
sleep disturbance. Therefore, it can-
not be considered a specific measure
for generalized anxiety. It does not
discriminate well among anxiety
disorders or distinguish anxiety disorders from anxious depression.
No disorder-specific self-report
screening instrument for psychotic
disturbances is available. As a clinician-rated tool the BPRS is frequently
used, a scale which was initially designed to measure symptom change in
patients with psychotic illness. Thus,
the items on the BPRS focus on
symptoms that are common in
patients with psychotic disorders,
including schizophrenia and other
psychotic disorders, as well as those
found in patients with severe mood
disorders, especially those with
psychotic features. The BPRS is designed to be administered by experienced clinicians on the basis of information obtained during a clinical
interview and from patient observation. The BPRS has been successfully
used to evaluate both inpatients and
outpatients. The BPRS contains several general items (e.g., anxiety, tension) and some relatively schizophrenia-specific items (e.g., hallucinatory
behaviours, mannerism and posturing).
Disorder-unspecific screening
instruments
We suggest using the BSI as well
as the PRIME-MD as non-disorderspecific screening instruments for all
disturbances taken care of in the
ISLANDS project. The BSI is a short
version of the SCL-90-R, contains 53
self-report questions, and is able to
measure depression as well as anxiety disorders and schizophrenia (by
means of the subscales "Paranoid ideation" and "Psychoticism"). The only
ISLANDS-specific disorder which
the BSI cannot measure is alcohol
abuse.
As an administered non-disorderspecific screening instrument we
recommend the PRIME-MD. PRIME-MD has two components: the
one-page Patient Questionnaire (PQ),
which is completed by the patient
before he or she sees the physician,
and the nine-page Clinician Evaluation Guide (CEG), which is a structured interview that the physician uses
to follow up on items checked positive on the PQ. The PQ is an initial
symptom screen for the mental disorders covered by the CEG. It consists
of 25 yes/no questions about signs
and symptoms experienced by the
patient in the past month, plus an item
referring to the patient’s overall
health. Fifteen items cover the majority of somatic complaints seen in primary care; one item refers to abnormal eating behaviour, two to symptoms of depression, three to anxiety
symptoms, and four to problems with
alcohol-related disorder. The PRIME-MD is able to measure following
ISLANDS-related disorders: depression (major depressive disorder, partial remission of major depressive
disorder, dysthymic disorder, probable minor depressive disorder),
anxiety (panic disorder, generalized
anxiety disorder), and probable alcohol abuse or dependence. Finally,
three rule-out (R/O) diagnoses are
included: R/O bipolar disorder; R/O
depressive disorder due to general
medical condition, medication, or
other drug; and R/O anxiety disorder
due to general medical condition,
medication, or other drug. The final
diagnoses are checked off on a diagnostic summary sheet.
During ongoing therapy outcome
measures should be used to quantify
changes of the severity of symptoms
and the treatment effects. We think
that the interval between the single
measurements should be approximately 3 months, respectively. Consequently a person who will take part in
our project over 3 months should be
tested two times, and a person who
will take part over a year should be
tested five times. Similar to the diagnostical tools also in outcome measurement a distinction can be made
between disorder-specific tools and
the unspecific ones.
96
Disorder-specific outcome measurement
We propose to use the BDI not
only as a screening instrument, but
also as a disorder-specific self-report
outcome measure for depressive
disorders.
Our proposal as a disorder-specific alcohol outcome measure is the
RTCQ. This self-report test is easy to
handle and does not require much
time. It can show a change in a person's perception of alcohol consumption. As an alternative or complement
the TLFB could be used. However,
the TLFB has to be clinically administered and requires more time. An
advantage of the TLFB is its therapeutical component, as it increases
the alcohol-related disorder’s awareness of her or his pattern of alcohol
consumption as well as of the amount
of consumed alcohol.
As self-report tool for anxiety
measurement we recommend the
BAI. This scale allows us to measure
the intensity of anxiety symptoms the
patient is suffering from. Generally,
anxiety can be stratified in three
levels. A grand sum between 0 – 21
indicates very low anxiety. A grand
sum between 22 – 35 indicates moderate anxiety and a grand sum that
exceeds 36 indicates high anxiety.
As the BPRS was initially designed to measure symptom change in
patients with psychotic illness, we
recommend its use also for measuring
outcome.
Disorder-unspecific outcome
measurement
We recommend using the GAS
and, alternatively or complementarily, the CGI as clinician-administered
non-disorder-specific outcome measures for all patients. A global assessment of the patient's situation is possible by using a Quality-of-Life measurement. We propose the use of the
QOLI for all patients.
Service batch II: Counselling for patients
Counselling is a process that enables a person to sort out issues and
reach decisions affecting their individual life. It involves talking with a
person in a way that helps that person
solve a problem or helps to create
conditions that will cause the person
to understand and/or improve his
behaviour, character, values or life
circumstances. It is important to
understand that counselling is not
about giving directional advice. It is
about helping and supporting a person to find an understanding and answers that work for that person. As
there is a tendency to mix up counselling with psychotherapy, the following clarifications are needed:
• Psychotherapy and counselling
are professional activities that utilise
an interpersonal relationship to enable people to develop understanding
about them and to make changes in
their lives.
• Professional psychotherapists
and counsellors work within a clearly
contracted, principled relationship
that enables individuals to obtain
assistance in exploring and resolving
issues of an interpersonal, intrapsychic, or personal nature.
So although psychotherapy and
counselling overlap considerably there are also some differences. The
work with clients may be of considerable depth in both modalities; however, the focus of counselling is more
likely to be on specific problems or
changes in life adjustment. Psychotherapy is more concerned with the
restructuring of the personality or
self. Furthermore: Both, psychotherapists and counsellors, work with a
wide variety of clients. Psychotherapists are more likely to work very
intensively, with more deeply disturbed individuals who are seen more
frequently over a longer period of
time. Counsellors are more likely to
work in specific areas where specialised knowledge and methods are nee-
ded (e.g. marital and family counselling, bereavement counselling,
school counselling, addictions counselling, HIV/AIDS counselling, etc.).
At advanced levels of training, counselling has a greater overlap with
Psychotherapy than at base levels.
Service batch III: Therapy
for patients
In this context therapy for patients
means self-help approaches. Therapeutic approaches with a professional
therapist available, the latter seeking
advice or supervision concerning the
therapy, are described in Services VII
to XI.
97
offered during the ISLANDS project
is not decided so far and needs to be
answered in D2.2 (ISLANDS service
delivery content). There are several
manualised therapeutic approaches
on the market that can be easily transformed into net-based applications.
Guided therapy for psychotic
disturbances
The ISLANDS consortium will
not offer a guided – therapy module
for these disturbances. Due to the specifications of the illness itself, this
seems to be not only prone to secure
failure but also unethical.
Guided therapy for depression
Limitations and specific
risks
One has to be cautious with guided therapy and other self-help
approaches to depressive symptoms
due to the comparably high risk of
self-harming or even suicidal behaviour in these patients. Furthermore,
efficacy of internet-based self-helped
programs without supervision by a
local Medicare professional is questionable, to say the least, with major
depression. There seems to be a
favourable effect with mild to moderate depressive syndromes.
Although eHealth applications as
a whole have proliferated in the
recent years, their diffusion and
distribution has often remained quite
low11, especially in the Mental
Health area. The actual use of eMentalHealth has in many cases been far
less than what was anticipated. This
led to the discussion of main constraints or barriers, which could contribute to problems of implementation
and usage of eMentalHealth systems
and services.
Guided therapy for alcohol-related
disorders
There is a variety of internet –
based self-help programs for alcoholrelated disorders [Toll et al., 2003,
Lieberman, 2003]. One of them will
be adopted for the ISLANDS program.
Guided therapy for anxiety disorders
Similar to alcohol-related disorders, the question which self-help
program for anxiety disorders will be
While patients appear willing to
accept eMentalHealth after they have
had some experience with it, (potential) service providers show considerably more reservations. The reasons
for professional wariness are quite
complex and range from
• ethical concerns about network
security and privacy or the possibility of harming patients with treatment model/tools so far
unknown
• technophobia and lack of training
and familiarity with computer
aided systems
• problems with time schedules and
convenience
•
problems with reimbursement for
online work
to challenges to fundamental views
on professional roles within the Mental Health field.
Because the challenges for eMentalHealth are of human rather than
technological variety the main focus
in the following consideration is on
this topic.
As a new medical practice, eHealth can be conceptualised as an innovation. Innovation literature can be
used to study why the diffusion or
eHealth remains comparably low.
Roger’s “Diffusion of Innovation
Theory” suggests that organizational,
structural and cultural aspects affect
health professionals perception of
eHealth. The introduction of these
services affects existing work practices and work flows. Therefore it is
necessary to develop strategies for
the introduction of eHealth applications, which take into account the particular structures and cultures of the
individual organisations within the
different Mental Health care systems.
Roger argues that an innovation is
more likely to be adopted, if it has
relative advantages and is compatible
with existing values and needs.
Tanrivedi and Iacono [12] explain
with their “Extended Knowledge
Barrier Metaphor”, which is based on
Attwell`s “Theory of Knowledge
Barrier” that in addition to economic,
organizational and technical knowledge barriers also Mental Health
professionals may resist the use of a
new technology, which they do not
understand, whose effectiveness on a
range of outcome variables requires
more research. For health professionals eMentalHealth is also associated
with a novel way of working and alterations of traditional roles, practices
and relationships. This requires substantial attitudinal changes.
There are a number of structural
characteristics common to most
health-care organizations, which
affect technological innovations.
These organizations are usually characterised by a hierarchical structure;
health care professionals have been
found to be inherently conservative.
Technological changes such as eMentalHealth may contribute to conflicts,
arising from the move towards the
emphasis on teamwork and collaboration.
Effective eHealth consultations
require a degree of collaborations and
teamwork between different occupational groups. An organization which
is small, complex and decentralized
has a potential to introduce eHealth
services, while a highly formalized
structure and centralization would
have an opposite effect; especially if
it is associated with a lack of resources and limited management support
[13].
Some countries require certification for eMentalHealth practitioners
to be able to claim payments for their
consultations. This certification process should be focused on ensuring
that clinicians have a good understanding of prevailing clinical, technological, and ethical practices.
EHealth supports also a cultural
change, which is driven by the global
consumers’
movement,
where
patients are insisting as being partners in their own care and being kept
fully informed. This new paradigm of
empowered clients requires also a
substantial change of role and attitude. Medical knowledge does not longer represent the powerbase of health
professionals. In future they also have
to act as coach and consultant to their
patients.
Security and privacy are two core
requirements for any eMentalHealth
consultation. All systems must keep
patient data secure; privacy is crucial
for real-time data management, data
storage and data forwarding processes. There exist a number of documented ethical and clinical guidelines, which have been published by
different groups, covering this field
[14].
Numerous eHealth evaluation frameworks have been proposed including comparisons of costs and
98
effects. For the relationship between
quality and eMentalHealth it is helpful to consider Donabedian`s
distinction between medicine’s technical and interpersonal components.
The technical dimension refers to clinical processes of care (e.g. diagnosis, treatment or follow up) and outcomes (e.g. health status or quality of
life); the interpersonal dimension
refers to social and psychological
aspects of treatment (e.g. user satisfaction and acceptance or doctor
patient relationship) [15].
Conclusion
EMentalHealth made a mere start
in Europe so far. Nevertheless there
seems to be a reliable infrastructure at
hand for its delivery and a broad range of potential services has been identified.
The main criticism of eMentalHealth applications as well as eHealth
applications in general is that there
would not be enough evidence of sufficient substance to back assertions
that it is safe, efficient and cost-effective. These criticisms have to be met
by further specific research.
Within the ISLANDS project the
consortium opted for a more proactive
strategy between the partners involved
in order to ensure the consistency and
compatibility not only of infrastructure, equipment and technological standards but also of data acquisition,
screening/testing methods/tools and
evaluation methodologies, which will
allow comparisons not only between
the pilot sites but also across geographical regions and other eMentalHealth approaches from outside the
ISLANDS project.
That way one of the major challenges after the pilot phase of ISLANDS
will be to determine a way in which
eMentalHealth advocates could work
together in the future, bring together
their experience and merge their data
pools into a convincing and persuasive
body of evidence.
In addition to that we have to state, that besides cost, ethical, legal or
technical issues, the implementation
of eMentalHealth services needs to
take account of the idiosyncrasies of
the health service sector and the particular structures and cultures of individual organizations; particularly if
the distribution of resources and
power is affected and potential changes in work practices may contribute
to behavioural barriers between the
participating working groups or even
individuals.
In order to be successful, generally speaking eMentalHealth providers
must focus on the needs of Mental
Health professionals instead of forcing to fit existing technologies and
contents on these services, so not to
replace a consumer focused approach
by a product focused approach.
The introduction of eMentalHealth services should follow a stepby-step approach. EMentalHealth
should fit into the Mental Health care
system and be introduced in a balanced way. Therefore tailor-made solutions have to be developed for each
cultural / geographical region in
question.
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
Hailey D, Roine R, Ohinmaa A. Systematic review of evidence for the benefits of telemedicine. J Telemed Telecare
2002; 8 Suppl 1: 1-7
Hersh W, Helfand M, Wallace J, Kraemer D, Patterson P, Shapiro S, Greenlick M. A systematic review of the efficacy of telemedicine for making diagnostic and management decisions. J
Telemed Telecare 2002; 8(4): 197-209
Salem D, Bogat GA, Reid, C. Mutual
help goes on-line. Journal of Community Psychology 1997; 25(2): 189-207
Maheu M, Whitten P, Allen A. E-health,
Telehealth & Telemedicine: A comprehensive guide. New York: Jossey-Bass,
2004 (in press)
Walker J, Whetton S. The Diffusion of
Innovation: Factors Influencing the
Uptake of Telehealth. Journal of Telemedicine and Telecare 2002; 8
(Suppl.3): 73-75
Tanrivedi H, Iacono CS. Diffusion of
Telemedicine: A Knowledge Barrier
Perspective. Telemedicine Journal
1999; 5,3: 223-244
Bullinger AH. Information Systems and
Organisational Structure. Dissertation
for the Master of Business Administration (MBA), University of Wales, Academic Press, Great Britain, 2001
Wootton R, Blignault I. Guidelines for
Telepsychiatry and e-Mental Health. In:
Wootton, Yellowlees, McLaren. Telepsychiatry and e-Mental Health; Royal
Society of Medicine Press Ltd., London, 2003
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Telecare 2003; 9 (Suppl. 2): 15-19
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Dr. Alex H. Bullinger, MBA
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Email: key@coat-basel.com
99
Original
Process Quality Analysis of Telepsychiatry:
Contributions of Statistical Control Process and
Critical Pathway Analysis
Carlos De Las Cuevas1 and Justo Artiles2
Department of Psychiatry, University of La Laguna, Santa Cruz de Tenerife
1
Economic Analysis Service, Canary Islands Health Service, Santa Cruz Tenerife
2
Key words
Statistical Control Process, Control Chart,
Quality, Critical Path Analysis, Telepsychiatry, Telemedicine
Process Quality Analysis of Telepsychiatry: Contributions of Statistical Control Process and Critical Pathway Analysis
Purpose: To describe the results of
an innovative process quality analysis
in a telepsychiatry routine service.
Methods: The process assessed
was “the teleconsultation of psychiatry” along an evaluation frame time
of 1 year. A continuous quality improvement approach was applied, using a
statistical control process and critical
pathway analysis. The statistical control process was developed using an
individual control chart.
Results: The mean number of
teleconsultations per session increased from 3.3 (SD = 1.2) in the first
stage to 6.1 (SD = 2.4) in the second
stage. This improvement process did
not have an important effect on the
variability of the process. The critical
path implied 179 minutes per session
and 33.81 (CI 95%: 32.58-34.96)
minutes per consultation. The total
labour hours required by Telepsychiatry Service would be 172 hours for
each professional (psychiatrist and
nurse). Accordingly, labour requirements were 0.104 of a Full-Time
Equivalent for each professional.
This indicated that there was no additional impact of telepsychiatry service on staff requirements. Full-Time
Equivalent of the psychiatrist in the
conventional model was 0.116.
Conclusions: The continuous
quality improvement approach minimised the working time and increased, in a systematic way, the productivity of the telepsychiatry service
These achievements can diminish the
total cost of the service, improving
the relative cost effectiveness with
respect to the conventional model.
Introduction
Telepsychiatry is the use of electronic communication and information technologies, originally developed to provide or support clinical psychiatric care at a distance, that enhance access to mental health care for
rural and underserved populations
(APA, 1998). With the development
of more technology and increasing
experience, it has become evident
that the goal of telepsychiatry is much
broader than originally designed and
nowadays this welfare alternative is
used in many countries and several
mental health frameworks (De las
Cuevas et al., 2003a).
In telepsychiatry, consumer and
provider satisfaction has consistently
shown that this mode of clinical service delivery is widely accepted
(Gammon et al., 1996; Clarke, 1997;
Urness, 1999), although only a few
number the studies carried out included a measure of preference between
telemedicine and face-to-face consultation (Williams et al., 2001; De las
Cuevas et al., 2003b).
The issue of whether telepsychia-
try is worth the cost or whether it pays
for itself is more controversial, but
the review of the literature have
demonstrated that telepsychiatry can
be cost-effective in selected settings
and can be financially viable if used
beyond the break-even point in relation to the cost of providing in-person
psychiatric services (Hyler & Gangure, 2003).
With the primary goals or benefits
of: improve access; reduce costs;
reduce isolation; and improve quality
of care, the Canary Island Health Service (CIHS) developed a Telepsychiatry Program, that began in year
2001, to complement the mental
health care of the citizens living at El
Hierro island The purpose of this
paper is to describe the results of an
innovative analysis of process quality
after the first year of operation. The
process assessed was “the teleconsultation of psychiatry”. The quality of
this process was evaluated through a
continuous quality improvement
approach, of which the variables studied were the variability of the consultation workload and the staffing
level rate of the telepsychiatry service. The workload (of consultation or
patients) is one of the variables that
most affects the cost effectiveness
relationship (Bergmo, 2000; Mielonen, 2000; Davis, 2001; Harno, 2001;
Lamminen, 2001; Simpson, 2001;
Wootton, 2001; Bjorvig,2002; Bracale, 2002; Cabrera, 2002; Ohinmaa,
2002; Valero, 2002), and therefore
this is a variable that must be monitored. To do this, a statistical control
process (SCP) was applied. SCP has
De Las Cuevas, Artiles
101
been applied to the health sector in
other instances and its use has resulted in improvements in efficiency and
productivity (Laffel & Blumenthal,
1989; Benneyan, 1998; Alemi & Sullivan, 2001; Caron & Neuhauser,
2001; Amin, 2001). In addition, the
staffing level rate of the telepsychiatry service was evaluated using a critical pathway analysis (CPA). CPA is
an analysis tool, which helps to identify the minimum length of time, needed to complete a process with
improved productivity and diminished costs. Telemedicine provides an
opportunity to implement a continuous quality improvement process.
Material and Method
Setting and description
The Canary Islands form a Spanish archipelago 700 miles far from
mainland Spain. The Canaries consist
of seven islands which have about 1.8
million inhabitants, 85% of them
living on the major islands of Tenerife and Gran Canaria. El Hierro, the
smallest and most westerly of the
islands, has over 7,000 inhabitants.
Until the introduction of telepsychiatry, the conventional model was a
psychiatrist who travelled to the
island every 2 weeks (2 visits per
month) to face-to-face consultations.
The telepsychiatry service provides
psychiatric consultations through
videoconference to individuals based
on a referral from general practitioners via email. Telepsychiatry sessions took place every Thursday (four
sessions per month).
Statistical Control Process
Statistical Control Process is a
standardising technique used to reduce variations and achieve performance benchmarks. In this way, a telepsychiatry service will be stable when it
produces, in a consistent way, the
number of teleconsultations that
satisfies the demand of the resident
population of El Hierro. The question
Description
First region
Mean
3,3
Standard deviation
1,20
Variation Coefficient
36%
Upper Control Limit
6,9
Lower Control Limit *
0
* If the control limit < 0, then set the LCL = 0
Second Region
6,1
2,40
39%
13,6
0
Table 1: Statistical description of control chart
addressed by the SCP was: Can telepsychiatry produce the same number
of consultation than conventional
face-to-face model.
The Statistical Control Process
was developed using an individual
control chart. Figure 1 shows the
general format of control chart. In
general, the control limits are situated
above and below of the central line of
a distance of three times the standard
deviation (sd). For interpretation
rules, the control chart is divided into
six equal zones that fall between the
Upper Control Limit and Lower Control Limit.
In our study, the target variable is
the “number of teleconsultations per
session” and the statistical control is
the mean number of teleconsultations
per session. The steps taken in constructing the control chart were:
1. First, the variable to be charted
was identified (number of teleconsultation per session)
2. Second, the appropriate frequency of sampling was determined
(four sessions per month).
3. Data was recorded in SPSS
10.0.
4. The control chart was constructed using the following information:
4.1. The mean value for the number of teleconsultations per session
was calculated.
where,
Teleconsulation’s mean per session
Number of session per year
Number of teleconsulation in
the session i
4.2. A moving range average was
calculated by taking pairs of data
(X1,X2),(X2,X3)…(Xn-1,
Xn),
taking the annual sum of the absolute
value of the differences between them
and dividing this sum by the number
of pairs. This is shown mathematically as:
Process Quality Analysis of Telepsychiatry: Contributions of Statistical Control Process ...
where
Moving range average
4.3. Upper control limit (UCL) and
low control limit (LCL) were calculated; where 2.66 is the constant used
when individual measurements are
plotted.
4.4. Plot the data point, mean and
control limits on the same graph
(Note: If the LCL < 0, then set the
LCL = 0)
5. The process was monitored
distinguishing special from common
causes of variation. Common cause
variation is the naturally occurring
fluctuation or variation inherent in all
process. Some examples of common
cause are: the time of the day, hospital case-mix, physical condition of
patients, etc. Special cause variation
is typically caused by some problem
or extraordinary occurrence in the
process. Examples of special cause
might include changes in clinical procedures, skill degradation, equipment
failure, new staff, etc (Bennayan,
1998). The interpretation rules used
to detect special causes of variation
are:
• One or more data points can be
found above a UCL or below an
LCL
• 7 or more consecutive points either above or below the CL
• 14 or more consecutive points
alternating up and down in a sawtooth pattern.
• 4 of five successive points on the
same side of the CL in zone b or
beyond.
• 2 of three successive points on the
same side of the CL in zone a
• 15 or more consecutive points
alternating above and below the
central line, all of which fall within zone c
6. Taking into account the above
(step 5), corrective action was taken
to control the process and improve
productivity.
102
Critical Pathway Analysis
The Critical Pathway Analysis for
the telepsychiatry service was developed through a multidisciplinary
teamwork that includes psychiatrist,
nurse and health economist. The Critical Pathway was developed through
the next steps:
1) Devise the protocol’s activities
of teleconsultation using the relevant
literature (Tachakra et al., 1997; Benger, 1999).
2) Discuss, improve and prepare
the definitive list of teleconsultation’s
activities.
3) Determine which activities
immediately precede and follow each
activity.
4) Identify the staff in charge to
perform each activity.
5) Estimate the duration time of
each activity.
6) Draw a network with activities
connected using numbers and arrows.
The times were measured using a
job-cost sheet to record the duration
of the protocol’s activities. Finally,
the Full-Time Equivalent was calcu-
lated. Full-Time Equivalent is the
percentage of time a staff member
worked. A full-time person valued as
1.00, a half-time person as 0.50 and a
quarter-time person as 0.25. FullTime Equivalent was calculated dividing labour hours required per year
over total hours available per year.
The standard of total hours available
per professional was 1645 hours per
year. The questions addressed by the
workload analysis were: 1) what is
the minimum time necessary to develop a telepsychiatry session? 2) What
staffing level is required by a routine
telepsychiatry service?
103
Results
Figure 2 and table 1 show the statistical control process using control
chart analysis. Reference lines include the mean value, ±1 standard deviation (SD), ±2 SDs, and upper and
lower controls. The control chart was
based on data from 166 teleconsultations developed through 40 sessions
over a twelve-months period.
There are several points to note.
An out-of-control signal was detected
in the first six-months of the evaluation period (Figure 2: first region):
seven consecutive sessions of tele-
Protocol Activities
Mean
B
C
D+E+F
G
H
Recall patient and sending email to psychiatrist
confirming teleconsultations
Setup equipment and establish contact with the
nurse
Planning the session according email information
Videoconference *
Reassert the treatment to patient
Commenting the session
Time per teleconsultation
Table 2. Time of protocol activities per teleconsultation (minutes)
Confidence Interval
Standard
Deviation
1,22
Lower
Limit
1,14
Upper
Limit
1,35
0,72
0,73
0,66
0,79
0,43
1,24
25,01
4,40
1,21
33,81
1,10
1,32
0,69
24,0
4,24
1,06
32,58
28,03
4,56
1,37
6,63
1,04
0,70
34,96
7,76
Code
A
psychiatry were on a particular side
of the central line during February
and March. The special cause of this
variation was identified: The patients
forgot to go to the consultation since
it was a new service. Once this was
identified as the special cause of variation, it was eliminated by introducing a reminder call to the patients.
When the statistical control was established, a productivity analysis was
performed taking as a reference the
annual activity level of the travelling
psychiatrist (305 consultations/year);
this fixed the standard performance
value at 6 teleconsultations per ses-
Process Quality Analysis of Telepsychiatry: Contributions of Statistical Control Process ...
sion. The effect of the improvement
process was observed from August to
the final evaluation period (second
region). In this way, the mean number
of teleconsultations per session increased from 3.3 (SD = 1.2) in the first
stage (first region) to 6.1 (SD = 2.4)
in the second stage (last months of the
year.) This improvement process did
not have an important effect on the
variability of the process, measured
by the variation coefficient. The consultation workload was controlled by
fixing the performance of telepsychiatry to 6 teleconsultations per session
through 50 sessions over the year, i.e.
305 teleconsultation per year.
The results of Statistical Control
Process are tied in with the network
analysis, which was developed
thought the critical pathway analysis,
which was shown to be useful for
minimising time and integrating and
reallocating activities. The network
analysis of the standard telepsychiatry session is shown in Figure 2,
where the number next to each activity represents the activity’s duration in
minutes. Nodes 1 and 2 mark the
beginning of the telepsychiatry session and node 9 is the finishing node.
The network diagram indicates that
activities A-B had to be completed
before activity C began. Activities DE-F were integrated within the videoconference itself (activities E-F were
developed in parallel). The critical
path is the activities group A-C-D-EG-H. Activity E´ is a dummy activity:
it is an artificial activity whose purpose is to distinguish between two or
more activities that both begin and
end at the same node. Adding up all
the minutes along this path results in
a total of 179 minutes per session,
where the activities D and E (teleconsulting and reviewing the treatment
with the patient) consumes 132 minutes (74% of the critical path time).
Table 2 shows the time spent on
different protocol activities in the
teleconsultation process. The average
time for teleconsultation videoconferencing activities was 25 (CI 95% =
24-26.03) minutes. When the rest of
104
Production Planning
- Teleconsultations per session = 6,1
- Sessions per year = 50
- Performance results = 305 teleconsultations per year
Workload Planning
- Duration of teleconsultations = 33,8 minutes
- Duration of the session = 3,4 hours
- Contracted hours staff:
Psychiatrist = 172 hours/year
Nurse = 172 hours/year
Table 3. Management guidelines for telepsychiatry service
the protocol is considered, the total
time per teleconsultation rise to 33.81
(CI 95%: 32.58-34.96) minutes.
Assuming the earlier performance
results (305 teleconsultation / year),
the total labour hours required by
telepsychiatry would be 172 [(33.81*
305)/60] hours for each professional
(psychiatrist and nurse). Accordingly,
labour requirements were 0.104
[172/1645] of a Full-Time Equivalent
for each professional. This indicated
that there was no additional impact of
TS on staff requirements. The Canary
Islands Health Service information
system indicated that Full-Time
Equivalent of the psychiatrist in the
conventional model was 0.116
conventional care was determined
with the use of a Critical Pathway
Analysis. The continuous quality
improvement approach minimised
the working time and increased, in a
systematic way, the productivity of
the telepsychiatry service. These
achievements can diminish the total
cost of the service, improving the
relative cost effectiveness with
respect to the conventional model:
the minimization of work-time reduces the variable cost and the increase
in productivity reduces the fixed cost
assigned to each teleconsultation. The
results of the present evaluation provide a management guidelines (Table
3). These guidelines are the result of a
continuous quality improvement process.
Discusion & Conclusion
In summary, our approach has the
following benefits: firstly, our recommendations are based on realistic
assumptions: statistical control process shows that the telepsychiatry
service has the capability of producing the same number of consultations as the conventional model. In
conjunction, the critical pathway analysis is an effective assessment
method that considers what tasks
must be carried out, what parallel
activities can be carried out, the role
of each team member as well as their
responsibilities and the resources that
are used for each protocol activity. As
a result of the entire previous one, the
relative cost effectiveness of telemedicine telemedicine can be improved.
Industrial quality management
analysis has been applied in other studies to the health sector and has
shown demonstrated improvements
in efficiency and productivity (Laffel
& Blumenthal, 1989; Benneyan,
1998; Alemi & Sullivan, 2001; Caron
& Neuhauser, 2001; Amin, 2001).
In this paper we applied two planning tools to conduct an analysis of
the telemedicine process in the Canary Islands. A Statistical Control Process was used to ascertain that the
level of usage fell within an acceptable (efficient) range. The feasibility
of achieving this range while using
the same level of resources as under
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adjusted X-bar charts: applications to
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Manag Health Care. 2001 Spring; 9 (3):
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(APA). (1998). APA Resource Document on Telepsychiatry, approved by
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Amin SG: Control charts 101: a guide to
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Bergmo TS: A cost-minimization analysis of a realtime teledermatology service in northern Norway. J Telemed Telecare. 2000;6(5):273-7.
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economic analysis of screening for diabetic retinopathy. J Telemed Telecare.
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Caron A & Neuhauser DV: Health care
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Clarke PHJ: A referrer and patient evaluation of a telepsychiatry consultationliaison service in South Australia. Journal of Telemedicine and Telecare
1997;3(Suppl1):12-4.
Davis P, Howard R, Brockway P: Telehealth consultations in rheumatology:
cost-effectiveness and user satisfaction. J
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De las Cuevas C, Artiles J, De la Fuente J & Serrano P: Telepsychiatry: Utopia or Welfare Reality. Med Clin (Barc).
2003 Jun 28;121(4):149-52.
De las Cuevas C, Artiles J, De la Fuente J & Serrano P: Telepsychiatry in the
Canary Islands: User Acceptance and
Satisfaction. Journal of Telemedicine
and Telecare 2003; 9, 4:
Gammon D, Bergvik S, Bergmo T &
Pedersen S: Videoconferencing in psychiatry: a survey of use in northern Norway. Journal of Telemedicine and Telecare 1996; 2:192-8.
Harno K, Arajarvi E, Paavola T, Carlson C, Viikinkoski P: Clinical effective
105
ness and cost analysis of patient referral
by videoconferencing in orthopaedics. J
Telemed Telecare. 2001;7(4):219-25.
Hyler, SE & Gangure, DP: A review of
the costs of telepsychiatry. Psychiatr
Serv, 2003, 54: 976980.
Laffel G & Blumenthal D: The case for
using industrial quality management
science in health care organizations.
JAMA. 1989 Nov 24;262(20):2869-73.
Lamminen H, Lamminen J, Ruohonen
K: Uusitalo H. A cost study of teleconsultation for primary-care ophthalmology and dermatology. J Telemed Telecare. 2001;7(3):167-73.
Mielonen ML, Ohinmaa A, Moring J,
Isohanni M: Psychiatric inpatient care
planning via telemedicine. J Telemed
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Ohinmaa A, Vuolio S, Haukipuro K,
Winblad I: A cost-minimization analysis of orthopaedic consultations using
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Simpson J, Doze S, Urness D, Hailey D,
Jacobs P: Evaluation of a routine telepsychiatry service. J Telemed Telecare.
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Tachakra S, Sivakumar A, Hayes J &
Dawood M: A protocol for telemedical
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Urness DA: Evaluation of a Canadian
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Wootton R, Hebert MA: What constitutes success in telehealth? J Telemed
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Prof. Carlos De Las Cuevas
Department of Psychiatry
University of La Laguna
School of Medicine, Ofra s/n
38071 Santa Cruz de Tenerife
Canary Islands,
Spain
E mail: ccuevas@ull.es
Report
Ethical Conduct within the ISLANDS Project
Thomas Senn1, Hubert Sulzenbacher2, Ullrich Meise2, Karl-Heinz Estoppey1,
Ralph Mager1, Franz Müller-Spahn1 and Alex H. Bullinger1
1
Center of Applied Technologies in Mental Health, Dept. of Psychiatriy, University Basel
2
Center for Online Mental Health, Dept. of Psychiatriy, Medical University Innsbruck
Key words
e-Mental-Health, e-Health, telepsychiatry,
telemedicine, ethical considerations
Ethical Conduct within the
ISLANDS Project
This paper indicates the issues to
which special sensitivity concerning
ethical aspects should be given
throughout an eMentalHealth project
like ISLANDS. This means, first and
most important, to secure an ethical
treatment of the participants involved, and secondly, to secure the high
scientific quality of research conducted within, suggested or even promoted by the ISLANDS project.
General research ethics related to
research with humans and research
involving testing and assessments are
firstly presented. This ethical issue
concerns the proposed screening,
counseling and treatment policies, as
well as the use of the research data, in
a way that guarantees privacy and state of the art therapy according to local
and European law.
Cultural and personal elements
cannot always be totally dismissed;
however, they can and should be critically examined.
Introduction
The ethical considerations within
the ISLANDS project are based on
information gathered from different
sources (Convention on human rights
on biomedicine from the council of
Europe [2]; Ethical code of conduct
from APA [1]; Declaration from Helsinki from the world medical association). General ethical principles are
presented. Subjects have to be informed about the experiment and give
written assent to participate. Researchers do only deceive subjects when
this is justified by the study’s significant prospective value. Deceived
subjects have to be clarified about the
real issues of the study. The privacy
of the subjects is ensured through all
steps of the project. The subjects are
protected from harm. The psychological tests are used in accordance to
legislative and contractual obligations. The professional knowledge for
psycho diagnostic testing is ensured
within ISLANDS. Personal information is regarded as confidential. Disrespect concerning the use of language should be avoided.
One of the main objectives of
ISLANDS is to create the scientific
base for appropriate tools that can be
used in a modular, non-conventional
remote psychiatric and psychotherapeutic supply for remote European
areas. Cost effective services (including its evaluation) are offered to different consumers (patients, significant others, professionals). All test
methods will be non-intrusive. A
medical practitioner is present during
each study. All used assessment tools
and protocols are verified by COAT
Based (ISLANDS partner, psychiatric clinic) regarding their impact to
users’ well-being before being applied.
In conclusion, the consortium
declares that ISLANDS does not
include any research involving the use
of human embryos, human embryonic
tissue, human fetuses, human fetal tissue, other human tissues, genetic
information, people unable to give
consent, or pregnant women. There is
no animal experimentation. The test
subjects will not receive any unlicensed medication, legal or illegal drugs
or any other substance other than that
normally required by their health condition and prescribed by a doctor on
site. Personal data on subjects will be
used in strictly confidential terms and
will be published as statistics (anonymously).
Methodology
The ethical issues highlighted in
this paper are based on information
gathered from various sources:
•
•
•
•
Convention on human rights and
Biomedicine of the Council of
Europe
American Psychological Association’s ethical Principles of
Psychologists and Code of Conduct
Universal Declaration on the
Human Genome and Human
Rights of the UNESCO [3]
Declaration of Helsinki: Recommendations Guiding Physicians in
Biomedical Research Involving
Human Subjects from the World
medical association [4]
Senn, Sulzenbacher, Meise, Estoppey, Mager, Müller-Spahn, Bullinger
•
National legal and ethical requirements of the Member States
(Greece, Spain, France, Austria)
where the research is performed.
General ethical principles
on research with human
subjects
Informed Consent
Previous to any intervention the
subjects have to be informed about
the aims of the study, procedures, and
methods in a clear and comprehensive way. All of the subjects are volunteers. They are clearly informed that
they are allowed to stop participating
at any time during the experiment.
After ensuring that the subject has
understood the information about the
study, the physician then obtains the
subject's freely-given written informed consent. Special attention should
be paid in regard to recognizing and
upholding the rights of those subjects
whose capability to give a valid consent to research procedures may be
diminished. Subjects with legal guardian aides as well as subjects who can
not rationalise the test course and
goal based on any impairment of their
cognitive abilities will be excluded
from the study.
Deception
Researchers do not conduct a study involving deception unless that
they have determined that the use of
deceptive techniques is justified by
the study’s significant prospective
scientific, educational, or applied
value and that effective non-deceptive alternative procedures are not feasible. This is clearly not the case for
the reseach done within the
ISLANDS project.
Researchers do not deceive prospective participants about research
that is reasonably expected to cause
physical pain or severe emotional
distress.
Researchers explain any deception that is an integral feature of the
design and conduct of an experiment
to participants as early as feasible,
preferably at the conclusion of their
participation, but no later than at the
conclusion of the data collection, and
permit participants to withdraw their
data (American Psychological Association, 20021).
Confidentiality
Privacy and confidentiality is a
central concept in the conduct of ethical research within ISLANDS.
The privacy of the subjects is
ensured through all steps of the research project, including data handling,
data analyses, and research communications. It is also ensured that all the
persons involved in research work
understand and respect the requirement for confidentiality. The subjects
should be informed about the confidentiality policy that is used in the
research.
Protection of subjects
Risks attend us every moment in
life and thus a totally risk-free setting
is impossible. However, subjects
should not be exposed to or induced
to take risks that are greater than those they would normally encounter in
their life. The subjects participating
in ISLANDS are protected from
harmful physiological and psychological effects that might be caused. All
the risks (both to physical and mental
appearance of the participant) related
to research procedure are minimized.
Ethics conduct in assessment and tests
Some of the work packages of
ISLANDS include testing and assessment of research subjects. The common psychological tests are used in
accordance to legislative and contractual obligations. Principles (not expli-
107
citly regulated) should also be followed as part of good practice.
Professional competence
The professional knowledge that
the use of assessment and diagnostic
tools (i.e. tests) requires, is guaranteed within ISLANDS. Partly the law
already regulates this; e.g., certain
tests are available only for psychologists’ use.
Instruments
Used assessment instruments are
valid and reliable. Eventual limitations will be taken into account when
communicating test results.
Personal information
Personal information must be
regarded as confidential. Custodian
of a large research database or register must ensure they have each person’s explicit consent to obtain, hold
and use personal information.
Due to the confidentiality of test
data and the anonymous nature of the
performance, the researchers are not
allowed to inform any authorities
about the participant’s performance,
even if the subject’s performance
might indicate for example safety
problems in activities of daily life like
road traffic.
Ethical perspective
language
on
Disrespect
Both overt and hidden disrespect
should be avoided in all research
communications and materials. The
terms used should be politically correct, e.g., the expressions “disorder”
or “substance use” should be used
instead of “illness” or “abuse”. Also
any images of otherness should be
avoided when describing people.
That is, all kinds of “us” vs. “them”
Ethical Conduct within the ISLANDS Project
arrays should be strictly avoided in all
communications. Finally, in all research communications and materials,
it should be kept in mind that having
problems is not equal to sickness and
infirmity but is a kind of life that
should be addressed with the same
respect as others, too.
Language that equates persons
with their condition or that has negative overtones should be avoided.
Sexism
Similarly, overt and hidden
sexism should be avoided in research
communications and materials of
ISLANDS. The language used should
be gender neutral: the pronoun he
should not be used to refer to both
genders, and the masculine or feminine pronoun should not be used to
define roles by gender. Also the word
“man” should not be used to refer to
all human beings. The use of the
generic “he” can be overcome for
example in using plural nouns or plural pronouns, replacing the pronoun
with an article or dropping the pronoun.
Other
Labeling people should be avoided when possible. Researchers
should carefully consider when – if
ever – it is adequate to use broad categories, such as “the alcoholic”, that
tend to present the subjects in the study as objects without individuality or
heterogeneity.
The language in all research communications and materials should be
maintained as value-free as possible.
In research reports the subjects
should be acknowledged. They
should preferably be described as
active subjects, not as passive subjects or objects, regardless of the research setting or methods.
108
References
[1]
[2]
[3]
[4]
American Psychological Association
(2002). Ethical Principles of Psychologists and Code of Conduct. American
Psychologist, 57, 1060-1073.
Council of Europe, Convention on
human rights and Biomedicine, 1997.
UNESCO, Universal Declaration on the
Human Genome and Human Rights,
1997.
World Medical Association, Declaration
of Helsinki: Recommendations Guiding
Physicians in Biomedical Research
Involving Human Subjects, 1996.
Dr. Alex H. Bullinger, MBA
Center of Applied Technologies in
Neuroscience (COAT-Basel /PUK)
University of Basel
Wilhelm Klein-Strasse 27
CH-4025 Basel
Switzerland
Email: key@coat-basel.com
Report
Potential Constraints and Obstacles relevant to
the Introduction of e-Mental Health
and Telepsychiatry
Ullrich Meise1, Hubert Sulzenbacher1 and Alex H. Bullinger2
Center of Online Mental Health, Dept. of Psychiatry, Medical University Innsbruck
1
2
When implementing e-mental
health services in the different pilot
sites it seems to be necessary to determine different factors (Wright 1998):
-
-
-
-
-
-
-
-
define the needs for telepsychiatry, assess the potential and
advantages of these applications
define the needs and priorities of
the different players; ensure that
diverse players are involved (professionals, patients, telecommunication companies and operators,
health authorities …)
define which telecommunication
infrastructure is available or could
be made available; assess the
accessibility of these structures
determine the most appropriate
technologies (telephone, www,
email, videoconferencing)
determine factors like costs,
financing and other resources
necessary
raise awareness about potential
telepsychiatry applications among
health care professionals and other
relevant players
ensure adequate legal, organisational and administrative arrangements are established and sustainable
establish a telepsychiatry database to monitor outcomes
identify socio-cultural factors,
legal considerations and potential
barriers relevant to the introduction of this technology.
Although e-health applications
have proliferated in recent years, their
diffusion has often remained low. The
actual use of telepsychiatry has in
many cases been less than anticipated.
The main constraints or barriers,
which can contribute to problems of
implementing e-mental health fall
into the following categories: human,
ethical, legal business and technological issues
-
-
1. Human issues
-
While patients appear willing to
accept telepsychiatry after they have
had some experience with it, providers exhibit considerably more resistance. The reasons for professional
wariness are complex and range from
- ethical concerns about network
security and privacy or the possibility of harming patients with
unknown treatment models
- professionals technophobia and
lack of training and familiarity
with equipment
- problems with time and convenience
- problems with reimbursement for
their online work and
- challenges to fundamental views
on professional roles.
-
2. Ethical , legal and
business issues
-
These include:
concerns about telecommunication network security and privacy
standards
-
-
questions about responsibilities
towards the patients, if the risks
will be covered by insurance companies and state licensing requirements
the often non-existent telemedicine policy and strategies also defining the roles of the different
players
financial problems like the high
expenses for hard- and software
difficulties to reimburse physicians for their telework
the general lack of third party
reimbursement and of a business
model supporting e-health activities or the uncertain long-term
funding of e.g. pilot projects
a lack of cost effectiveness since
e-mental health can enhance the
services or may multiply demand
for previously inaccessible mental
health services or
legal difficulties arising from the
possibilities of cross-boundary
consultations.
3. Technological issues
These include technical and
scientific difficulties like:
- inadequate telecommunication
networks
- a lack of user friendly information
systems and interfaces
- a lack of satisfactory bandwidth
- a rapid development of technology
- a scarcity of evaluation data about
the effects of telepsychiatry
Potential Constraints and Obstacles relevant to the Introduction of e-Mental Health and Telepsychiatry
“There is currently a substantial
gap between the widespread
demand for telehealth and the
scientific evidence supporting its
efficacy and cost effectiveness”
Considerations of these
barriers
Because the challenges for emental health are of human rather
than technological Variety, we will
focus on this topic.
As a new medical practice, ehealth can be described as an innovation. Innovation literature can therefore be used to study why the diffusion of telemedicine remains low.
Rogers’
“Diffusion of Innovation Theory”
suggests that organisational structures and cultures will affect health professionals’ perception of telehealth.
The introduction of these services
affects existing work practices and
work flows. Therefore it is necessary
to develop strategies for the introduction of telehealth applications, which
take into account the particular structures and cultures of the individual
organisations within the different
mental health care systems. Rogers
argues that an innovation is more
likely to be adopted, if it has relative
advantages and is compatible with
existing values and needs.
Tanrivedi and Iacono explain in
their “Extended Knowledge Barrier
Metaphor”, based on Attwell’s “Theory of Knowledge Barrier”, that in
addition to economic, organisational
and technical knowledge barriers,
mental health professionals may also
resist the use of a new technology
which they do not understand. More
research is necessary on a range of
outcome variables which may
influence effectiveness. For health
professionals e-mental health is also
associated with a novel way of working and alterations of traditional
roles, practices and relationships.
This requires substantial attitudinal
changes.
There are a number of structural
characteristics common to most
healthcare organisations which affect
technological innovations. These
organisations are usually characterised by a hierarchical structure and
health care professionals have been
found to be inherently conservative.
Technological changes such as emental health may contribute to conflicts, arising from the increasing
emphasis on teamwork and collaboration. “ The use of telehealth requires the development of new routines,
which alter the traditional practices
and relationships.”
Effective telehealth consultations
require a high degree of collaboration
and teamwork between different
occupational groups. An organisation
which is small, complex and decentralised has a potential to introduce
telehealth services, while a formalised structure and centralisation would
have a negative effect; especially if it
is associated with a lack of resources
and limited management support.
E-health also supports a cultural
change, which is driven by the global
consumers’ movement, in which
patients are insisting on being partners in their own care and being kept
fully informed. This new paradigm of
empowered clients also requires a
substantial change of role and attitude. Medical knowledge no longer
represents the power-base of health
professionals. In future they also have
to act as coach and consultant to their
patients.
Security and privacy are two
core requirements for any e-mental
health consultations. All systems
must keep patient data secure; privacy is crucial for both real-time and
store and forward approaches. A
number of documented ethical and
clinical guidelines exist which have
110
been published by different groups.
Some countries require certification for telepsychiatry practitioners
to be able to claim payments for their
consultations. This certification process should be focused on ensuring
that clinicians have a good understanding of prevailing clinical, technological, and ethical practices.
Numerous telemedicine evaluation frameworks have been proposed including comparisons of costs
and effects. For this relationship between quality and telepsychiatry it is
helpful to consider Donabedian’s
distinction between medicine’s technical and interpersonal components.
The technical dimension refers to clinical processes of care (e.g. diagnosis, treatment or follow up) and outcomes (e.g. health status or quality of
life); the interpersonal dimension
refers to social and psychological
aspects of treatment (e.g. user satisfaction and acceptance or doctor
patient relationship)
Besides cost, ethical, legal or
technical issues, the implementation
of telepsychiatry services needs to
take account of the idiosyncrasies of
the health service sector and the particular structures and cultures of individual organisations; particularly if
the distribution of resources and
power is affected and potential changes in work practices contribute to
behavioural barriers.
In general, to be successful telepsychiatry providers must focus also
on the needs of mental-health professionals and not be forced to fit their
services to existing technology.
“Consumer focus must not be
replaced by product focus” The introduction of e-mental health services
should follow a step-by-step approach. Telepsychiatry should fit into the
mental health care system and be
introduced in a balanced way. Therefore tailor-made solutions should be
developed for each region in
question.
Meise, Sulzenbacher, Bullinger
111
Literature
Walker J, Whetton S (2002): The Diffusion of Innovation: Factors Influencing
the Uptake of Telehealth. Journal of Telemedicine and Telecare 8;S3:73-75
Wootton R, Blignault I (2003): Guidelines for Telepsychiatry and e-Mental
Health. (in: Wootton, Yellowlees, McLaren. Telepsychiatry and e-Mental
Health); pp 293-304 Royal society of
Medicine press Ltd., London
Wright D (1998): Telemedicine and
Developing Countries. Journal of Telemedicine and Telecare 4;S2:1-87
Hsiung RC (2003): E-therapy: Opportunities, Dangers and Ethics to Guide Practice (in: Wootton, Yellowlees, McLaren.
Telepsychiatry and e-Mental Health); pp
73-82 Royal society of Medicine press
Ltd., London
Tanrivedi H, Iacono CS (1999): Diffusion of Telemedicine: A Knowledge Barrier Perspective. Telemedicine Journal
5,3:223-244
Univ. Prof. Dr. Ullrich Meise
Dep. of Psychiatry
Medical University Innsbruck
Anichstrasse 35
6020 Innsbruck, Austria
E mail: ullrich.meise@uklibk.ac.at
Telepsychiatry and e-Mental Health
Book
Review
Richard Wootton, Peter Yellowlees and Paul Mc Laren
The Royal Society of Medicine Press,
368 pages, 2003
The challenge of providing mental health care in the 21stcentury is
considerable, both in the industrialized and developing world. This is the
fist book to cover the emerging practice of telepsychiatry and e-mental
health. Focusing on both clinical and
educational applications, the international team of authors demonstrate
the broad spectrum of technologies
currently available to health professionals including video, Internet and
telephony.
This book presents a unique and
formidable overview of current academic literature which complements
a comprehensive selection of practical ideas and advice on technical, clinical and medicolegal areas. Direct
experiences of real-time telepsychiatry gives the reader first-hand information about how diagnoses and
patient management can be achieved.
In addition, the authors explain how
the Internet can provide advice and
information to doctors, plus self-help
or even therapy to patients. The future of mental health provision, including the economics of such services
and the particular challenges faced by
health professionals in the developing
world, is discussed through experimental ideas such as the development
of commercial online clinics and
automated diagnosis.
Written by experts with substantial experience from across the world,
this book is designed to provide a
comprehensive companion to all
mental health professionals: Trainee
and qualified psychiatrists whether
practising or considering using telepsychiatry and the Internet, nurses,
psychologists, social workers, managers, mental health service planners
and administrators, and IT staff working in the mental health sector.
Royal Society of Medicine Press Ltd
1 Wimpole Street,
London Q1G OAE UK
207E Westminster Road, Lake Forest
IL 60045 USA
http://www.rsm.ac.uk
Report
Some Considerations about the Concept
of Presence in Telepsychiatry
Carlos De Las Cuevas1 and José Luis González de Rivera 2
1
Department of Psychiatry, University of La Laguna, Santa Cruz de Tenerife
2
Department of Psychiatry, University of Madrid
Key words
Presence, Telepresence, Telepsychiatry,
Virtual Reality.
Some Considerations about the
Concept of Presence in Telepsychiatry
The authors reflect about the concept of presence and its relevance in
the practice of telepsychiatry considering the use of videoconferencing
technology as a mean of providing
mental health consultations across
distances. This brief paper stresses
the importance of examining the new
context created by new communication technologies, and of understanding of the novel practitioner-patient
relationships created, paying attention to secondary and peripheral contexts that could potentially be ignored
because of telepresence.
According to Bashshur (1995),
telepsychiatry can be conceived as an
integrated system of mental health
care delivery that employs telecommunications and computerized information technology as an alternative
to face-to-face contact between psychiatrists and patients. Videoconferencing is the central technology that
is currently used in telepsychiatry,
since it permit live, two-way interactive, full-colour, video, audio and
data communication (Janca, 2000).
A wide variety of studies concerning telepsychiatry, interactive video
consultations, have been performed
showing high rates of consumer and
provider acceptance and satisfaction
(Gammon et al., 1996; Clarke, 1997;
Urness, 1999; De las Cuevas et al.,
2003). However, when a telepsychiatry videoconference system is used to
bridge remote locations, a virtual
environment is created and it is likely
that some information cues present in
the physical environment are not
available in the virtual environment
(Turner, 2001). Since this fact could
have unknown effects on decisions
made in these environments, the study and analysis of the concepts of
presence and telepresence become
necessary in an attempt to clarify the
possible limitations of this new welfare modality.
Virtual reality created by videoconferencing means that users experiences a mediated environment as if
it were real and that this virtual environment can give rise a subjective
sensation of being in a remote or artificial environment, but not the surrounding physical environment (Held
& Durlach, 1992; Sheridan, 1992;
Steuer, 1995; Kim & Biocca, 1997).
This "illusion of nonmediation" where psychiatrist and patient "...fails to
perceive or acknowledge the existence of a medium in their communication environment and responds as
they would if the medium were not
there" (Lombard and Ditton, 1997) is
called telepresence or “virtual presence” (Barfield & Weghorst, 1993; Sheridan, 1992), a facet of presence
which is a more wide concept.
According to Kim and Biocca
(1997), presence could be defined as
“a person’s perception of being at a
specified or understood place”. For
these authors, the sensation of presence is unstable and oscillates around
three senses of place. From momentto-moment the user may feel present
in the physical environment (Distal
Immediate), the virtual environment
(Distal Mediated), or the imaginal
environment (Reduced Attention to
Distal Stimuli, i.e., the space of
daydreams, dreams, and hallucinations). As individuals experience sensations coming from the physical
environment or the virtual environment, their sense of presence, or
being there, may oscillate momentto-moment between these two senses
of place, or they may withdraw their
attention to these stimuli and retreat
into the imagination. Therefore, at
any moment users might feel "present" in one of three places, but when
the incoming information from the
unmediated physical space is technologically or attentionally diminished
or suppressed, and the media interface allows the mind to focus on information coming from the virtual environment, a person may experience
telepresence.
In a face-to-face psychiatric consultation the mental health professional has access to much more of the
patient’s context, while in a telepsychiatry session the psychiatric has
access only to the context that is viewable on the videoconference, being
the presence very different.
Turner (2001) considers three different contexts influencing presence
in telepsychiatry. Primary context
refers to the immediate presence of
De las Cuevas, González de Rivera
the participants. It refers to what
appears salient to the participants.
Within telepsychiatry, the primary
context is the image on the video
monitor. Within a traditional encounter, the primary context is the immediate distance around the participants.
Within that primary context, some
secondary context is available, but is
not the focus of participants. Within
the telemedicine encounter, this may
include sounds that give information
regarding what is occurring outside
the image displayed on the video
monitor. Within traditional encounters, secondary context refers to the
room within which participants meet.
Peripheral context is the ancillary
context that is not a part of the telemedicine encounter at all. Within the
traditional encounter, the peripheral
context may include the walk into the
building, the walk down the hallway,
and the impromptu meeting with nurses outside of the patient's room.
We propose to distinguish between three main applications of telepsychiatry a) clinical, concerned
mainly with diagnostic interviewing
and treatment supervision, b) consultation with family practitioners and
paramedics and c) psychotherapy. In
the review conducted by Hilty et al.
(2003) the degree of satisfaction
among users of the clinical application was very high, albeit satisfaction
among the nurses and family practitioners who consulted a psychiatrist
expert was not so evident. The diagnostic reliability of telepsychiatry
was high, with good interrater reliability for a wide range of psychiatric
disorders in children, adults and geriatric populations.
A significant technical consideration made by Hilty is that most positive studies use transmission speed
equal or higher than 128 kbs, which is
the minimal speed required to simulate real life experience. In our experience, we prefer to operate at 384
Kbps. 384 Kbps is certainly more
comfortable because of clearer picture resolution, smoother motion and
synchronicity of sound. Nevertheless,
113
we need to have in mind that the quality of the videoconference is a combination of hardware, transmission
speed and room environment, although debate on quality has however
centred on the transmission speeds as
the most significant of these factors.
For telepsychiatry purposes, and considering presence as the goal to achieve, videoconference rooms can be
thought of as one-half of a pair; each
room is an extension of the other.
Videoconference rooms that share the
same interior design help all participants feel that they are in the same
room. This removes the natural sense
of distance and promotes a sense of
closeness and privacy, An adequate
lighting that ensure the transmission
of good quality images and a room
design that take into account the
required acoustical needs also facilitate the sense of presence. The appearance of the telepsychiatry room can
affect the way participants feel about
teleconsultations. The surroundings
should be warm and comfortable. The
colours selected for the interior walls,
floor and furnishings should be pleasant; avoid saturated colours. Colours
such as taupe, blue and salmon
remain "truer" after video transmission than do greens, reds or browns.
The issue of “presence” is particularly important in psychotherapy,
where the mediated interaction between patient and therapist introduces
new parameters more relevant to consideration about the setting. In fact,
the American Psychiatric Association
Resource Document on Telepsychiatry (1998), while clearly endorsing
the usefulness of telepsychiatry for
clinical interviews, emergency evaluations, case management, forensic
psychiatry and clinical supervision,
is, albeit not negative, more reserved
in terms of its application for psychotherapy.
Lombard and Ditton (1997) define the feeling of presence as the subjective experience of 'being there' in
mediated environments such as virtual reality, simulators, cinema, television, etc
From the point of view of counter
transference issues, Kaplan (1997)
signals that some psychiatrist are
reluctant to carry on mediated
psychotherapy, and the perception of
this reluctance may deter the patients
from asking or exploring for this possibility. On commenting on this issue,
Joyce Aronson (2000), in the introduction to her excellent book on
Psychotherapy by Telephone makes
the, probably accurate, sexist remark
that “Men often confine their telephone use to the accomplishment of specific tasks, and women are usually
more comfortable in relating over the
phone”.
Relationship is, in fact, a key issue
on psychotherapy. Counselling and
some forms of psychotherapy, such as
cognitive-behavioural techniques,
seem more appropriate for telepsychiatry than the more empathic
methods. However, Saul (1954)
published the first report on the use of
the telephone as an adjunct for
psychoanalysis, and Robertiello, as
soon as in 1972, was reporting the use
of this same media in conducting
psychoanalytically oriented psychotherapy sessions.
McLaren et al. (1995) found
increased interpersonal distance
appeared to enhance communication
on some patients who felt more comfortable self-disclosing at a distance.
However, they also noted that the
technology limited ability to perceive
certain nonverbal behaviours. In
addition, both the patients and the
psychiatrists were somewhat distracted by the equipment and felt selfconscious viewing themselves on the
monitor.
In fact, diluting and controlling
the presence of the psychotherapist,
so as to feel less influenced by him,
may be an important motivation to
seek telepsychotherapy by some
patients. In our own experience,
(Gonzalez de Rivera, 2004) social
phobics and obsessional patients are
more likely to complete on line questionnaires on stress reactivity and to
inquire or solicit internet-mediated
Some Considerations about the Concept of Presence in Telepsychiatry
psychotherapy. This trend may be
related to Kraut et al. (1998) research
on internet users, which tend to feel
more lonely and depressed than controls, and to have lighter and more
restricted interactions in the physical
world. Excessive use of internet, they
contend, has a negative effect on the
socialization experience. If this is so,
encouraging telepsychotherapy may
be a double-edged sword: In one
hand, it may facilitate therapy for
people unable or unwilling to tolerate
the physical presence of a therapist.
On the other hand, this very physical
presence and the interaction in the
real –non-mediated- world may be
the most important therapeutic tool
for those patients, and telepsychiatry
psychotherapy would be, then, inappropriate.
In our view, a medium term position will be to consider the virtual
relationship achieved by telepsychotherapy as a Transitional Object, in
Winnicott terms, and use it as and
adjunct to facilitate and promote a
therapeutic relationship. Examples of
similar uses of objects and situations
in psychotherapy are illustrated by
Grolnick et al. (1978). A case is reported by Aronson (2000) of the treatment of a very fragile patient by interspreading consultation-room sessions
with telephone sessions.
In her two influential books, Sherry Turkle (1984, 1995) contends that
the irruption of mediated communication in our lives has introduced a
new element not previously present:
the interaction with the computer
itself –or, more precisely, with the
program the machine is running. Starting by the simple observation of the
deep absorption of children on computer-games, Turkle (1984) goes on
analysing the mentality of hackers,
often isolated and ineffectual in the
real world, who become heroes when
launched through internet. She
depicts well this ability to achieve a
deep interaction with the computer in
her following sentence, worth quoting: “The romantics wanted to escape rationalist egoism by becoming
one with nature. The hackers find
soul in the machine”. Psychiatry has
now not only a new tool, but also a
new area worth exploring, that of
“Identity in the Age of Internet” (Turkle, 1995)
Although not seriously intended
for psychotherapy uses, the program
ELIZA, developed by Weizenbaum
(1976) in M.I.T. in the late 60´s as an
experiment on artificial intelligence,
so engages the user that some may
end up by experiencing a real feeling
of presence, and treat the program as
a real therapist.
In order to finalize, the implementation of telepsychiatry activity provides the opportunity for healthcare
providers to understand the importance of communication processes to the
healthcare encounter. Professionals
involved in the practice of telepsychiatry must be conscious of the important role that presence and telepresence play in providing information
regarding the mental healthcare context.
References
APA Resource Document of Telepsychiatry via Videoconferencing. Approved by
APA Board of Trustees 7/98. www.psych.
org/psych_pract/tp_paper.cfm
Aronson, J: Use of the Telephone in
Psychotherapy. New Jersey, Jason
Aronson, 2000
Barfield, W., & Webhorst, S. The sense
of presence within virtual environments: A conceptual framework. Proceedings of the fifth International Conference of Human-Computer Interaction, 1993, 699-704.
Bashshur, RL. On the definition and
evaluation of telemedicine. Telemed J
1995; 1: 19-30.
Clarke, PHJ. A referrer and patient evaluation of a telepsychiatry consultationliaison service in South Australia. Journal of Telemedicine and Telecare
1997;3(Suppl1):12-4.
De las Cuevas C, Artiles J, De la Fuente J & Serrano P. Telepsychiatry in the
Canary Islands: User Acceptance and
Satisfaction. Journal of Telemedicine
and Telecare 2003; 9, 4: 221-224.
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Gammon D, Bergvik S, Bergmo T &
Pedersen S. Videoconferencing in psychiatry: a survey of use in northern Norway. Journal of Telemedicine and Telecare 1996; 2:192-8.
Gonzalez de Rivera, JL: Instituto de Psicoterapia & Investigación Psicosomática. http://www.psicoter.es/estres. asp
Grolnick, SA, Barkin, L and Muensterberger, W: Between Reality and Fantasy. Transitional Objects and Phenomena. Jason Aronson, New York, 1978
Held, R. M., & Durlach, N. I. Telepresence. Presence, 1992, 1(1), 109-112.
Hilty, DM, Liu, W, Marks, S and Callahan, EJ: The effectiveness of telepsychiatry. A review. Bulletin of the Canadian
Psychiatric Association, October 2003
Janca, A. Telepsychiatry: an update on
technology and its applications. Current
Opinion in Psychiatry, 2000; 13: 591597.
Kaplan, E: Psychotherapy by telephone,
videotelephone and computer videoconferencing. Journal of Psychotherapy
Practice and Research, 1997, 6:227-237
Kim, T & Biocca, F. Telepresence via
Television: Two Dimensions of Telepresence May Have Different Connections to Memory and Persuasion. Journal of Computer-Mediated Communication, 1997, 3 (2):http://www.ascusc.
org/jcmc/vol3/issue2/kim.html
Kraut, R, Lundmark, V., Patterson, M,
Kiesler, S, Mukopadhyay, T and Scherlis, W: Internet Paradox: A Social Technology That Reduces Social Involvement and Psychological Well-Being?
American Psychologist, 1998, 53:
1017–1031
McLaren, P., Ball, C., Summerfield, A.
B., Watson, J. P., & Lipsedge, M.
(1995). An evaluation of the use of
interactive television in an acute psychiatric service. Journal of Telemedicine
and Telecare, 1, 79-85.
Lombard, M and Ditton, At the Heart of
It All: The Concept of Presence. Journal
of Computer-Mediated Communication, 1997, 3 (2): http://www.ascusc.
org/jcmc/vol3/issue2/lombard.html
Robertiello, RC Telephone sessions.
Psychoanalytic Review, 1972, 59:633-634
Saul, LJ. A note on the telephone as a
technical aid. Psychoanalytic Quarterly,
1954, 20:287-290
Sheridan, T. B. Musings on telepresence
and virtual presence. Presence, 1992,
1(1), 120-126.
Steuer, J. Defining virtual reality:
Dimensions determining telepresence.
In: Biocca, F., & Levy, M.R. (eds.),
Communication in the age of virtual
reality. Hillsdale, NJ: Lawrence Erlbaum Associates, 1995, pp. 33-56.
Turkle, S: The second self: Computers
and the Human Spirit. Simon &
Schuster, New York, 1984
De las Cuevas, González de Rivera
Turkle, S: Life on the screen: Identity in
the Age of Internet. Simon & Schuster,
New York, 1995
Turner JW. Telepsychiatry as a case study of presence: Do you know what you
are missing. Journal of ComputerMediated Communication, 2001; 6 (4):
http://www.ascusc.org/jcmc/vol6/issue
4/turner.html
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Technol Info, 1999, 64: 262-269.
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Human Reason: From Judgement to
Calculation". San Francisco. W.H. Freeman. 1976.
Prof. Carlos De Las Cuevas
Department of Psychiatry
University of La Laguna
School of Medicine, Ofra s/n
38071 Santa Cruz de Tenerife
Canary Islands,
Spain
Email: ccuevas@ull.es
115
Report
The Telemed Project (RACE-Project R 1086):
Lessons learned for Telepsychiatry from the
first EU funded Telemedicine Project
Paul Mc Laren1 and Aime Charles-Nicolas2
1
South London & Maudsley NHS Trust, London
2
University Hospital of Fort-de-France, Martinique
Key words
Telepsychiatry,
EU-funding,
nonverbal
communication, videoconferencing, broadband.
The Telemed Project (RACEProject R 1086): Lessons learned
for Telepsychiatry from the first
EU funded Telemedicine Project
ISLANDS is the latest EU funded
Telepsychiatry project. The Telemed
Project (RACE-1068) which ran between 1990 and 1994 was the first.
This paper reviews the technical and
organisational background to Telemed and summarises key results.
High levels of acceptance were found
among acute adult psychiatric patients. Telemed was highly ambitious
but failed to produce technical innovation or to generate a marketable
videoconferencing kit. It did launch a
Telepsychiatry research programme
which has continued in London.
Research questions arising from the
project centred on the impact of the
videoconferencing medium on the
clinical consultation.
Introduction
The RACE-1068 Telemed Project
was the first major telemedicine project funded by the European Commission. The driving force behind
RACE was the search for clinical
applications for broadband communications links. The Consortium mem-
bers of Telemed are listed in Appendix I. Key results from Telemed have
been published elsewhere [2, 7]. This
article will review the project process
and results from the Telepsychiatry
work group within the project.
Telemed was a multidisciplinary
multi-professional project, with the
primary objective of developing
healthcare applications for emerging
broadband telecommunication links.
Clinical applications included imaging in cardiology, radiographic image database management and Telepsychiatry. The consortium contained
technical, clinical and research experts, managed by Detecon in Berlin.
Telemed and Telepsychiatry
Within Telemed Workgroup 5 had
the tasks of first developing a Low
Cost Videoconferencing system
(LCVC) and then a Medium Cost
Videoconferencing System (MCVC)
for remote diagnosis and treatment in
psychiatry. This workgroup had partners in France, at the Croix Rouge
(Centre Pierre Nicole) in Paris and
subsequently the Centre Hospitalier
Specialise de Ville-Evrard , the Free
University of Berlin, the United
Medical and Dental Schools of Guy’s
& St Thomas’s hospitals and the
Department of Cognitive Psychology
at Birkbeck College in London. Technical support for the specification and
construction of the videoconferencing kit was provided by STC (Standard Telephones and Cables).
The project consortium was diverse. This was stimulating but also
generated considerable organisational demands. The technical environment at the time of inception of the
project was rapidly changing, in
respect of communication options
and the videoconferencing kit. This
led to lively debate between the technical partners in the early phases,
about the choice of communication
carrier, whether the emerging broadband network or satellite should be
used. The availability of broadband
links, at costs which had been built
into the project, was limited and
although a common platform was
sought but it was soon recognised that
this was not realistic to achieve
within the timescale of the project.
Workgroup 5
The aims for workgroup 5 were to
develop an LCVC for remote diagnosis and treatment, to perform a requirements capture for the use of videoconferencing in mental health care
in France, Germany and the United
Kingdom and then to build and test a
Medium Cost Videoconferencing
system (MCVC) in clinical psychiatry. The Cognitive Psychology Group
at Birkbeck College studied the effects of altering the image parameters
on the LCVC on laboratory recognition tasks.
Mc Laren, Charles-Nicolas
Method
The kit
Three sets of the LCVC were
built. Two were installed at Guy’s
Hospital in an acute psychiatric unit
and one was installed at Birkbeck
for the laboratory studies. The LCVC
was based on an Archimedes 310M
personal computer using a Watford
Archimedes realtime digitiser connected to a monochrome video camera. The software could run on
1 Megabyte of memory and was configured to load and run from disk
when switched on. It had a mousebased interface and the image was
displayed in a quarter-screen window
(160 x 128 pixels). The user could
select the image parameters of 16
grey levels at 25 frames per second or
64 grey levels at 12.5 frames per
second with an image of 128 x 128
pixels. The miniature camera was
mounted on top of the monitor. A selfview image was displayed on a separate local monitor. If the user sat
about 1.3 m in front of the camera,
then a satisfactory head and shoulders
shot was obtained. In Guy’s Hospital
the LCVC ran over a co-axial cable
between two floors in the psychiatric
unit. Sound was generated and transmitted separately using two Technics
HiFi amplifier and loudspeaker systems connected with coaxial cable.
The kit from Guy’s was taken by car
to Ville-Evrard in Paris for field
testing for two weeks. It was set up
between two rooms in an acute psychiatric unit. The unit cost of the
LCVC at the time of construction was
approximately £ 1500.
The MCVC was also based on an
Archimedes PC connected via a
Craycom multiplexer to a British
Telecom Megastream leased line.
Two MCVC kits were built and used
to connect the acute ward at Guy’s
with the Speedwell Mental Health
Centre about 10 km away. The installation of the Megastream link and
117
testing produced considerable delay
which meant that the availability of
the leased line was limited for clinical
research. The leased line was expensive, £ 6000 for the year and its use
could not be continued after the project funding ran out.
Evaluation
Within the project a range of
study designs were employed to evaluate the use of the LCVC in clinical
settings. These included single case
studies, case series and comparative
studies. Qualitative and quantitative
methods were used to collect data
through observation, participant observation, user self-report on structured and semi-structured questionnaires. A log was kept of individual
interactions. Observers watched interactions initially by sitting in the
room and then via a close circuit television system into one of the LCVC
rooms from an adjacent room. As
confidence grew in the acceptability
and reliability of the system, patients
were left on their own.
The Cognitive Psychology group
at Birkbeck examined the relationship between picture parameters and
cognitive tasks such as the recognition of facial expression using student
volunteers.
A key assumption of the evaluation performed by the Guy’s group,
was the need to understand the changes in the clinical interview process
caused by the medium, the LCVC.
This was influenced by the University College London (UCL) Social
Psychology Research Group [12].
This group was funded by the British
Post Office, to study the social psychology of the use of the new telecommunications media, audio conferencing and videoconferencing and
to identify factors that would improve
the efficiency of their use in business.
These authors developed the construct of social presence to explain
how different media might impact on
social exchange. This was derived in
turn from work by Morley and Stephenson [10], on inter-party and
interpersonal exchange. Inter-party
exchange relates to acting out a role
and an agenda, interpersonal exchange is to do with developing a personal
relationship. The UCL group regarded social presence as being made up
of factors such as sociable-unsociable, insensitive-sensitive, cold-warm,
personal-impersonal. Media with a
high degree of social presence are
judged as being warm, personal, sensitive and sociable.
The LCVC was introduced into
the routine operation of the ward at
Guy’s. This was facilitated by the
senior psychiatrist on the project who
was also the Consultant Psychiatrist
on the ward where the LCVC was
sited. The psychiatrists on the ward
and the nursing team were asked to
consider using the LCVC to substitute for face-to-face communication
in a range of clinical tasks. These
included senior doctors supervising
junior doctors, the ward doctor communicating with the nursing team and
senior and junior doctors interviewing patients. Patients were offered
the opportunity to see the LCVC andto use it informally before using it to
talk to the psychiatrist. Informed
written consent was obtained from
patients entering the study.
Different approaches to collecting
subjective data were explored. This
included the Personal Questionnaire
Rapid Scaling Technique designed by
Mulhall [11]. This is an ideographic
technique but for the purposes of this
study statements were generated from
service users and doctors who had
used the LCVC. Key themes were
identified and two versions of the
questionnaire produced, one for
professional users and one for patients. The statements in Table 1 were
used to collect data on professional
user responses.
The Telemed Project (RACE-Project R 1086)
Table 1
PQRST statements for professional users
1. My satisfaction was
2. My need to see the other today is
Table 3
Focussed Observation Scale for Health
Professionals
1. How easy did you find making contact
3. My need to seek advice from a
colleague is
118
for this interaction ?
2. How comfortable did you feel establis-
4. My understanding of the problem was
hing dialogue once contact had been
5. The reassurance I gave was
made?
6. The level of rapport I established was
the dialogue?
4. How much did the equipment interfere
9. My anxiety was
ded task(s)?
5. How confident are you to make deci-
In Table 2 the PQRST items given
to patients after they had used the
LCVC are listed.
6. Do you think you need to talking per-
Table 2
7. Did the equipment you were using
sions on the basis of this interaction?
son to the other to complete your task
effectively?
interfere with the dialogue?
8. Do you think the equipment upset the
1. My anxiety was
2. The degree to which I feel better is
3. My level of frustration was
other?
9. Did you find the equipment upsetting ?
10. How anxious did you feel using thee-
4. My disappointment was
5. The extent to which my problems were
quipment?
11. How self-conscious did you feel using
understood was
the equipment?
6. My need to see the doctor today is
7. My ability to explain what I wanted was
8. My satisfaction was
9. The reassurance was
A rating scale, the Focussed
Observational Scale (FOS), was also
developed for patients and health
professionals. The FOS questions are
listed in Table 3. Each item was rated
on a five point numerical scale from
1 labelled ‘Not at all’ to 5 labelled
‘Very’. The first three questions refer
to the ease with which a dialogue is
established. The next three questions
refer to the task that needs to be performed during the interaction. The
final group of questions referred to
the interpersonal aspects of the exchange.
The French experience
with your ability to perform your inten-
10. The clarity of my explanations was
PQRST statements completed by patients
Results
3. How clear was it to you when to end
7. My frustration was
8. My enjoyment was
Videotape recordings were made
of the image transmitted over the
LCVC in a proportion of the interactions to facilitate the study of nonverbal aspects of the communication.
A version of this questionnaire
was also developed for patients. This
is in Table 4. The first two questions
guage the general response and the
last three relate to their reaction to the
LCVC.
Table 4
Focussed Observational Scale for Patients
1.
Do you feel better after talking to the
doctor/nurse?
2.
Do you feel worse after talking to the
doctor/nurse?
3.
Do you now want to talk to your doctor
in person?
4.
5.
Did you feel upset by the machine?
Did the machine make it easier to talk
to the doctor or nurse?
6.
Would you be willing to use the machine again?
In the Telemed project France was
represented by the Centre PierreNicole in Paris and subsequently by
the Centre Hospitalier Specialise de
Ville Evrard. Their task was to specify and to test the impact of using a
Low Cost Videoconferencing System
(LCVC) for remote diagnosis and
treatment.
The clinical setting in Paris for the
installation of a telephone equipment
combining the image with the voice
was prepared by Prof. A. CharlesNicolas. One end of the link was
located at the Centre Pierre-Nicole, a
drug addiction treatment and rehabilitation center headed by Prof. CharlesNicolas. In this center, managed by
the Croix Rouge Française, there was
a unit caring for mothers who were
drug addicts and HIV positive together with their new-born babies. The
other end was 2 kilometers away in
the paediatrics and obstetrics department of Cochin Hospital. This videolink included the delivering of diagnosis and a psychological support.
It should allow the mothers, still pregnant or not, addicted to heroin to have
interviews with the addiction staff of
Pierre Nicole Center. It allowed also
the latter to get advice from the
Cochin paediatricians about the care
of the babies. This setting has been
replaced by the Ville Evrard Psychiatric Hospital where two sets were
transported in and tested over a two
week period. A series for pilot studies
were performed in which patients and
clinical staff were asked to take part
in a clinical task mediated by the
videolink. The FOS instruments were
translated into French and checked by
back translation. The focus of the
observational and self-report assessment was to determine whether the
medium interfered with the clinical
task. Clinical tasks which were studied included:
• Review of inpatients by a ward
doctor
• Psychotherapy assessment
• A comparison of face-to-face,
telephone and novel audio-video
conditions.
General findings of the French
group
The Psychiatric patients (sometimes from ethnic group highly deprived) adapted very easily to the videoconferencing medium. Professionals
were much more wary and expressed
concerns that the medium would
upset the patients. The psychotherapists felt distanced by the medium.
The French psychiatrists were
concerned about the impact of the
consultation on the therapeutic relationship [4, 9]. Exploratory work
was done on therapeutic processes,
looking at the impact on nonverbal
behaviour.
The most striking finding from
this phase was the ease with which
patients took the using of the system.
One of the more deplorable outcomes of this experience was the lack
of cross fertilization between workgroups. The groups came together for
project management issues but they
were so disparate in clinical expertise
that there was little scope for scientific collaboration.
This first phase was technically
possible because the connection of
the LCVC needed a coaxial cable.
The Medium Cost Videoconferencing
System (MCVC) to be tested in phase
2 of this project should be linked
across broadband links. Unfortunately, the high cost of broadband at this
time put an end to the French participation in this consortium.
119
General findings of the UK group
The Birkbeck group completed
their deliverables on time and confirmed that basic facial expression
recognition tasks could be completed
over the LCVC. There was considerable delay in achieving the technical
deliverables for the project. This was
in part due to technical difficulties in
linking the MCVC to the broadband
network, but also because the communications costs for the use of broadband in France and Germany far
exceeded what had been put in the
budget. The result was that most of
the clinical evaluation was performed
on the LCVC connected with co-axial
cable between two rooms in the inpatient unit at Guy’s and in VilleEvrard. While the original plan was to
test the MCVC in the United Kingdom, France and Germany, it was
only tested in London. Considerable
effort and resources went into a requirements capture identifying patterns
of healthcare delivery in the areas to
be studied but this bore little relevance to the final clinical study, which
had been demarcated before the project started by the project plan.
The potential of the LCVC for
remote teaching and tutoring of students and trainees was recognised at
an early stage and the LCVC was
used successfully for medical student
teaching [6].
Professional users complained
that the PQRST was complicated,
time consuming and difficult to complete. The PQRST system proved
over-elaborate and gave inconsistent
responses. It was abandoned after the
first phase of the study for the more
concise FOS.
General observations from the
clinical trials of the LCVC
It was difficult to get the nurses on
the ward to use the LCVC for communication. They had pressures on
their time with high levels of patient
turnover and the project lacked a
champion within the nursing team.
Finding an appropriate room to position the LCVC was challenging and
demanded considerable attention. A
balance had to be struck between
accessibility in a clinical area and not
impeding access to that room for
other professional users. Space was at
a premium and it was considered desirable that the LCVC was kept close
to but separate from the nursing
station. In one of the wards the LCVC
was in a room with a close-circuit
television link to an adjacent room.
The rooms were in demand on the
busy wards. They also overlooked a
courtyard and were not far from a
busy road. Extraneous noise sometimes interfered with the sound quality
in the LCVC.
Over the first 15 months of the
study there were no technical failures
or delays in getting a satisfactory
image. The high levels of patient acceptance were striking and not restricted to young users. One middle
aged West Indian woman, with severe schizophrenia and detained against
her will adapted, very quickly to
using the LCVC. When questioned
she said that in her Pentecostal church
a microphone was passed around
during the service and using the
LCVC microphone reminded her
church. No spontaneous complaints
were made about improving the image. The LCVC image quality did not
appear to observers to be limiting the
interaction but on occasions the
sound quality did. Audio feedback
was a problem if users spoke softly
and the amplifier had to be turned up.
One patient insisted on leaning forward to use the microphone which
moved his head out of the camera
range. Attention needed to be paid to
the relationship between the picture
parameters and ambient illumination.
In tasks with little movement 64 grey
scales gave better image definition.
At this level there was still considerable glare off dark skinned users,
which mad it harder to see facial
expression. The frame rate at 25 frames/s proved inadequate for captu-
ring involuntary jerking movements.
Even at 64 grey scales writing on a
page of A4 could not be interpreted at
the remote end.
Two patients, one with hypomania and one with schizophrenia became focussed on the technology and
this distracted them from the interview. A patient with schizophrenia
said, “I look better on the screen” and
also , “It could be a temptation for
some people to take their clothes off”.
One doctor reported getting fatigued
by the effort of concentrating on the
screen, after thirty to forty minutes of
continuous use. On further questioning he explained that he found it
more difficult to leave periods of
silence and had to keep the dialogue
moving.
Not all patients admitted to the
ward during the study were asked to
use the link but most were. Some opportunities were missed because of
lack of room availability. Refusals
were given particular attention and
details of the reasons for refusal to
participate in the study were recorded. Most were due to illness rather
than concerns about the link. One
patient with schizophrenia asked to
stop after he had started to use the
LCVC and the observers thought he
may have incorporated the LCVC
into his delusional system. Psychiatrists were reluctant to use the LCVC
for sensitive interactions such as
given a diagnosis of HIV and asking
patients to leave the ward because of
difficulties with their behaviour. One
patient refused after the brief trial
and two after they had started to use
the LCVC. Other psychotic patients
used the link on up to eight occasions
without incorporating the technology
into their psychopathology. Another
patient reported that she would be
keen to use the link because she
would feel more comfortable being in
a different room from her male therapist. She also felt more positive
about being able to control the image
and limit it to a head and shoulders
view. The main predictor of refusal
was compulsory treatment with seven
out of thirty-three such patients refusing. The protocol and link was
acceptable to even seriously ill psychiatric patients. Only one with Bulimia Nervosa refused after a trial run.
She also reported discomfort talking
on the telephone.
Two experienced Psychotherapists were asked to use the LCVC to
assess patients [5]. The rationale for
this was that as Psychotherapists they
would be sensitive to the effects of
the medium on the process. One felt
the machine brought a quality of
distance to the interaction. He described wanting to ‘climb into the machine to get closer’ to the patient. He felt
inhibited in asking questions about
sexuality and was confused if a feeling of irritation was a countertransference to the patient or the LCVC. He
reported that he had also felt uncomfortable talking to patients on the
telephone. A second, psychodynamically orientated, psychotherapist felt
that on the LCVC, he was having a
‘nice chat’ with the patient rather than
getting’ under the surface of the problem’ He claimed that he could no
longer detect subtle nonverbal cues
such as pupillary changes. He felt
that his nonverbal behaviour, which
would usually put the patient at ease
during an interview was missing on
the LCVC. He summed up the whole
experience as, ‘trying to propose marriage to someone in Australia on the
‘phone that you don’t even know’.
Figure 1
120
The reactions of these Psychotherapists, who were not actively involved
in Telemed, echoed the reservations
of other professional users who reported uncertainty as to the origins of
feelings generated during an LCVC
consultation. Is a reaction during a
consultation determined by the
LCVC or the patient? The possible
contagion effect from telephone
‘phobia’ is worthy of further investigation.
In respect of the quantitative data,
patients completed FOS questionnaires on 47 consultations on the LCVC.
High levels of acceptance were reflected by 35 scoring 4 or 5 when
asked if they would use the LCVC
again to talk to their psychiatrist. For
the same interactions the degree to
which the professionals thought the
patients were upset by the link (Question 8 on the professional FOS) was
compared with the actual patient
response (Question 4 on the patient
FOS). In 25 of 44 interactions the
psychiatrists over estimated the
degree to which the patient was upset
by the LCVC. Six under-estimated
this distress and in 13 it was estimated
correctly ( Figure 1)
Exploratory studies
An exploratory study was performed on the reliability of the Brief
Psychiatric Rating Scale (BPRS),
rated by independent psychiatrists
seeing the patient by LCVC and faceto-face, with the order randomised.
Four patients and two psychiatrists
participated. Significant positive correlations were found and for the
observational subscale the correlation
coefficient was 0.84 [1]. The reliability of cognitive testing over the
LCVC was also explored [3].
Studies also looked at levels of
messy turn taking, when the participants spoke simultaneously in conversation, and mutual gaze for the
LCVC consultations. Rates of messy
turn taking were higher for LCVC
consultations than face-to-face but
this difference did not reach statistical
significance. Episodes of mutual gaze
appeared longer in LCVC consultations than one would predict from
normative data. Numbers were small
and the range was large making firm
conclusions difficult.
When interviewing a patient on
the LCVC a user can only see the
head and shoulders image of the other
user. Nonverbal communication from
other body areas is lost. The effects of
this loss of non-verbal communication on the clinical impression formed by the psychiatrist was studied.
Six areas of potential clinical significance were chosen for investigation:
anxiety, depression, anger, flattening
of affect, incongruity, and involuntary movements. Twenty-three one
minute segments taken from five
interviews were used for rating. Each
interview had been simultaneously
videotaped from two camera angles,
one of the head as seen over the
LCVC and the other of the body of
the interviewee viewed from the side.
Incongruity and involuntary movements occurred too infrequently to be
included in the analysis. The results
showed that, in general, a head only
view does not significantly impair
clinical judgements of depression,
anger, and flattening of affect; but
that it does impair the assessment of
anxiety.
121
The MCVC
The ultimate objective for Workgroup 5 of Telemed was to establish
a videoconferencing link over broadband. This was done, but only after
considerable delay. A case series was
studied of patients attending an outpatient clinic at the Speedwell Mental
Health Centre. One MCVC was
installed there and the other at Guy’s
hospital about 10 km away. Patient
responses were positive and a protocol for running such a remote clinic
developed (8). Prescriptions for medication were posted to the patient’s
home. This phase of the study was
terminated prematurely because no
further funding was available for the
broadband link.
Discussion
The LCVC and MCVC were technically obsolete before the end of the
Telemed project and had no potential
for commercial exploitation. The
main benefits accruing from the
inclusion of technical and clinical
academic partners together in the project were building new relationships
and mutual understanding. The planning of Telemed was highly detailed
and this reduced the flexibility for
following leads in an area of new
research. Workgroup 5 recognised at
an early stage that the technical results would be of limited value and
focussed on studying user responses
and research methods for understanding the impact of the medium on
clinical communication in psychiatry.
The report of the incorporation of
the technology into a psychotic delusional system is significant and worthy of further study. Previous authors
such as Solow [13] had not obtained
this finding. Another interesting finding was the tendency of psychiatrists to over-estimate the degree to
which the LCVC upset patient users.
This may be a novelty effect, an effect
of image quality or evidence of professional bias but its importance
should be elaborated before Telepsychiatry services can be more widespread. Telemed started to look at the
impact of the medium on the clinical
communication but barely scratched
the service. Useful exploratory work
was performed on the methods which
could be used to tease out these
issues.
Telmed stimulated the research
groups at Guy’s and the Croix Rouge
to work further in this field.
Literature
[1]
[2]
[3]
[4]
[5]
[6]
[7]
Ball, CJ & McLaren, PM (1995) “Comparability of Face-to-Face and Videolink Administration of the Brief Psychiatric Rating Scale” American Journal
of Psychiatry 152-6
Ball, CJ; McLaren, PM; Summerfield,
AB; Lipsedge, MS & Watson JP (1995.)
A Comparison of Communication
Modes in Adult Psychiatry. Journal of
Telemedicine and Telecare. 1, 22-26.
Ball, CJ; Scott,N; McLaren, PM & Watson, JP (1993) “Preliminary Evaluation
of Low Cost Video-conferencing
(LCVC) System for Remote Cognitive
Testing of Adult Psychiatric Patients”
British Journal of Clinical Psychology
32, 303-307
Glikman, J; McLaren, PM; Lipsedge,
M; Abraham, A; Marcellot, JG &
Bagoe, MC La Pratique des Conferences Cliniques Telephoniques Entre
Equipes Pshciatriques en Europe Presented at LXXXX eme Congress de Psychiatrie et de Neurologie de Langue
Francaise Saint Etienne, France 15-19
June 1992
McLaren, PM; Ball, CJ & Watson, JP
(1993) “Assessment for Psychotherapy
by Interactive Television Suitable for
Transmission Through Telephone
Links” Psychiatric Bulletin 17, 104-05
McLaren, PM; Ball, CJ; Summerfield,
AB; Lipsedge, M & Watson, JP (1992)
“Preliminary Evaluation Of A Low Cost
Video-Conferencing System For Teaching In Clinical Psychiatry” Medical
Teacher 14, 103-109
McLaren, PM; Ball, CJ; Summerfield,
AB; Watson, JP & Lipsedge, M (1995)
“An Evaluation of the Use of Interactive Television in an Acute Psychiatric
Service” Journal of Telemedicine and
Telecare 1, 79-85
[8]
[9]
[10]
[11]
[12]
[13]
McLaren, PM; Blunden, J; Lipsedge, &
M; Summerfield, AB (1996) “Telepsychiatry in an Inner-City Community
Psychiatric Service” Journal of Telemedicine and Telecare 2, 57-59
McLaren, PM; Glikman, G; Abraham,
A; Ball, CJ; Lipsedge, M & Watson, JP
Comparison of User Responses to a
Digitised Interactive Videoconferencing System for Remote Diagnosis and
Treatment in Psychiatric Services in
France and the UK Presented at World
Congress on Telemedicine Toulouse
November 30 - December 1 1995
Morley I.E. & Stephenson G.M. (1969)
Interpersonal and inter-party exchange;
A laboratory simulation of an industrial
negotiation at the plant level. British
Journal of Psychology, 60. 453-545
Mulhall , D.J. (1976). Systematic SelfAssessment by PQRST ( Personal Questionnaire Rapid Scaling Technique).
Psychological Medicine,6. 594-97.
Short J.A., Williams E., Christie B.
(1976). The Social Psychology of Telecommunications. London. Wiley International
Solow C.& Weiss R.J. (1971) 24 hour
Psychiatric Consultation via TV. American Journal of Psychiatry.127: 12.
Appendix I
The Telemed Consortium
Alcatel Espace
Alcatel-STK
C.N.U.S.C.
Croix Rouge, Paris
Detecon
Dt. Herzzentrum
IDATE
Inst. Hospitalier Montpellier
Irish Medical Systems
Norwegian Telecom
SEL
SIETTE
STC
Swedish PTT
Swiss PTT
Telefonica Sistemas
Telesystemes
University of Florence
University of Heidelberg
University of London
122
Dr Paul McLaren MB BS MRCPsych
Honorary Consultant Psychiatrist
South London & Maudsley NHS Trust
Speedwell Mental Health Centre
62, Speedwell Street
London SE 8 4 AT
Email: PMcl639251@aol.com
and Medical Directo
The Priory Ticehurst House
Ticehurst, Wadhurst
East Sussex TN5 7HU
United Kingdom
Professeur Aime Charles-Nicolas MD,
PhD
Professor of Psychiatry and Psychological Medecine
University Hospital of Fort-de-France
PO Box 632
97261 Fort de France (Martinique)
France
Email: aime.charles-nicolas@martinique. univ-ag.fr
Report
Perspectives of Communication Technology in
Psychiatry: The ISLANDS Project in Greece
Antonios Politis1, Artemios Pehlivanidis1, Angelos Amditis2, Zoi Lentziou2,
† Marios Markidis1, Georgios Trikkas1 and Andreas Rabavilas1
Athens University Medical School, Dept. of Psychiatry, Eginition Hospital, Athens
1
2
Key words
telepsychiatry,
information
technology,
telematics, Islands Project
Perspectives of Communication
Technology in Psychiatry: The
ISLANDS Project in Greece
Abstract: The genesis and application of new communication technology in delivering psychiatric services in Greece is presented. More
specifically in Greece the application
of communication technology in delivering mental health services includes the low cost telephone lines.
Recently new communication technologies has been introduced in mental health in order to provide information and educational material on mental health issues. Moreover this articel
focuses on conceptual issues of the
Islands Project in Greece such as: the
aim and methodological issues in the
development of this project and
underlying the lack of other projects
and the lack of a comprehensive research strategy that specifies the objectives of telepsychiatry in remote areas in Greece.
Introduction
Contemporary trends concerning
health and welfare, as described by
the World Health Organization suggested that “… health, which is a state of complete physical, mental and
social well being, and not merely the
absence of disease or infirmity, is a
fundamental human right and that the
attainment of the highest possible
level of health is a most important
world-wide social goal whose realization requires the action of many
other social and economic sectors in
addition to the health sector”. Even if
these criteria are not fully met by the
medical services provided worldwide, the main objective is to provide to
the entire community high quality
medical and welfare services, especially to those most in need. This may
be the case of the mental health needs
in the remote areas (rural and insular).
Telemedicine is a term applied for
specific clinical appellations, such as
teleoncology, teledermatology, or
telepsychiatry. Furthermore, diagnostic medical services such as radiology and pathology use this technology
to capture, transmit, store, and retrieve information and also are provided
by specific designations which, in
this instance are teleradiology, telecardiology and telepathology, respectively. Bird [1], provided the first formal and published definition of telemedicine as “the practice of medicine
without the usual physician-patient
confrontation”. Another definition
was proposed by Bashshur [2]. This
definition viewed telemedicine as a
system of care composed of six
essential elements: (a) geographic
separation between provider and recipient of information, (b) use of information technology as a substitute for
personal or face-to-face interaction,
(c) staff including physicians, assistants, and technicians, (d ) the deve-
lopment of an organizational structure suitable for system or network
development and implementation, (e)
normative standards in terms of physician and user regarding quality of
care, confidentiality, and acceptance.
The development of new communication technologies promises to
enhance access to healthcare for
remote disadvantaged communities,
since all citizens have equal rights to
benefits pertaining to the healthcare
system. Successfully functioning in
Greece are the low cost telemedicine
systems, that includes telecardiology
and teleradiology. There is a growing
need for mental health services, in the
national health care system, in order
to cover gaps, between urban areas
and insular areas in Greece.
The application of communication technology and essentials of
telemedicine in the delivery of psychiatric services, is telepsychiatry.
Telepsychiatry therefore includes all
forms of contemporary communication technologies applied to mental
health services: synchronous real
time audio data (telephone), synchronous real time audio and video data
(videoconference), store and forward
(e-mental health services). The later,
could be define as new communication technologies and includes both
the internet dissemination of psychiatric information and educational
material through web sites and the
use of the e-mail in providing direct
services by professionals. Aims of the
present article are to describe the current communication technology in
delivering psychiatric services and to
Perspectives of Communication Technology in Psychiatry: The ISLANDS Project in Greece
present a conceptual framework for
the development of Islands Project in
Greece.
Communication technology
and psychiatric services in
Greece
a. Emergency Psychiatric Help Line
Over the years the development of
telephone counseling and listening
services has become widespread
throughout the world [3]. In Greece
alternative mental health services
with the use of communication technology begun in 1987 with the use of
Help Telephone Line located in
Athens Mental Health Center [4]. Ten
years later 1999 a new Telephone
Help Line, the Emergency Psychiatric Help Line (EPHL), was created at
Eginition Hospital under the support
of the Department of Psychiatry of
Athens University. EPHL as a special
interest line provides services in situations related to mental health problems [5]. EPHL acts as a bridge between psychiatric services and
patients in the community and offers
information concerning mental disorders to the families of mentally ill and
consultation to medical practitioners
in remote rural and insular areas.
During the first year of function
EPHL (from May 1999 to May 2000)
accepted a total number of 2055 phone calls [6]. During the period May
2002 to May 2003 , more than 3900
phone calls and during the period
2001 to 2004, 9000 phone calls. The
major domains of reasons for seeking
telephone-help was: loneliness, counseling of mentally ill parents and
patients (delusional or not), psychological crisis and management of
anxious user, psychiatric counseling
in health care practitioners. EPHL
also, has provided services in the
community by facilitating psychological interventions in the context of
major disasters [7]. This role may be
reflective of the community accep-
tance of communication technology
in providing mental health services.
Despite the fact that EPHL has been
receiving phone calls from all over
Greece, its potential and purpose are
limited and cannot provide full psychiatric coverage to all (mainly insular) under serviced communities.
Finally, considering that there is a
growing need for mental health services a significant question to be asked
is whether the development of full
scale telepsychiatric services with the
application of new communication
technology (NCT) (both telephone, emental health units and videoconference units) can cover the existing
gaps and the needs in the national
mental healthcare system [8].
b. E-mental health
The department of Psychiatry at
Athens University, Eginition Hospital
has commenced the operation of the
“Glaucopis-net”, (http://glaucopis.
eginitio.uoa.gr) a network aiming to
provide e-mental health services
through the internet. Glaucopis-net is
being deployed with the help and
know-how of the laboratory of Medical Physics at Athens, Greece, University. The net is directly linked to
the Athens ‘Asclepieion Park’, developed by the above mentioned laboratory. The 'Asclepieion Park of Athens'
is the first pilot application of the
'Modern Asclepieions' concept in
which Health and Culture are promoted in parallel for the benefit of the
citizens, the patients, the people who
look after them and the healthcare
and welfare workers. The 'Modern
Asclepieions' concept is based on the
Ancient Asclepieions, as they were
conceived, developed, functioned
and evolved in the Ancient Greek
World (http://asclepieion.mpl.uoa.gr/
Parko/enchoose.htm). The “Glaucopis-net” website aims to provide emental health services and information to the general population. During
the three years of functioning 20012004 more than 3000 visitors joined
124
the net anonymously in order to obtain medical information. The net is
linked directly to the mental health
services already provided by the
Department of Psychiatry and to the
Counseling Center for Students.
Among the questionnaires the website host are and several assessing the
internet use and the extent to which it
has affected every-day lives of users.
The main target of the “Glaucopis-net” are mostly specific groups
of the urban and remote under-serviced areas that have access to internet
providing both information regarding the EPHL and educational material. The use of new communication
technology (NCT) through the “Glaucopis-net” may be appropriate in
order (a) to help people who avoid to
visit classical psychiatric services to
get in contact by telephone with a
mental health specialist (b) to uncover new types of possible problems
such as the internet abuse and (c) to
provide information on mental health
services [9].
The
Islands
Objectives
Project
The objectives of the Islands Project has been formulated and includes
“…. the development of services in
order to provide modular, non-conventional, remote psychiatric and
psychotherapeutic assistance for
remote areas. By these means quality
of life of the users, quality of mental
health care and the economic
strength of the region should improve
and overweight the costs of implementation and service support. The
project will reduce inequalities in
mental health services and status
among European regions …”
Politis, Pehlivanidis, Amditis, Lentziou, † Markidis, Trikkas, Rabavilas
The Islands Project in
Greece:
(a) The Islands
The Greek pilot will take place in
the Cyclades islands for the period
August 2004 to February 2005 (for
intervention) and June 2005 to September 2005 (for post-evaluation).
Data concerning the prefecture of
Cyclades is available. Nineteen islands with a population of 110.000
people are serviced by 3 psychiatristis, all occupied at the general hospital, on the island of Syros. A classical
example is the island of Andros
which is the second largest island of
the Cyclades. It is situated in the
Aegean sea, 37 n.m. from the east
cost of the peninsula of Attika. The
island had a population of 10.000
peoplte census of 2002. The number
increases significantly to 3 or 4 times
during the summer months owing to
the influx of the tourist. There are no
primary or secondary mental health
services. Tertiary services are contracted to mental health hospitals on
the city of Athens, that distances 4
hours, and psychiatric services provided by the General Hospital of the
island of Syros that distances 3 hours,
but without the possibility to provide
hospitalization. Users of mental
health services have to travel mostly
to Athens for psychiatric assessment,
treatment and follow up. The health
center of the island provides basic
psychiatric follow up to about 60 outpatients every month. The medical
staff of the health center deal with
acute or chronic psychopathological
manifestations every month (psychosis, depression and others problems
related to substance abuse, acute
stress manifestations and dementia)
and merely number of patients are
admitted in psychiatric hospitals in
Athens for specialized psychiatric
help. However, there are no data
regarding the delivery of psychiatric
services from the population and there are no epidemiological data regarding the prevalence and incidence of
psychiatric disorders in the island.
Our department therefore decided to
study the potential benefits of the
application of communication technology in the delivery of special psychiatric services to Andros as a pilot
plan for the rest of the islands
through three different communicational channels:
a. desktop videoconference
b. low cost telephone line (EPHL)
c. ISLANDS system
(b) conceptual observations on the
pilot study in Greece
New Communication technology
(NCT) is intend to be used in order to
provide affordable high-quality mental health services including diagnosis and continuity of care to patients
in areas that are deprived from psychiatric services. The planning and
application of NCT in such remote
insular areas must take in consideration all possible methodological limitations [10]. There are no studies indicating the frequency of NCT use in
mental health from the population in
Greece. However, it seems that use of
low cost telephone lines and the
access in the internet in order to get
information or educational material
or counseling is more frequent in
urban areas than in remote rural and
insular underserved areas. This gap
between urban and remote areas in
the use of communication technology
may be the result of various factors.
Among them social factors (such as
stigma, acceptance of a new communication relationship with a specialist), financial, age related, educational factors and lack of information on
the existing services may affect the
accessibility to mental health services
trough the NCT. Access refers to an
individual ability to obtain needed
services. Access has various dimension such as geographical, financial,
social, cultural and psychological.
Often in the geographical dimension
of the island we can identify urban
and rural, remote areas. The presence
125
of rural and urban areas in the same
island may lead to a different pattern
in delivering mental health services
with NCT. Insular remote areas are
sparsely populated and often transportation is needed to visit specialist
or low cost telephone lines are in use
in order to get counseling in these
remote insular areas. Patients evaluated by NCT must still travel to the site
where the equipment is located. These facts lead us to believe that a gap
may exists also in delivering mental
health services in the geographical
dimension of the island with different
implications for the NCT applications. Considering that economic
subsidies will always be necessary,
except the cost of equipment, transmission lines, other infra-structure;
technical personnel; requirements;
space and training staff. Thus evaluating the accessibility, feasibility,
effectiveness and costs-efficiency of
the new communication mental
health services between urban insular
and remote insular areas may lead to
an improvement of the quality of care
provided by the local Health Center,
decreasing both the access to tertiary
services and the citizen anxiety during an emergency situation. Could
other types of services, such as visits
by psychiatrists or trained primary
care physicians supplemented by
telephone contacts with a psychiatrist, provide more personal service at
the same or a lower cost? Can a structured interview with the patients and
the relatives conducted by another
clinician, followed by a telephone
call, accomplish objectives similar to
those of a modular, distributed telepsychiatry platform, which will allow
transfer of critical parameters in a
secure medical telecare network between patients, their family members
and/or stationary centres, equipped
with medical staff, enabling virtual
telepresence, remote monitoring and
teleconsultation with medical experts.
Parameters such as the quality of
human interaction and the importance
of personal contact may influence the
acceptance of the NCT. It is one thing
Perspectives of Communication Technology in Psychiatry: The ISLANDS Project in Greece
to conduct an emergency assessment
via NCT to decide whether a person is
delirious or suicidal and quite another
to have a sustained relationship via
NCT with a chronically ill individual? Thus, a satisfaction analysis for
specialists, service users relatives and
health care professionals has to be
tested.
At all events the implementation
of NCT is not solely bound either to
therapy or teleconsultation. It equally
applies to a major parameter of a
national psychiatric healthcare system, the continuous tele-education of
healthcare providers. However, the
successful application of this new
method in healthcare is greatly depending on a careful structural planning, so that its functional cost would
not exceed the cost of the problem it
is supposed to solve.
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Politis A, Lambousis E, Markidis M, Bergiannaki I, Christodoulou GN. Athens
Emergency Psychiatric help line: report
from the first year of service. Technology
and health care 2001; 9: 356-357
Politis A, Markidis M, Lambousis E, Bergiannaki I, Christodoulou GN. Effects of
a Major earthquake on phone calls to a
psychiatric emergency help line. Technology and health care 2001; 9: 354-355
Markidis M, Politis A. Telepsychiatry:
prospects for the use of new technologies
in every day practice. Psychiatriki, 1999 ;
10 :.263.
9.
10.
Lambousis E, Politis A, Markidis M,
Christodoulou GN. Development and
use of on line mental health services in
Greece. J Tele Telecare 2002; 8: 51-52
Frueh BC, Deitsch SE, Santos AB. Procedural and methodological issues in
telepsychiatry research and program
development. Psychiatric Services
2000; 51: 1522–1527
Prof. Dr. Antonios Politis
Lecturer in Psychiatry
Athens University Medical School
Eginition Hospital
72-74 Vas. Sophias Ave
11528 Athens
Greece
E-mail: glaucopis@med.uoa.gr
126
Report
History of Telepsychiatry in the Czech Republic
Pavel Doubek, Alan Kott and Jiri Raboch
Psychiatric Department of the 1st Medical School, Charles University, Prague
Key words
telepsychiatry, help-lines, crisis intervention, counselling
History of Telepsychiatry in the
Czech Republic
The development of telemedicine
and hence of telepsychiatry has
always been connected to the development of communicational technologies. First telepsychiatric services
in the world were the telephone helplines, the very first coming from London. This article concerns about the
history of telephone help-lines in
Czech Republic and former Czechoslovakia, describes the types of helplines available and gives future possibilities for telepsychiatry in this
region as a pattern for Eastern European countries.
Introduction
The development of telemedicine
and hence of telepsychiatry has
always been tightly connected to the
development of communicational
and audio-visual technologies. Its
present-day expansion is made possible because of the wide-ranging
introduction of digital data transfer
technologies.
Telepsychiatry has generally been
thought of as being the delivery of
health care and the exchange of
health care information for purposes
of providing psychiatric services
across distances. The relatively recent
term „e-mental health“, however, is
increasingly being applied, relates to
mental health services provided
through any form of electronic
medium, most commonly via the
Internet or telephony.
The expansion of telephone lines
was the first step towards telepsychiatry. Nonetheless at that time terms
like telepsychiatry or telemedicine
were not commonly used.
The cornerstone of telepsychiatry
in Central and Eastern Europe was
the foundation of the first Czech helpline in 1964.
Help-lines in Europe
We may consider help-lines to be
the first real-time telepsychiatric services. For already 50 years help-lines
have its unique place in the system of
urgent medical aid providing crisis
intervention via telephone.
The first telephone help-line has
been working in London since
November 1953. An Anglican vicar
Chad Varah founded it in the catacombs of a church. It was working 24
hours a day. The main purpose of this
help-line was the prevention of high
suicide rates in London. Its origin was
very simple. Vicar Chad Varah was
inspired by the fact that in London
there were three suicides a day. It is
said that a suicide of a fourteen years
old girl made him place an advertisement “Call me before you commit
suicide” in a newspaper. The response to the advertisement was unimaginable. Varah couldn’t manage hund-
reds of telephone calls and he had to
engage his relatives and friends. And
so the first European help-line originated. Inspired by the London model
many help-lines all over the world
emerged.
From the very beginning Varah’s
conception of the telephone help was
an apolitical, irreligious, independent
and on volunteer-ship based organisation. It was named The Samaritans.
This organization trained and psychotherapeutically educated various specialists like psychologists and psychiatrists to provide help to people in a
crisis and especially to those endangered with suicide till nowadays.
According to the results of a study
published in Great Britain in 1982 a
statistically significant reduction in
suicidal rates could be observed in
those places where help-lines were
established.
Nowadays help-lines are working
not only in Europe but also in America, Australia and Asia.
In Europe the densest network of
help-lines can be found right in Great
Britain. There are as many as three
thousand help lines that fulfil the
definition of Telephone Helplines
Association (THA) that a help-line is
an non-profit organization offering
all or at least a part of its services via
telephone. These services include
support, counselling, and information
access as well as links to specialists.
In the vast majority the employees of
the help-lines working in Great Britain are unpaid volunteers.
THA is the only help-lines associating organization. Nevertheless the-
re are not more than 650 help-lines
that work in a standardised way.
In 1986 Esther Rantzen, a famous
TV moderator, has founded a Child
Line in London. From the beginning
it was working 24 hours a day and it
covered all the area of Great Britain.
The first help-line in continental
Europe has been founded in Western
Berlin in 1956. In 1957 in Zurich
another help-line named “Given
Hand” appeared. Between 1957-1975
other 13 help-lines were set up. After
a short period of scepticism they were
generally accepted. Since 1975 these
services are accessible from all over
the Switzerland with as many as 50
thousand contacts per year in 1975
and twice as many in 1981.
The help-lines can be contacted
using a three digit emergency calls
telephone numbers since 1976 in
Switzerland.
The help-line founded in Czechoslovakia in 1964 became a model
for founding similar facilities in Central and Eastern Europe. In many of
these countries help lines are named
by the Czech specific term “Linka
du˚ v eˇ r y” (=Line of confidence).
In Poland professor Bukowczyk
founded telephone help-lines since
1967, named “Telefon zaufania”.
In Hungary they have their helpline since 1971, the first being called
“Leki Elsögy Telefonszolgát”.
In former Soviet Union the first
help-line was founded in Moscow in
1971 to prevent suicides. There are
other help-lines working in many of
the bigger cities in Russia now.
Help-lines were founded in Bulgaria and former Yugoslavia.
In most of these countries, as well
as in the Czech Republic, help-lines
are a part of the official health care
system. Towns, cities, regions or
church usually fund help-lines in
Western Europe.
In Geneva in 1960 International
committee and International secretariat of help-lines was established and
in 1967 International Federation of
Telephonic Emergency Services
(IFOTES) was constituted. This orga-
nization works in close relation to
WHO and many other international
heath and social institutions and organizations.
At an IFOTES congress in Geneva in 1973 international standards of
telephone help were postulated. These standards are generally accepted
by all help-lines whether or not they
are members of the IFOTES.
Help lines in Czech
Republic
In the Czech Republic (former
Czechoslovakia) there is a forty years
tradition of telephone help-lines. Doctor Miroslav Plzák founded the first
Central and Eastern European telephone help-line named „Linka d u ˚ v e ˇ r y ”
in 1964 in Prague at the Psychiatric
Department of the 1st Medical School
of the Charles University. Because of
his personal initiative this help-line
was included in the official health care
system. The founding intentions of
this help-line were similar to those
already mentioned. It had to prevent
people from committing suicide, help
them with their depressions and other
mental problems and disorders. The
foundation of this help line is still an
unappreciated success of the Czech
health system. In the following year in
Brno (the second biggest city in Czech
Republic) a help-line called “Linka
nadeˇ j e” (= Hope line) was founded
by professor Hádlik. In 1967 “Linka
du˚ v eˇ r y mládezˇ e ” (= help line for
youth) has been opened also in Prague
at the Psychiatric Department of the
1st Medical School of the Charles University.
Fruitful though by political situation limited international contacts
were from the very beginning used to
share experiences from different countries.
The process of establishing help
lines was very quick and so in 1996
there were 37 registered help-lines in
the Czech Republic and around 60 in
2000.
128
The term “linka d u ˚ v e ˇ r y ” is used
as a unifying characteristic of different telephone help-lines with very
similar goal: Urgent and emergency
telephone contact with people in
need.
Some of the help lines have specialised on a specific part of population
(children, teenagers, seniors); other
help-lines have oriented in particular
problems of specific population
(alcohol, drugs, AIDS, homosexuality, home violence, etc.)
Number of telephone calls at the
end of the ninetieths was approximately 50 thousand per year.
The rising number of help-lines
had brought several changes in the
conception of their practice:
1. Not only specialists but as well
trained laymen work for the helplines. They are not licenced psychotherapists. They accomplish acute
intervention only.
2. The need to protect and support
the professionals as well as the need
of professional growth and information exchange led to the establishment of Czech association of helpline workers in 1995.
3. Specialised software is used by
many organizations to store and evaluate data coming from the help lines.
4. Specialized educational programmes for help-line workers were
created. They should be prepared for
various calls of different degree of
emergency or abuse. They should be
able to react quickly but circumspectly. They should be well informed
about the community situation, they
should be able to provide psychosocial information or give links to proper
specialists or workplace. But as well
they should remain authentic human
beings. This can be achieved by different ways. The first one is a specialized training in telephone crisis intervention that includes practice in
general help-line work as well as in
specialized themes (dependence, sex,
legal aspects, abuse and violence, suicide, reaction to traumatic experience, etc.) The second one is a selfexperience psychotherapeutic trai-
Doubek, Kott, Raboch
ning that has its value especially in
personal growth and development.
Casuistic seminars where different
approaches are presented and discussed are the third way. And the other
possibilities include Balint supervision seminars, individual supervision,
self-experience, or literature study.
Working at a help-line
The work at help-lines is very
eventful. People may call because of
themselves or because of somebody
else. They may be in great tension but
as well they may be worried about
somebody or something. The helpline worker must be well prepared for
all of these situations. Easy ones or
even abusive calls (invectives, senseless requests) may follow urgent
emotionally filled difficult calls. This
all contributes to enormous psychic
burden of the help-line workers. Following the principles of mental health
hygiene may be the easiest way to
prevent the burn-out syndrome.
The aims of telephone crisis intervention
The first aim is to calm down the
calling person to stabilize his or hers
situation, to reduce the risk of crisis
progression or to prevent suicidal
behaviour.
The perspective aim is to work out
the closest future with the calling person and if possible to find possible
ways of solution.
Help-lines have wide indications
but their main purpose is not to make
a diagnosis but to solve a problem.
Help-lines types
1. Help-line as an independent
organisation. Other services are not
provided.
129
2. Help-line with outpatient clinic
where the calling person can be invited to come if necessary.
3. Help-line being a part of a inpatient clinic
Types mentioned above differ not
only in help flexibility and promptness in urgent cases but as well in
overextension of the workers and in
the degree of dependence on subsequent services.
Personal specific problems are
solved in online counselling. If the
query is somehow general and if the
asking person agrees the query will
appear in the Archives of online
counselling.
Both chat and online counselling
complement each other and give the
lekarna.cz visitor a unique possibility
to obtain relevant information not
otherwise found on the web.
Conclusion
The development of telepsychiatry and e-mental
health in Czech Republic
With the introduction and development of the Internet in the Czech
Republic specialized counselling and
later on-line chats have emerged on
medical servers. E-mail counselling
running since November 1999 on the
web pages lekarna.cz was a forerunner to an on-line chat. Any web visitor could address his or her query
about medical problems using an email box. The query was quickly redirected to a specialized doctor and the
answer was sent back to the person
via e-mail. Repetitions of some queries as well as 10-15 queries per day
made the web page provider to start
an on-line chat and on-line counselling. Both services have been introduced three years ago.
Chat offered to the visitors many
interesting topics that could be
discussed in general public. This project was supported by General University Hospital in Prague.
Nowadays live discussion takes
part every week at lekarna.cz. A week
before the discussion is advertised at
the lekarna.cz homepage as well as
the specialist profile and a simple CV.
Those who cannot join the live chat
may ask their questions in advance.
These questions will be answered
during the discussion. All these
discussions are saved in the Archives
files and are accessible with a full text
search engine.
The development of modern telecommunication technologies made
other than only help-lines telepsychiatry tools possible. Nowadays we are
witnesses of a huge boom of internet
mediated help and education possibilities that give a person in need but as
well professionals and informal
carers opportunities to access to help
or counselling from the best specialists all over the world.
The Psychiatric Department of the
1st Medical School of the Charles University in Czech Republic is one of the
ISLANDS project partners and participates in the development of integrated system for long distance psychiatric assistance and non-conventional
distributed health services. This project extends the possibilities and tools
of present-day telepsychiatry.
References
[1]
[2]
[3]
[4]
[5]
Eis Z. Volejte linku du˚ v eˇ r y! H&H
Jinocˇ a ny, 1993
Knopová D, Bahbouh R, Basˇtecká B,
Bouchal M, Eis Z, Havránková O,
Kucˇera Z, Lucká Y, Nováková Z,
Tichy´ V, Zajíc R, Zemanová E. Telefonická krizová intervence – Linka
du˚ v eˇ r y. Remedium Praha , 1997
Kopecˇ ek M.: Internet v lékasˇské praxi.
Psychiatrie, 2002, 6 (2), 92-96
Plzák M, Br`ezinová B, Zvolsky´ P:
Depresivní stavy v dospeˇ l ém veˇ k u.
SZdN, Praha, 1967
Sekot M.: Vyhodnocení vy´ s ledky
Vánocˇ n í linky proti depresi. Cµes. a
slov. Psychiat., 2000, 96(8), 434-436
[6]
[7]
Wootton R, Craig J. Introduction to
Telemedicine. London: Royal Society
of Medicine Press, 1999
Wootton R, Yellowlees P, McLaren P.
Telepsychiatry and e-mental health.
London: Royal Society of Medicine
Press, 2003
Pavel Doubek, M.D.
Psychiatric Department of the
1st Medical School,
Charles University, Prague
Ke Karlovu 11
120 00 Prague
Czech Republic
E Mail: doubekpavel@ceskapsychiatrie.cz
130
Report
Telemedecine in French Guyana
Thierry Le Guen1, Nicolas Poirot2, Olivier Tournebize2 and Antonio Guell3
Hospital Complex Andrée Rosemon of Cayenne
French Space Medicine and Physiology Institute, Toulouse Cedex
3
French Space Agency, Kourou, Cayenne
1
2
Key words
French Guyana, Satellite, Telemedicine
portable workstation
Telemedecine in French Guyana
From December 2001 to May
2002 a Telemedicine survey was done
in French Guyana within the framework of an agreement between Cayenne Hospital (CHAR) and the
French Space Agency (CNES), with
technical support of the French Space
Medicine & Physiology Institute
(MEDES).
Expertise were done by specialists of the CHAR in tree specialities
(Dermatology, Parasitology and Cardiology). Medical reports elaborated
with Telemedicine portable workstation, from 4 remotes sites of the Amazonian forest, were sent by satellite
phone to the Cayenne Hospital.
The survey was assessed on medical, technical and economical ways.
The results shown that objectives
initially defined were reached, and
decision of extension up to all remote
medical dispensaries was taken by
health authorities.
Introduction
From December 2001 to May
2002, within the framework of a collaboration between the Hospital
Complex Andrée Rosemon of Cayenne (CHAR), the French Space Agency (CNES) as well as the French Space Medicine and Physiology Institute
(MEDES) an experimentation of tele
consultation per satellite took place in
French Guyana, at the issue of which
it was decided to make profitable and
to extend the installation of telemedicine portable workstation to the whole guyanese territory. The goal of this
article is to explain the methodological steps, to present the results and to
envisage the prospects of this project,
in particular in the field of psychiatry.
The context
French Guyana is a vast overseas
department of the size of Portugal,
covered by 80% by the equatorial
forest. The 200 000 inhabitants are
divided to 80% in 3 cities of the littoral: Cayenne, Kourou and St-Laurent
of Maroni. These cities have the 3
hospitals, the private clinics and the
majority of the health devices of the
territory. 21 centres and isolated
health dispansaries depend on the
CHAR of Cayenne.
The centres and health stations are
held either by general practitioners
and paramedical personnel in the
important communes, or by the paramedicals, nurses or agents of health
for the small communes. They are the
only access of the rural populations
[1], approximately 20% of the Guyanese to the cares. These professionals
of health thus face technical plates
and means of telecommunications
limited to any type of request for care,
tropical pathologies, gynaecologyobstetrics, traumatology, urgencies.
The means of communication, put
aside on the littoral, are the water and
air ways, what complicates the work
of the health professionals at the interior for the management of the emergencies and the pathologies requiring
a particular expertise. Rounds of specialists are organised on the rivers in
order to try to mitigate the difficulty
of access for the isolated populations
to specialized care and to limit the
delay in the diagnosis and therapeutic
treatment In spite of these efforts, the
inequality of medical treatment compared to the urban populations
remains real.
This geographical configuration
was perfectly appropriate for the
experimentation of telemedicine in
order to facilitate the access for the
isolated populations to the specialist’s
expertise of the CHAR of Cayenne.
Three specialities were selected for
the experimentation: dermatology,
parasitology and cardiology.
Map of French Guyana (According to :
«Géographie de la Guyane». Jacqueline ZONZON; Gérard PROST – Edition: SERVEDIT)
The choice of the specialities was
made by the doctors of the CHC after
a demonstration of sending macro
and microscopic images and ECG
numerical recording via satellite from
real situation in two isolated communes, carried out in October 2000. The
choice was dictated by the important
effect of parasitic pathologies (Paludism, leishmaniosis, intestinal parasitosis …) and dermatological ones
(leishmaniosis, various dermatosis
…). The interest of these specialities
being that the principal attacks could
effectively remotely be diagnosed
and the objective evaluation of the
telemedicine system was possible to
estimate the efficiency and limits of
the use (systematic second reading of
the blades for parasitology, negatives
after treatment for control for the dermatology).
4 sites were selected: Maripasoula, Staint-Georges, Antecume Pata
and Trois-Sauts. Each one of these
sites was equipped with a telemedicine portable workstation including a
laptop, a digital camera, a digital
electrocardiogram, a microscope and
a satellite telephone INMERSAT M4.
A specific software was developed in
order to respond to the study’s protocols defines by the guyanese doctors.
Methodology
The principal objective of this
project was the qualification of an
application of telemedicine likely to
bring an improvement in the treatment of certain medical pathologies
in isolated sites. In particular the defines objectives were stated in three
headings: medical, technical and economical
Medical Objectives
In the field of parasitology, dermatology and cardiology (electrocardiogram) we excepted the validation
of a methodology allowing to carry
132
out a remote diagnosis, starting from
a centre of expertise (CHAR) and for
the benefit of patients located in isolated sites which normally would not
have access to this type of diagnosis
or have it in times incompatible with
a correct treatment of the pathology.
At the same time the objective of
the experiment, always in medical
terms, was to not only validate reliable medical protocols making it possible to establish a diagnosis and a
therapy but, as guarantee as this diagnosis and this therapy, to make sure
the use of average technique like the
tele transmission by satellite of the
data, are medically (depending on the
parameters of the profession and the
state of the art) correct.
Technical Objectives
• Validation of the availability and
the reliability for the system in time
and a “difficult” environment ( tropical rain forest, important water content, random quality of the power
supply, cloud cover, etc).
• Ergonomics of the system compared to the level of the users, as well
in emission, in reception and handling of the data.
• Quality and reliability of the
data compared to the requirements of
the users and the need for the medical
practice.
Economical Objectives [2, 3, 4, 5]
• Validation of the estimated costs
as well in term of investments as in
term of exploitation and maintenance
cost.
• Comparison of the costs inferred
from the use of the system of tele
medicine and the costs of “traditional” medical interventions (evacuation by helicopter in particular)
In general, to allow the authorities
(health and medical authorities) to
make reasoned decisions in term of
choice of equipment and fitting out
Telemedicine suitcase
the territory in particular the isolated
sites.
Results
196 files were sent during the 6
months of experimentation (51 in
dermatology, 108 in parasitology and
37 in cardiology). The analysis by
speciality allows to refine the use and
the usefulness of the telemedicine
network.
1. Parasitology
2. Dermatology
51 files sent during 6 months, 32
from Trois-Sauts, 12 from Maripasoula, 6 from Antecume Pata
and 1 from Saint-Georges.
3. Cardiology
In 6 months 37 files were sent, 2
from Saint-Georges and 35 from Trois-Sauts. 4 files were related to thoracic pains, 2 were referred for routine
inspections among patients having
cardiac antecedent and 31 files corresponded to systematic electrocardiograms before the prescription of
Halofantrine for falciparum Paludism
treatment.
Discussion
1. Parasitology
The requests for expertise was
related primarily to confirmation’s
request for paludism diagnosis
(99/108 which means 92% of the
expertise requests) on blood smears
and/or thick drops.
Le Guen, Poirot, Tournebize, Guell
Images of cutaneous lesions
and/or cutaneous smears were sent
within the framework of a diagnostic
confirmation of leishmaniosis for 8
patients (7,4% of the expertise
requests), 6 of them presenting cutaneous ulcerations.
A diagnosis of intestinal parasitosis (0,6%) was required based on
stool analysis perform in saline water
for a patient who was suspected of
amoeba dysenteriae (fever and bloody-stools Diarrhoea)
Base on 108 responses sent to us ,
12% of the latter had none formulated
diagnosis, we did not find any parasitologic contamination for 7 subject
(6,6%) with 95 of certainty.
For a great part of the files ( 73
which means 67,6% of the files) the
response was transmitted with 95% of
diagnostic certainty. Only 7 responses
were given without any certainty
which means 5% of the files.
One notes for 71 patients only
one recourse to the expertise without
needing additional information to
conclude the files.
In the same way, there was for 25
patients one resort to the expertise
with 1 to 2 complements of information (achievements of new blades of
smears or drops thick or strips ICT,
clinical and parasitologic follow up at
D3 even D7 of the paludal initial
access, information on the therapeutic treatment carried out).
Six patients presented new paludal episodes (between 2 to 4).
Therapeutic prescriptions were
carried out for 60 files with the molecule indication, the way of administration, the posology.
Concerning the prescription of the
Halofantrine (22), it way almost
always recommended to realize a
pre-therapeutic ECG (Cf. Cardiology
synthesis).
Therapeutic advice (18 files)
(molecules choice, reference and
referral to founded protocols) and
prophylactic advice ( 4 files) ( use of
mosquito nets, of insecticides) were
recommended. We find a clinical follow up advice twice.
133
Technical complementary measures (new blades of smear blood (10),
thick drop (36), strips ICT (15)) were
required to optimize returned result
for 61 files.
In the same way, technical advices
(12 files) were made on the use of the
microscope coupled with the digital
camera (in term of luminosity, of the
enlargement done, of the quality of
the pictures).
The technical methods according
to protocols drawn up (time of colouring, type of colouring, conservation
of the blades, contamination of the
blades by mushrooms)
To improve the treatment of the
relapses which have occurred among
certain patients, recommendations
were provided to the health care personnel concerning the possible complements of examinations to forward
to CHAR and to the Institute Pasteur.
In a context of a well trained field
worker the diagnostic remain relatively easy but a formal diagnosis
remain to be establish by a biologist.
It was possible for us to validated
the system on the qualitative level by
comparing for the same patient the
result returned by telemedicine and the
result after reading and checking the
blades transmitted to the laboratory of
Parasitology-Mycology of CHAR.
At total, for the same period, 85
files could be compared:
- 78 concerning the search for
paludism ( on 509 requests for blades
from health centres sent to the laboratory for the same period)
- 7 concerning the search for cutaneous leishmaniosis
There is no discordance for the
search of leishmaniosis between the
tele medicine reading and the reading
% de
accuracy
P.fal
P.viv
P.fal+
P.viv
P.mal
P.sp
95%
75%
50%
0%
Total
24
8
1
0
33
28
9
1
2
40
3
2
0
0
5
1
0
0
0
1
2
1
2
2
7
Non for- Leish
mula-ted
diag.
7
1
2
3
13
8
0
0
0
8
Amib
Total
1
0
0
1
73
22
6
7
108
Table I: parasitology results
SITES
Trois-Sauts
Eczema
12
Infectious
17
• Parasitology 11
- Leishmaniosis 9
- Scabies 2
• Bacteriology 1
• Viral 2
• Mycology 3
Various
1 Folliculitis
1 tumefaction under
cutaneous
1 oral ulceration
Maripasoula
4
2
1 ulcerate leg
1 mal perforant plantar
1 sweat dermatite
1 melasma
1 cheloid
1 Sutton’s disease
1 ulcerate leg
1 pustulosis
0
11
• leishmaniosis 1
• mycology 1
Antécume Pata
2
2 mycology
Saint-Georges*
Total
0
18
0
21
Table II: dermatology results
• The file from Saint Georges did not allow a diagnosis
carried out on blades within the routine framework at the laboratory.
There is 3 cases of discordance
(3.5%) for the diagnosis of paludism:
- one is due to a writing error at
the time of the returned result.
- For the second, it was answered
P.vivax at 95% of certainty; on the six
photographs controlled in tele medicine, one confirms the P. falciparum
diagnosis, the other fives are more in
favour of P.vivax .
- The last file responded P. falciparum in telemedicine was controlled
P.vivax on blades; only one image
made it possible to establish the diagnosis, the second being fuzzy therefore non-interpretable.
The request for control in tele
medicine and the request of blades
returns towards the laboratory are
thus very important. Indeed, the
reading of the blades makes it possible to have an overall picture.
2. Dermatology [6, 7]
On the 51 files, one finds the following diagnostic index:
• Accurate diagnosis: 44 files out
of 51
• Dubious diagnosis: 2 files out of
51, 1 suspicion of clinically atypical
leishmaniosis and 1 incomplete observation for lack of clinical information.
• Absence of diagnosis: 5 out of
51: 3 by deficiency of initial observation (fuzzy photographs, non-interpretable, and/or misses clinical information) and complementary absence
of return to the dermatologist’s
request of explanations, 1 by need to
make a cutaneous biopsy (diagnosis
posed in a second time) and 1 by
interpretation error from the receiving doctor.
In Summary, the dermatology tele
consultation is reliable and as efficacious as (28 cases out of 31) a traditional consultation.
An improvement can still be
introduce by a more detailed initial
observation and a better quality of the
exchanges.
46 files out of 51 could be evaluated, the other 5 patients having been
134
lost of sight. On 46 patients, 28 are
completely cured, 10 have improved,
6 are stabilized, and 2 have worsened
(1 related to the pathology and 1 related to the misuse of the tele medicine). Finally our estimate is that we
were able to prevent an transfer from
Trois-Sauts: a child with an important
rash impetigo of the face potentially
leading to serious infectious complications was diagnosed and treated
effectively with antibiotherapy, via
distant telemedicine communication.
A control using the same telemedicine device showed a very drastic
improvement of the conditions.
On the whole, one can retain only
one failure related to the use of tele
medicine, by a bad diagnosis posed
initially, and a bad secondary orientation. In the large majority of cases,
the quality of the images is excellent.
In 4 cases out of 51, the images were
fuzzy and did not allowed diagnosis
with certainty. The richness of the
comments and exchanges between
the hospital specialists and the actors
of health in the communes allowed to
help at the continuous training of these latter.
3. Cardiology [8]
4 files having for reason of consultation “thoracic pain”
- Only one of these patients had a
pathological recording having required an EVASAN (Sanitary Evacuation) on CHAR at a first place, then
after 2 days of hospitalization, an
EVASAN on Martinique for coronarography. A first transmission approach of a layout paper by fax, sent by
the doctor of Saint-Georges and
checked by the cardiologist allowed
the medical evacuation of the patient.
The electronic file was established
secondarily to test the functionality of
the tele medicine system. There is a
lapse of time of 4h10 between the
sending of the request and the diagnostic return.
- The three other files had normal
layouts.
The delay of the response are too
important: several hours to several
days. This time limit in the event of
an acute cardiovascular problem is
too long. It is advisable to adapt the
cardiology protocol.
Routine inspection among patients
having cardiac antecedents. 3 files for
routine inspection further to known
cardiac antecedent (complete arrhythmia by FA, systolic breath from a
trisomic child). The layouts are normal in both cases.
Systematic electrocardiograms
before treatment by Halofantrine.
31 records were systematically transfered in order to diagnoses potential
eqg conduction anomalies before any
prescription of Halofantrine for falciparum Plasmodium treatment.
4. Out of Protocol
The users were confronted with
pathologies not included in the frameworks defined for the pre-operational phase, so they used the electronic messaging as support of information transmission and request of
expertise, by joining images as
attachments, or in certain cases the
dermatology files.
Pathologies:
• Tenosynovitis of the hand, initially labelled as the carpal ternal
syndrome
• Phlegmon of the thumb
• Exocervicitis on ectropion
• Stomatitis
• Talipes of a new-born baby
• Snake bite
Analysis:
• Snake bite: an EVASAN was
prevented since the reptile was formally identified on the attached
photograph ( Bothrops atrox) and the
patient did not show any clinical
signs of serious poisoning.
• Phlegmon of the thumb: an
EVASAN was carried out in emergency after surgeon’s advice, the image attached highlighting a functional
urgency. The vocal communication
by itself would not made it possible to
appreciate the gravity of the situation.
• Talipes: the physiotherapist of
CHC transmitted to the nurse of Tro-
Le Guen, Poirot, Tournebize, Guell
is-Sauts protocols of massages and
physiotherapy preparatory to the surgical treatment, preventing at the
same time an EVASAN of the newborn and the mother for a specialized
consultation.
5. Economical Assessment
As shown by the recent economical studies of telemedicine [9, 10],
there is an absence of methodological
consensus on this particular subject.
All users are unanimous to say that, in
addition, the traditional methods of
economical evaluation in health do
not take into consideration the overall
specificities of the medical practice
supported by a telemedicine network.
Within the framework of the preoperational setting of the telemedicine network per satellite in French
Guyana, it was not possible for us to
set up a scientific methodology for
economical evaluation by comparing
the activity of the centres using tele
medicine with the centres not equipped but having a comparable activity.
Nevertheless a particular effort was
carried out to define and allow the
exploitation of economic indicators,
of efficiency and of the use of the set
up system.
A specific synthesis card was defined with the support of a professor
and researcher of health economy at
the ENST of Brest (Myriam LeGoffPronost) [11].
This card is complete by the doctor-coordinator at the end of each tele
medicine file.
This card includes 56 items:
• 11 “administrative” items allowing to locate the cases (name of
health professionals, of the patient,
date …)
• 12 “medical” items in three headings (final diagnosis, clinical evolution, hospitalization) to specify the
case of the patient during the whole
medical treatment process, tele consultation, treatment and local evolution, or the become of the patient after
his hospitalization in order to be able
to correlate the initial medical data
exchange on the network with the
135
final results, in particular for the confirmation or the invalidation, of the
tele-diagnosis.
• 16 “functioning of the telemedicine” items in two headings, treatment of the case without telemedicine, to try to have comparative data
between the normal practice and the
use of the network of tele medicine
per satellite, and appreciation of the
tele medicine in term of contribution
to the medical practice.
• 17 “economical” items, in three
headings
• The time passed, by the various
health professionals concerned, for
the specific use of the system.
This specific time for the users of
the health centre does not include the
time of examination (for example this
heading, in the case of a parasitology
request includes the time to constitute
the electronic file, of taking digital pictures and verify them, but does not take
into account the time of taking samples,
of preparation, and for blade’s reading,
time normally passed by the professional out of the use of the system).
For the doctor-coordinator and the
specialists it is the time of data analysis and of writing responses. The
time to constitute the synthesis card is
also taking into account.
• Medical extra costs, allowing an
evaluation of the impact of the network in term of treatments carried out
locally, which would not have been
prescribed without the exchanges
permitted by the network of tele
medicine.
• The economies achieved in term
of EVASAN but also in term of
impact on the whole medical chain.
Besides the functional approach
of the analysis reserved for the synthesis card, more classical evaluation
data were collected: investment cost,
functioning cost, EVASAN. However
we have dissociated the fixed costs
from the variable costs depending on
the functioning of the network, as
well in term of personal time, as of
costs of telecommunications which
are the two principal factors.
The average cost of a file is 78
Euro of which 53 Euro goes for the
cost of satellite communication
(INMERSAT).
On a total of almost 200 files, 3
EVASAN were prevented thanks to
the tele medicine per satellite system,
both from “out of protocols”, coming
from Trois-Sauts, located at three
hours from Cayenne (roundtrip medical helicopter):
• A snake bite
• Talipes of a new-born baby
• an important impetigo of a child
face being able to involve serious
infectious complications
These three prevented EVASAN
represent a cost directly avoided by
the tele medicine per satellite system
of 14 250 Euro HT (before taxes);
6. Technical Assessment
French Guyana shows logistic
(transport of the material by air or
river) and extreme climatic characteristics for electronic material (heat,
very important hygroscope supporting the moulds and premature wear).
A standard, equipment was selected
with specific humidity and dust proof as well as shock-proof . To hold
account of the constraints of moisture, we had absorbers containers of
moisture and microwave ovens to
dehydrate the absorbers of moisture
in a regular basis.
The constraints concerning the
electric provisioning of the sites
(power generating unit, sector) of
variable quality and being able to
undergo abrupt variations, led us to
protect the material by a catch lightning protector out of frontal connected to an inverter, itself connected to
the electronic material.
INMARSAT RNIS Service
The 64 Kbytes/s terrestrial RNIS
service from INMERSAT M4 was
selected as being the only alternative
of telecommunication in the Amazonian zone allowing a deployment
without pre-existent infrastructures to
equip the centres and health stations
of the capacity and especially suffi-
cient data to support the exchange of
information.
A certain number of breakdowns
were noted concerning the antennas
of the terminals:
• 2 intrinsic breakdowns: “HP
LNA roasted” on a terminal, breakdown related to a technical problem
on the antennas, defect of series of the
manufacturer on a new model of terminals.
• 2 extrinsic breakdowns: bad
handling of the cable of the antenna
by the health professionals.
Assessments and
Outlines
The very encouraging results of
the experimental phase led to the perpetuation of the installations on the
initial 4 sites and to a development on
8 other isolated sites in 2003 and
2004.
Others specialities will be the
object of specific protocols: ophthalmology, gynaecology-obstetrics, paediatrics, diabetology, traumatology.
A connection with the CHU of
Fort de France will also make it possible to transfer files of neurosurgery
and carcinology.
Concerning telepsychiatry, it
appears reasonable to use the existing
infrastructures. The network of videoconference joining the three hospital
of the littoral allows to contemplate,
on the occasion of a phase of pre-operational study, the feasibility of the
telepsychiatric consultations within
the framework of the ISLANDS project (Integrated System for Long
distance psychiatric Assistance and
Non-conventional Distributed health
Services).
Each telemedicine portable workstation having at its disposal a web
cam, an extension of telepsychiatry
towards the equipped villages, according to protocols elaborated at the
time of the first phase, is completely
possible.
136
Conclusion
References
The pre-operational phase of the
network of telemetry per satellite in
French Guyana brought a certain number of knowledge.
First of all, that it is possible, in
spite of the extreme operational difficulties of French Guyana, to deploy a
telemedicine network in truly isolated
sites and to follow pre-established protocols. The dermatology forms part of
the medical specialities with the imagery which were evaluated the most in
telemedicine. Paradoxically if very
many works and a good number of
operational networks of telemedicine
use the microscopic teletransmission
of images with diagnostic aiming, they
almost exclusively relate to the anatomopathology and the cytology. Very
little examples of the use of tele microscopy for the diagnosis in parasitology
was found in the bibliography which
reinforces the interest of the choice
carried out in French Guyana.
Then , that it is essential to take
care to integrate to the maximum the
applications of telemedicine to the
pre-existent system of care, to limit the
impact in the work organization and to
facilitate the appropriation of the tools
by the professionals.
Finally, that the quality of the care
remains the final objective. It is imperative to implement the methods and
tools allowing an initial evaluation of
the system. These methods must be
integrated into the protocols of specialities in order to allow a monitoring of
the network activity, and to crosscheck the information if necessary.
The efficiency of a system
obviously goes through the relevance
of the technical choices, the elaboration of scientifically validated procedures, but especially by the implication of the health professionals and the
acceptance by the patients of this new
form of medical practice.
In conclusion, the tele consultation
is a reliable and useful medical practice in isolated sites, reasonable in term
of cost and technically well controlled.
[1]
[2]
[3]
[4]
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[11]
Edlin M. Success in rural telemedicine.
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cept et méthodes ”, in T. Le brun, J.C.
Sailly, M. Amouretti L’évaluation en
matière de santé. Des concepts à l pratique, Sofestec/Cresge Editeur, pp.15-32.
Dechant H.K. et al. [1996]: “ Health
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Staged Approach ”, Telemedicine Journal, 2, pp.303-312.
Giraud A. [1992]: L’évaluation médica-le des soins hospitaliers, Economie,
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Al-Qirim NA. « Teledermatology: the
case of adoption and diffusion of telemedicine health Waikato in New Zealand ». Telemed J E Health. 2003 Summer;9(2):167-77.
Weinstock MA, Kempton SA. « Case
report: teledermatology and epiluminescence microscopy for the diagnosis of
scabies. Cutis. 2000 Jul;66(1):61-2. »
Saxena SC, Kumar V, Giri VK. « Telecardiology for effective healthcare services. » J Med Eng Technol. 2003 JulAug;27(4): 149-59.
Lobley, D. [1996]: “ The Economics of
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Congrès mondial de télémédecine, Toulouse, mars.
Dr. Thierry Le-Guen
Char Cayenne
Rue de Flamboyants
97300 Cayenne
French Guyana
tleguen@nplus.gf
Acknowledgement
Special thanks to Stéphanie
Gaston for her hard work translating
this article.
The Neuropsychological Testbattery „TAP-M“ as a relevant tool
for the assessment of driving ability of elderly people
Ageing people need autonomy and mobility to maintain a high quality of life in old age. Driving as an individual's transport of choice is a key
issue in the mobility of the elderly. In Western society the older population is increasing both in absolute and relative terms, and there will be
a corresponding increase in the number of elderly people holding a driving licence. The mean frequency of elderly drivers on European roads
can be approximated to around 12% of all drivers today. This is expected to reach 20% by year 2010. During this process the numbers of older
drivers will become evenly distributed between the genders due to an even more significant increase in the number of elderly female drivers.
This task is considered in the European project “AGILE” (AGed people Integration, mobility, safety and quality of Life Enhancement through
driving). The project has two general aims:
1. developing knowledge to establish rational pan-European policies for delivering certification of fitness to drive
2. helping the elderly to continue to drive safely for as long as possible
Increases in age-related competences like defensive driving behaviour, and improved anticipation may compensate for age related decline in
cognitive capabilities and functioning. As a result elderly drivers are usually not overepresented in driving accident statistics. However, elderly drivers tend to be overly involved in specific types of accidents in specific situations, such as intersections, or, when changing lanes, merging with traffic or leaving a parking position. Moreover, the prevalence of different dementing illnesses is about 5-7% in elderly drivers.
Many of these are currently not diagnosed sufficiently early enough by existing assessment schemes for elderly drivers.
One of the most relevant psychological functions playing a role in driving is a person´s attentional performance. It is generally agreed upon
that attention has to be conceived as a multi-factorial phenomenon. Based on the well-known Test forAttentional Performance (TAP) which
was initially developed for the assessment of attentional deficits in patients with cerebral lesions the German company “PSYTEST” developed a short form of this test namely TAP-M. This test was compiled to measure the attentional aspect of the ability to drive.
The core of the procedures are reaction time tasks of low complexity allowing the evaluation of very specific deficiencies. The tasks consist
of simple and easily distinguishable stimuli that the patient react to by a simple motor response. Thus, the influence of a number of factors that
would have an inhibiting effect on testing are kept to a limit. As much as possible, it was attempted to account for factors that may disrupt
testing, such as motor problems, visual disorders and language deficits.
The subtests in the newly developed test battery TAP- M permit to assess a variety of attentional aspects such as alertness, divided attention,
flexibility of focused attention, inhibitory processes, working memory, visual search, selective visual attention, suppressing potentially distracting stimulation which are relevant for save driving. The final choice of subtests to be integrated into the TAP-M was based on the decision
of the AGILE members.
The Neuropsychological Testbattery “TAP-M” now consists of newly developed subtests :
• Executive control,
• Active visual field,
• Distractibility and
• Alertness (a modified, shorter version)
and already existing subtests of the Testbattery of Attentional Performance (TAP) that is already in the market:
• Divided Attention,
• Visual Scanning,
• Go/Nogo and
• Flexibility.
The standardization and validation of the test battery was supported by several European institutions being members of the European project
“AGILE” (AGed people Integration, mobility, safety and quality of Life Enhancement through driving). All the tests were validated with an
On-road test drive, in order to compare the actual ability to drive with the cognitive performance. With the “TAP- M” the German Company
“PSYTEST” now has a new product to evaluate specific deficiencies which could influence the ability of save driving.
The tests are available in German, French, English, Italian, Spanish, Greek, Swedish, Dutch, in spring 2005.
Vera Fimm – Psychologische Testsysteme • Kaiserstrasse 100 • D-52134 Herzogenrath
Tel.: 0049 (0) 2407 / 918980 • Fax: 0049 (0) 2407 / 917153 • e-mail: info@psytest.net • www.psytest.net
Charles University Prague
MMU
UHFF
www.islands-project.etsit.upm.es
Co-funded by

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