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 Ð 2004

Editorial Klinik, Diagnostik, Therapie und e-Mental Health: Challenges 57 Rehabilitation for the Future Organ der M. F. Cabrera Österreichischen Gesellschaft für Psychiatrie und Psychotherapie

Reviews The Future of Telepsychiatry 59 in Europe P. McLaren S2

Telepsychiatry and e-Mental 64 04 Health: Electronic Telecom- munication in Psychiatry H. Sulzenbacher, A. H. Bullinger, T. Senn, E. Bekiaris, U. Meise

Original Papers On the Integration of Telepsychia- 74 try Services in European Remote Areas: the ISLANDS Project Case Study M. F. Cabrera, M. T. Arredondo, M. Rodriguez, E. Bekiaris

Services and Architecture for the 79 ISLANDS System: Toward a Modular Non-Conventional Tele- psychiatry System A. Amditis, Z. Lentziou, M. Panou, A. H. Bullinger, E. Bekiaris

Towards the Development of Tools 89 for Remote Interventions M. Panou, E. Bekiaris, A. Amditis

The ISLANDS Treatment Scenarios 93 and Service Batches A. H. Bullinger, T. Senn, E. Bekiaris, U. Meise, R. Mager, F. Müller-Spahn, H. Sulzenbacher

Process Quality Analysis of Tele- 100 psychiatry: Contributions of Stati- stical Control Process and Critical Pathway Analysis Dustri-Verlag Dr. Karl Feistle http://www.dustri.de C. De Las Cuevas, J. Artiles I Reports Ethical Conduct within the 106 ISLANDS Project T. Senn, H. Sulzenbacher, U. Meise, K. Estoppey, R. Mager, F. Müller- Klinik, Diagnostik, Therapie und Spahn, A. H. Bullinger Rehabilitation Organ der Österreichischen Gesellschaft für Potential Constraints and Obstacles 109 Psychiatrie und Psychotherapie relevant to the Introduction of e-Mental Health and Telepsychiatry U. Meise, H. Sulzenbacher, A. H. Bullinger S2 Some Considerations about the Con- 112 cept of Presence in Telepsychiatry C. De las Cuevas, J. L. González 04 de Rivera

The Telemed Project (RACE-Pro- 116 ject R 1086): Lessions learned for Telepsychiatry from the first EU funded Telemedicine Project P. McLaren, A. Charles-Nicolas

Perspectives of Communication 123 Technology in Psychiatry: The ISLANDS Project in Greece A. Politis, A. Pehlivanidis, A. Amdi- tis, Z. Lentziou, † M. Markidis, G. Trikkas, A. Rabavilas

History of Telepsychiatry in the 127 Czech Republic P. Doubek, A. Kott, J. Raboch

Telemedicine in French Guyana 131 T. Le Guen, N. Poirot, O. Tournebize, A. Guell

Bookreview Telepsychiatry and e-Mental Health 111 R. Wootton, P. Yellowlees, P. McLaren

Guest Editors Maria Fernanda Cabrera, Madrid Evangelos Bekiaris, Thessaloniki Alex H. Bullinger, Basel Maria Theresa Arredondo, Madrid Dustri-Verlag Dr. Karl Feistle http://www.dustri.de Angelos Amditis, Athens II Hubert Sulzenbacher, Innsbruck Zeitungs grün der Al fred Sprin ger, Wien Peter Stix, Graz Franz Gerst enbrand,Inns bruck Anton Tölk, Linz Hartm ann Hin terhu ber,Inns bruck Karin Treichl, Hall in Ti rol Korne li us Kry spin-Exner † Da vid Vys so ki, Wien Klinik, Diag nos tik, Thera pie und An dre as Wal ter, Wien Reha bi li ta ti on Jo han nes Wan ca ta, Wien Organ der Alexan dra Whit worth, Salz burg Österrei chi schen Gesell schaft für Heraus ge ber Psychia trie und Psychotherapie Albert Wuschitz, Wien W.Wolfgang Fleisch hacker, Innsbruck http://www.oegpp.at Rein hard Hal ler, Fras tanz Hans Georg Zapotoczky, Graz Hart mann Hin ter hu ber, Inns bruck Kurt Jellin ger, Wien Wer ner Schö ny, Linz In ter na tio na tio na ler Ma ri an ne Sprin ger-Krem ser, Wien wis sen schaft licher Beirat Chris toph Stup päck, Salz burg Man fred Acken heil, Mün chen Wilhelm Wolf, Wien Jo sef Al den hoff, Kiel Mat thias C. An ger mey er, Leip zig Jules Angst, Zürich Geschäfts füh ren der Hel muth Bec kmann, Würz burg Heraus ge ber Hans Brenner, Bern Alexan dra Deli ni-Stu la, Basel Ullrich Meise, Innsbruck Pe ter Fal kai, Hom burg Zei tungs grün der As mus Fin zen, Ba sel Franz Gers ten brand, Inns bruck Hans Förstl, München Hart mann Hin ter hu ber, Redak tions di rek to rin Wolf gang Gae bel, Düs sel dorf Inns bruck Kor ne li us Kry spin-Exner † Sylvia Holter, Wien An dre as Heinz, Ber lin Flo ri an Hols bo er, Mün chen Isa bel la Heu ser, Ber lin Verant wort li che Wissen schaft li cher Wolf gang Mai er, Bonn He raus ge ber Hans-Jür gen Möl ler, Mün chen Beirat Bru no Mül ler-Öhr ling hau sen, Ber lin W.Wolf gang Fleisch ha cker, Inns bruck Wilfried Biebl, Innsbruck Franz Müller-Spahn, Basel Reinhard Haller, Frastanz An dre as Con ca, Rank weil Anita Riecher-Röss ler, Basel Hart mann Hin ter hu ber, Max Friedrich, Wien Wulf Rössler, Zü rich Inns bruck Eber hard Ga briel, Wien Pe ter Rie de rer, Würz burg Kurt Jellin ger, Wien Wer ner Schö ny, Linz Chris ti an Ge rets eg ger, Salz burg Hein rich Sau er, Jena Ma ri an ne Sprin ger-Kremser, Bernhard Grössl, Graz Norman Sarto ri us, Genf Wien Ka rin Gu tier rez-Lo bos, Wien Chris toph Stup päck, Salz burg Christian Haring, Hall i. Ti rol Wilhelm Wolf, Wien Hans Pe ter Kapf ham mer, Graz Sieg fried Kas per, Wien Heinz Kat schnig, Wien Ge schäfts füh ren der Günther Klug, Graz He raus ge ber Pe ter Kö nig, Rank weil Ull rich Mei se, Inns bruck Ilse Kry spin-Ex ner, Wien Mi cha el Le ho fer, Graz Gerhard Lenz, Wien Re dak tions di rek to rin Hei di Möl ler, Inns bruck Syl via Holter, Wien Micha el Musa lek, Wien Wal ter Pie rin ger, Graz Heinz Pfolz, Wien August Ruhs, Wien Alois Saria, Innsbruck Bernd Sale tu, Wien Brigit te Schmidl-Mohl, Wien Mar ti na Schö nau er-Cejpek, Graz Ger hard Schüss ler, Inns bruck Ger not Son neck, Wien Bar ba ra Sper ner-Un ter we ger, Dustri-Verlag Dr. Karl Feistle III Inns bruck http://www.dustri.de (n) »Neu ro psy chiatrie« veröf fent licht Übersich ten, Ori gi nal ar bei ten, Ka su isti ken, ak tu elle, kur ze wissen - schaft li che Mittei lun gen, Fragen aus der Praxis, Briefe an die Heraus ge ber, Le ser an fra genaus der Pra xis mit Ant wor ten, Newslet ters (Be rufs po li tik, Stan des fra gen) und Per so na li en, Kon greß an kün di gun gen, Buch be spre chun gen etc. aus al len Be rei chen der Neu ro lo gie und Psych ia trie.

Klinik, Diag nos tik, Thera pie und Reha bi li ta ti on Organ der He raus ge ber Österrei chi schen Gesell schaft für Ös ter rei chi sche Ge sell schaft für Psych ia trie und Psy cho the rapie Psychia trie und Psychotherapie (Präsident: Univ.-Prof. Dr. W. Wolfgang Fleischhacker), Baumgartner Höhe 1, A-1145 Wien, http://www.oegpp.at Telefon: +43-1-9106011311, Fax: +43-1-9106011319, Email: [email protected], Ho me pa ge: http://www.oegpp.at

Ge schäfts füh ren der He raus ge ber Univ.-Prof. Dr. Ull rich Mei se, Uni ver si täts klinik für Psych ia trie Inns bruck, Anich stra ße 35, A-6020 Innsbruck, Telefon: +43-512-504-3616, Fax: +43-512-504-3628, Email: ullrich.mei- [email protected]

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Dustri-Verlag Dr. Karl Feistle IV http://www.dustri.de (n) 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 me- ment and competent service in the possible users in the psychiatric and thods for electronic communication, point of need. psychotherapeutic field. According to clinicians have been using informa- In the second article, Sulzenba- different mental health problems tion and communication technologies cher et al. describe the use of electro- (phobia, depression, alcohol-related in healthcare. However, rapid and far- nic telecommunication in psychiatry. disorder and psychotic disturbances) reaching technological advances are After a defination of the terms ‘tele- each category comprises modules to changing the ways in which people psychiatry’ and ‘e-health’ and a short help users suffering from or concer- relate, communicate and live. Tech- presentation of basic of electronic ned with this problem. nologies that were barely used ten telecommunications the current psy- The next paper, reports on the years ago, such as the Internet, e- chiatric utilisation of the telephone, results of a new process quality mail, and videoconferencing are videoconferencing, and the Internet is analysis in a telepsychiatry routine becoming familiar methods for dia- described. service. In it, De las Cuevas and gnosis, therapy, education and trai- The third paper, by Cabrera et al., Artiles, provide the methods and the ning. This is producing a promising is an attempt to develop and compre- statistical analysis of a one year tele- field – e-mental health – whose focus hend the potential of e-mental health consultation psychiatric service in the is the use of communication and through the presentation of the Canary Islands. Results showed that information technologies to improve ISLANDS project whose specific the continuous quality improvement the mental health care processes. goal is to develop services to provide approach diminished the working This area has developed rapidly, modular, non conventional, remote time and increased the productivity of accumulating knowledge and propo- psychiatric and psychotherapeutic a telepsychiatry service. sing innovative affirmations. This is a assistance for remote areas. The next paper indicates the gene- multidisciplinary field that requires In the next paper, Amditis et al. ral ethical principles that apply to the the cooperation among different pro- describe the architecture and compo- ISLANDS project research. In it, fessions: psychiatrists of different nents of the telepsychiatry platform Senn et al give the general ethics rela- specialties at one end, and software planned for this project. The result is ted to research with humans and rese- programmers, designers and compu- based on the analysis of the state of arch involving testing and assess- ter engineers at the other. The results the art telemedicine systems, as well ment, that concerns the proposed of this collaboration are represented as, in the extensive compilation of the screening, counselling and treatment by the ISLANDS project partners in different kind of available techno- services provided in the context of the present compilation of papers. logies. this project. The first paper in this issue is a Next, Panou et al. discuss on the Meise et al. report on the potential discussion of the future of telepsychi- need of computer based tools to sup- constraints and obstacles relevant to atry in Europe by McLaren that exa- port Web and teleconference based the introduction of e-mental health. mines different aspects of this disci- interventions. The paper presents the The main restrictions identified and pline. His paper outlines the main preliminary tools that are being deve- analysed in the paper fall into five challenges for public mental health loped within the framework of the categories: human, ethical, legal, services in Europe. In order to make a ISLANDS project. business and technological. positive impact with the use of tele- After that, Bullinger et al. present In their contribution, De las Cue- psychiatry in e-mental health, it will the ISLANDS scenarios and service vas and González examine the con- need to demonstrate how it can help batches. The treatment scenarios con- cept of presence in telepsychiatry. service planners and providers to sist in the specification of nine cate- Their report outlines the relevance of address accessibility, user empower- gories which address the needs of the recent context created by the new e-Mental Health: Challenges for the Future 58 communication technologies and the of these methods clearly depend on a network in truly isolated sites and fol- novel patient-practitioner relation- careful structural planning. low pre-established protocols. Tele- ships. After that, a report by Doubek et consultation is a reliable and useful The next article, by McLaren and al. concerns the history of telephone medical practice, reasonable in terms Charles-Nicolas, is concerned with help lines in Czech Republic and of cost and technically controlled. the first EU funded telepsychiatry gives future possibilities of telepsy- All in all, the current special edi- project, the Telemed Project (RACE- chiatry in this European Region. The tion contributes significantly to the Project R 1068). The paper reviews paper describes different help lines cumulative knowledge of emerging the technical and organisational back- available that cover different opera- e-mental health. The writings in this ground to Telemed and summarizes tion modalities: independent organi- journal are evidence of a scientific key results. sation, outpatient clinic and inpatient reality today, specifically, what many Following this, a paper by Politis clinic. psychologist of psychiatrist once con- et al., reports on the perspectives of Finally, Le Guen et al. present in sidered futuristic therapy is now cli- using communication technologies their paper the six month follow-up nical actuality. The future is present, applied to psychiatry in Greece. It is results of an experimentation proto- at least in the human mind. thought that the implementation of col of teleconsultation per satellite in telepsychiatry is not only bounded to French Guyana. The results reveal therapy or consultation, but also to the that, in spite of the extreme operatio- education of the healthcare providers. nal difficulties this geographical area, Authors concluded that the application it is possible to deploy a telemedicine Neuropsychiatrie, Volume 18, S 2, 2004, page 59-6318Ð125

Review The Future of Telepsychiatry in Europe

Paul McLaren

The Priory Ticehurst House and South London & Maudsley NHS Trust, London

Key words the communication between an isola- an Union (EU). Tertiary services have Telepsychiatry, Videoconferencing, Mental ted struggling institution and an aca- been piloted from the South London health, tertiary and secondary Services demic centre and thereby raise clini- & Maudsley NHS Trust in London to cal standards in the institution. Subse- the Channel island of Jersey [5]. Gon- quent Telepsychiatry research has run calves [4] described a Telepsychiatry in the same groove. Since its incep- component in a telemedicine link bet- The Future of Telepsychiatry in tion, it as been promoted as a potenti- ween Lisbon and the Azores. Man- Europe al solution to or the inequalities in nion et al [8] in Ireland reported on a This paper will discuss the future mental health service provision pro- link established between a hospital on of Telepsychiatry in Europe. Tele- duced by geography and market for- the mainland and the island of Inish- psychiatry has been researched for ces. The combination of an advanced more, off the west coast of Galway. over 50 years but has still to make a telecommunications infrastructure, Frier [1] et al. reported on the use of significant impact on service delive- low population density and unequal videoconferencing in a psychology ry. Costs are falling and access to the distribution of medical resources was Service in the Highlands of Scotland, technology increasing and Telepsy- offered as the recipe for successful an area which has one of the lowest chiatry has the potential to deliver Telemedicine in general and Telepsy- population densities in the EU. This culturally competent and effective chiatry in particular. These factors service operated over 200 km bet- mental health services in a market occur where the bulk of Telepsychia- ween Inverness and the Isle of Skye, which spans the new European Com- try research has been reported in using BT VC 7000 videoconferen- munity. Australia, Canada and the western cing units connected by ISDN at United States. More recent develop- 128 kbits/s. Twenty-seven adults and ments have focussed on improving seven children were treated with communication between primary and Cognitive Behavioural Therapy Introduction secondary health services [6] and bet- (CBT) by videoconferencing. Most ween elements in increasingly distri- service users complained of poor Telepsychiaty has been defined by buted and fragmented community sound and picture quality, but were Wootton, Yellowlees & McLaren teams [14]. still satisfied with the consultation . [20] as the, ‘Delivery of health care These results highlighted important and the exchange of health care issues for future developments such information for the purposes of provi- as the challenge of balancing the ding psychiatric services across Telepsychiatry in Europe costs of high quality video imaging distances’. It is not new. The earliest against economic feasibility and reports in the literature were from The research reported in this sup- sustainability in what may be low Nebraska in the late 1950’s, when plement on the ISLANDS project volume services. Wittson & Dutton [19] reported on represents an important extension of Mielonen et al [11] reported on the use of a closed circuit television Telepsychiatry experience in Europe. the use of videoconferencing in Oulu system operating over a microwave It will generate valuable information in Finland, where videoconferencing link to connect the Academic Depart- on the generalizability of the results at 384 kbits/s was used for family the- ment of Psychiatry at the University of earlier studies. This is not the first rapy, occupational counselling, clini- of Nebraska with a state psychiatric project to look at the use of Telepsy- cal consultation and teaching. In 1996 institution 100 km away. The aim of chiatry to enhance mental health ser- videoconferencing was used in this this research group was to improve vices to the periphery of the Europe- area for a total of 249 hours, which The Future of Telepsychiatry in Europe 60 increased to 434 hours in 1997. the anticipated migration of labour Telepsychiatry consultations can During 1997, 45% of the time was from east to west will generate incre- be routinely recorded in digital for- used for teaching, 26% for occupatio- asing demand for international men- mat and monitored remotely. This nal counselling, consultations and tal health care within the EU. may become a key element in the cli- therapies, 23% for training and 6% The treatment of mentally disor- nical mental health record, offering for administration. dered offenders is another major chal- protection to the consumer against This same group [12] reported on lenge with which Telepsychiatry may abuse and the professional protection the use of videoconferencing for assist [22]. against malicious allegations. In a discharge planning from a mental Most Telepsychiatry services have Telepsychiatry consultation the po- health unit. The majority of partici- been performed in real time, as ‘live wer in the encounter is tipped towards pants stated that they would prefer to links’. A trend in other areas of Tele- the service user, relative to the face- have their next meeting by videocon- medicine has been the development of to-face condition. They are seen ference. The most common reasons store and forward services, for exam- closer to or in their own home, not in given were the reduced need for ple in Teledermatology. In these servi- the professionals office in an intimi- travelling and the ease and speed of ces a clinical history and still image dating institution. the consultations. An economic ana- are captured at a remote site and sent Communications technology has lysis showed that at a volume of by electronic mail to a specialist for an crept into many areas of mental 50 care planning consultations per opinion. It is difficult to envisage the health care delivery without research year, the videoconferencing alternati- drivers which would lead to the deve- or clinical champions. The telephone ve is about FM 2340 cheaper than lopment of store-and-forward clinical is often used by professionals to fol- conventional meetings and the muni- Telepsychiatry. Further opinions could low up patients with whom they have cipality would save about FM be sought in current services through a therapeutic relationship. This has 117,000 by using the medium. Six sending video clips on DVD’s or vide- rarely been formalised but where it hours of travelling time could be used otapes but this is employed only in has, it has been deemed advantage- for other purposes when the meeting exceptional circumstances. Watching ous. Simon et al [18] reported a ran- was held by videoconferencing. the tape will give the expert less infor- domised controlled trial of a system mation than a face-to-face interview for giving General Practitioners feed- and will be as time consuming. Store- back on prescribing to depressed and forward Telepsychiatry may patients versus feedback on prescri- The future of mental become a tool for professional super- bing plus care management including health care in Europe vision A consultation can be recorded systematic follow up by telephone. digitally, stored as a record and trans- The care management with telephone The main challenges for public mitted to a remote supervisor for follow up significantly improved mental health services in Europe are viewing and commenting. The Trom- clinical outcomes in this depressed accessibility, user empowerment and so group [3] reported the use of vide- sample. Telephone help lines, such as getting culturally competent services oconferencing for psychotherapy the Samaritans, over which users to the point of need in a timely supervision using 384 kbits/s ISDN disclose painful or intimate personal fashion. If Telepsychiatry is to make a (Integrated Service Digital Network) details, to people they may never positive impact, on mental health connections. Trainees had five face- meet are hugely popular. The telepho- then it will need to demonstrate how to-face sessions, alternating weekly ne offers a combination of accessibi- it can help service planners and pro- with videoconferencing. The quality lity, anonymity and confidentiality viders address these challenges. The- of supervision could be satisfactorily which may make it a suitable tool for re is little in the literature to support maintained by videoconferencing, for psychotherapy [7]. claims that it can do this. Most rese- up to half of the 70 hours required for The educational and information- arch in the field has been technology training. A precondition for this esti- gathering components of the cogniti- driven rather than being proposed as a mate was that the supervision dyad ve behavioural therapies (CBT) are solution to a service need [13]. Tele- should meet face-to-face and establish ideally suited to computerization. The psychiatry will not make a poor servi- a relationship characterised by mutual building blocks of the therapeutic ce provider effective or a failing ser- trust and respect. Major concerns relationship, which are central to all vice efficient but it could be a power- reported by the participants were the therapies, are still poorly understood ful tool for opening up the mental loss of non-verbal cues and the effects and still too nebulous to digitize. This health care market in Europe and this had on spontaneity, the expres- may lead to the development of giving consumers greater choice as to sion of personal emotional material, hybrid models of CBT with the in- where they get their care. The migra- and the experience of social and emo- formation-gathering, self-monitoring tion of elders from north to south and tional presence. and educational components delive- McLaren 61 red by information technology while though it was obviously unplugged Recognition that adequate assess- the therapist focuses on live sessions, from the mains and the telephone ments can be made by videoconferen- face-to-face or by videoconferencing. line, because visiting professionals cing for the purposes of compulsory This will allow the total time in thera- were concerned that it posed a risk to treatment will be an important deve- py for service users to be increased, confidentiality. Such prejudices are lopments. So also will the develop- while the therapist’s time is reduced less common as experience with ment and adoption of national and and better focused. The efficiency information and communication international guidelines to ensure that and effectiveness of the psychothera- technology grows but there is still a the increased access offered by Tele- pies could be improved and if the need for professional education on psychiatry does not result in harm. relationship component is delivered the technology. This is often overloo- Afurther challenge is remunera- by communications technology then ked in technology driven projects. tion for Telepsychiatry consultations. access will be improved and costs to Governments have been slow to service users reduced. remunerate doctors for providing ser- The delivery of psychotherapy by vices via videoconferencing, alt- such systems should not be seen as a Factors influencing hough this does now happen in the threat to existing service providers. technology adoption USA. Other health systems have only Attempts should be made to integrate allowed payment for videoconferen- the technology into other service deli- Key issues in technology adop- cing when it is undertaken as part of very models. tion have been described by Rogers the clinician’s daily work, as in the Most professional and service [16]. He hypothesised that about case of public sector health systems users who have been asked, have 5–10% of any population were ‘early in Australia, the United Kingdom and found Telepsychiatry services accep- adopters’ of the new technology and Canada. There has not, however, been table [2, 13, 14, 15]. They like the in Telepsychiatry, it is these individu- acceptance by governments of pay- increased access and the choice that als who are still setting the pace. ments for videoconferencing in the they have via such services, and it has Rogers also hypothesized that same manner as face-to-face services. been suggested that they also like to 70–80% of providers will adopt if Payments for email and telephony have the ability, if they wish, to there is evidence to support its adop- services are unusual. There are some ‘switch off’ the practitioner. It has tion. Rogers’ final group were the health sectors in the USA that will been suggested that some service remaining 10–15% of any population pay for short email medical consulta- users may prefer being assessed or who are described as ‘laggards’. This tions, although not usually in mental treated electronically, namely those group is the last to change. The health. patients who are paranoid or avoi- evidence base for Telepsychiatry Afactor which has inhibited the dant.. The potential of Telepsychiatry needs to be further strengthened to development of sustainable funding to improve access for those with generate the critical mass of adopters systems for Telepsychiatry services is severe and enduring mental illnesses required to make it economical. The that the costs of setting up go to the needs particular attention. ISLANDS programme will provide service provider and most of the cost valuable information in this respect. savings go to the patient in terms of Younger mental health professionals reduced travel and opportunity costs. are coming through with much stron- The provider has to offer the same The legal and ethical ger information technology skills and amount of professional time in direct framework are much more aware of the power of contact with the service user. Possible information and communication areas where costs may be saved for There have been many concerns technology to enhance efficiency at the provider are in terms of reduced expressed about the risks to safety work. This will lead to further inno- downtime from professional staff tra- and security of personal data when vation, more rapid adoption and ulti- velling. It has been assumed that information technology is used. The- mately improve the provision of men- Telepsychiatry services and video- se concerns tend to be magnified by tal health services. conferencing interactions are inferior the idea that information is transmit- Key issues for the future develop- to face-to-face, because they are me- ted over distance. In an early phase of ments of Telepsychiatry health servi- diated and communication is lost due the Telemed project ( see McLaren & ces are licensure, registration and to the limitation of channels by the Charles-Nicholas in this supplement) professional insurance within coun- medium [17]. There is no body of evi- when the LCVC was installed in a tries and across national, regional or dence to support this in clinical use. It room on a ward, the research team international boundaries. Changes to is possible that for some tasks video- were asked to remove a computer legislative frameworks tend to be re- conferencing is a superior medium with a camera mounted on top even active, following changes in practice. and it may be that a premium should The Future of Telepsychiatry in Europe 62 be charged for remote services. Cost Professionals stated that they did not ted interactions has the potential to savings and convenience accrue to see a need for videoconferencing reassure professionals as to the ways the service user. where accessibility is not a problem. in which the process is changed in Telepsychiatry in future will pro- The most important problem identi- clinically significant ways. bably use Internet Protocols in a bro- fied was the extent to which commu- adband environment, and the speed of nication skills needed to be adjusted implementation will depend in part on to meet the demands of the medium. the rate of broadband roll out. This is In a further analysis [10], it was Conclusion less of a problem in public sector ser- reported that the use of videoconfe- vices, where fibre optic networks are rencing in this way threatened profes- Psychiatrists using videoconfe- increasingly being deployed, but will sional nursing constructs about the rencing have had issues with picture remain difficult in terms of making nature and practice of therapeutic resolution and video frame rate. GPs, the last connection into the home. The relationships. nurses, clinical psychologists and further development of broadband An additional complication for social workers provide the bulk of networks will undoubtedly accelerate research is the rapid development of mental health services. Their role in the use of Telepsychiatry. the technology. In the two to three Telepsychiatry service provision has, The commercial potential of Tele- years that it takes to complete a clini- been one of supporting the patients. If psychiatry has yet to be realised in the cal trial the specification of the equip- Telepsychiatry is to make a real private health care market. Signifi- ment tested is likely to become obso- impact on service provision it will cant adoption of digital technology lete. It is likely, however, that Tele- need to be embraced by the bulk of has taken place in the banking and psychiatry services will become in- professionals providing services ,nur- entertainment sectors and these will creasingly cost effective on the sing and social workers and be seen to be the drivers for getting broadband- broadband Internet [21]. Much more facilitate the development of their links into the home. Partnerships could be gained from Telepsychiatry professional roles. between health care providers and research if smaller projects could be A key research question to be telecommunications providers will be combined to improve statistical po- asked in community mental health required before significant roll out wer and reduce administrative costs. care is which communications me- can take place. The ISLANDS project will stimulate dium is most appropriate for which international collaboration and furt- task . More research is required to her multicentre research. analyse the costs and benefits of Relatively little is known about using the telephone, videoconferen- Further research the significance of image parameters cing, email, the post and face-to-face in videoconferencing for clinical pro- communication for core clinical There is a need to strengthen the cesses. Videoocnferencing equip- tasks. There is a need for international evidence base for Telepsychiatry. ment with a broad range of specifica- standards of service delivery in Tele- Most of the published research is on tion has been used in published rese- psychiatry. pilot projects with limited informa- arch. The bandwidth is usually quo- Telepsychiatry has been piloted in tion on sampling, statistical power ted, but not the picture parameters a wide range of geographical loca- and image parameters. Getting fun- and it is these that matter more to the tions and service models. Service ding for trials with sufficient power to clinician and the patient. The expe- user responses have been generally, demonstrate clinical effectiveness in riences of communicating over a but not uniformly positive and these a range of disorders and settings has videophone connected by the tele- responses need further clarification. proved difficult. There is also a need phone network and a rollabout video- Professionals have embraced video- for meaningful economic evalua- conferencing unit connected by a conferencing for supervision, educa- tions. Some qualitative research has high capacity digital line are very dif- tion and administration, but are still been reported. May, et al ( 9) reported ferent. High specification equipment wary of using it for communicating on a Telepsychiatry referral service costs more to buy and costs more to with service users for clinical tasks. for patients being treated by GPs for connect. It produces a better quality This wariness may owe more to pre- anxiety and depression, using the Bri- image but what quality of image is judice and professional defensive- tish Telecom VS1 desktop videopho- good enough for which task? Basic ness, than objective assessment. The ne over 128 kbits/s. Twenty-two information on the relationship bet- costs of kit and communication links patients and thirteen doctors were ween image parameters, such as defi- have limited the diffusion of such interviewed after a video-link consul- nition, colour scale, frame rate and applications to areas with low popu- tation. Twenty-two patients and thir- image size, and clinical outcomes is lation density, where economic bene- teen professionals were studied. still lacking. Microanalysis of media- fits are obvious. Costs of both are McLaren 63

falling rapidly and the readiness with improve communication between pri- try and eMental Health. Richard Woot- which service users, even while suf- mary and secondary care? British Medi- ton, Peter Yellowlees & Paul McLaren fering from acute and severe mental cal Journal ; 313:1377-81. (Eds). Royal Society of Medicine Press. [7] Kaplan EH (1997) Telepsychotherapy. London 2003 illness, adapt to clinical consultations Journal of Psychotherapy Practice [21] Yellowlees P. Your Guide to eHealth – by videoconferencing, suggests that Research ;6; 227-237. third millennium medicine on the Inter- this mode of service delivery could [8] Mannion-L, Fahy-T-J, Duffy-C, Bro- net. Brisbane: University of Queens- become commonplace, both for derick-M, Gethins-E. (1998) Telepsy- land Press, 2001. chiatry: an island pilot project. Journal [22] Zaylor C, Whitten P, Kingsley C. (2000) accessing scare national and interna- of Telemedicine & Telecare 1998 : 4 :( Telemedicine services to a county jail. tional tertiary expertise and for im- suppl 1): 62-3. Journal of Telemedicine and Telecare proving communication between ele- [9] May CR, Gask L., Ellis N., Atkinson T., ;6; (suppl 1) 93-95 ments in distributed urban communi- Mair F, Smith C, Pidd S Aneez E. Tele- ty services. Mental health services are psychiatry evaluation in the north-west of England: preliminary results of a qualita- facing growing demands and struggle tive study. Journal of Telemedicine & Dr. Paul McLaren to deliver effective treatments in suf- Telecare 2000: 6; (suppl 1); 20-22 Honorary Consultant Psychiatrist ficient quantity. Efficient communi- [10] May C, Gask L, Atkinson T, Ellis N, South London & Maudsley NHS Trust cation between service elements and Mair F, Esmail A. Resisting and promo- ting new technologies in clinical practi- 62, Speedwell Street getting effective treatment to service ce: the case of Telepsychiatry . Social Deptford users in a timely fashion are two of Science and Medicine. 2001: 52:12; London SE 8 4 AT the major challenges facing mental 1889-1901. health services this century. Telepsy- [11] Mielonen-M-L, Ohinmaa-A, Moring-J, Email: [email protected] chiatry has been shown to have the Isohanni-M. (1998) The use of video- and conferencing for telepsychiatry in Fin- Medical Director potential to improve both. Within two land. Journal of telemedicine and tele- The Priory Ticehurst House decades videoconferencing could be care 4 (3), P: 125-31, the preferred medium for contact [12] Mielonen M, Ohinmaa A, Moring J, Iso- Ticehurst, Wadhurst between professionals and mental hanni M. (2000) Psychiatric inpatient East Sussex TN5 7HU care planning via telemedicine. Journal health service users in Europe. United Kingdom of Telemedicine and Telecare ; 6: 152- 157 [13] McLaren PM, Laws VJ, Ferreira AC, O’Flynn D, Lipsedge M, Watson JP. References Telepsychiatry; outpatient psychiatry by videolink. Journal of Telemedicine & Telecare. 1996: 2 ( suppl 1) 59-62. [1] Frier V, Kirkwood K, Peck D, Robert- [14] McLaren PM, Ahlbom J, Riley A, son S, Scott-Lodge L, Zeffert S. Telemdi- Mohammedali A, Denis M. The North cine for Clinical Psychology in the Lewisham Telepsychiatry Project: Be- Highlands of Scotland. Journal of Tele- yond the pilot phase. Journal of Telemedi- medicine & Telecare 1999: 5: 3: 157- cine & Telecare 2002, 8 ( suppl 2) 98-100. 161 [15] McLaren PM, Mohammedali A, Riley A, [2] Gammon-D, Bergvik-S, Bergmo-T, Gaughran F. (1999) Integrating interac- Pedersen-S. (1996)Videoconferencing tive television-based psychiatric con- in psychiatry: a survey of use in nor- sultation into an urban community men- thern Norway. Journal of telemedicine tal health service. Journal of Telemedi- and tele-care: 2 (4), P: 192-8 cine and Telecare, 3, Supplement 1. [3] Gammon D., Sorlie T, Bergvik S., Hoi- 100-102. fodt TS. (1998) Psychotherapy supervi- [16] Rogers EM. Diffusion of Innovations. sion conducted by videoconferencing: a New York: The Free Press, 1962. qualitative study of users’ experiences. [17] Short J, Williams E, Christie B. The Journal of Telemdicine and Telecare 4: social psychology of telecommunica- Supplement 1. 33- tions. New York: John Wiley & Sons, [4] Gonçalves-L, Cunha-C. Telemedicine 1976. project in the Azores Islands. Archives [18] Simon GE, Von Korff M, Rutter C, Wag- d'anatomie et de cytologie pathologi- ner E. (2000) Randomised trial of moni- ques 1995,: 43 (4), P: 285-7, toring, feedback and management of [5] Harley J., McLaren PM, Blackwood G, care by telephone to improve treatment Tierney K and Everett M. 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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 graphical, economic, linguistic, ethi- prehensive definition is presented Telepsychiatry, e-Mental Health, Tele- cal-juridical, social, and medical below: phone, Videoconferencing, Internet aspects have to be considered. Telemedicine is defined as the delivery of health care and sharing of medical knowledge over a distance using telecommunications systems. Telepsychiatry and e-Mental [101] Health: Electronic Telecommuni- Introduction cation in Psychiatry Telemedicine is not an invention The terms Telepsychiatry and of the electronic age, but the develop- E-Mental Health describe the use of Definitions ment of electronic communication telecommunications media in psychi- media has increased the speed of atry. Telepsychiatry is mostly used in When assessing the quality of information transfer so much, that the connection with psychiatric video- health-care systems, general access to use of telemedicine could now be conferencing, while the term E-Men- medical care is undoubtedly a key acceptable from an economic, but tal Health is related rather to the Inter- criterion. As it is more difficult to also an ethical view. As on the one net. Communication media with a achieve adequate access to health- hand medicine over large distances is wide range of possibilities for use in care for people living in rural areas currently only efficiently realisable psychiatry are the telephone, video- than for those in urban environments, through electronic media and as on conferencing, and the Internet. The the improvement of medical care in the other one of the most important telephone is a well-tried medium in remote regions has to be seen as a benefits of electronic communication emergency medicine and crisis inter- major task for every health-care media probably lies in overcoming vention, but rarely usable for psychi- system. The most obvious solution geographical barriers, the terms 'tele- atric diagnosis because of the lack of for this problem is increased settle- medicine' and 'e(lectronic)-health' are visual information. Videoconferen- ment of physicians and establishment inseparably connected. cing, on the other hand, offers the of hospitals, but as this is expected to The term 'e-health', which was reliability of psychiatric face-to-face reach its economic limits soon becau- developed recently in analogy with diagnosis, if the transmission speed is se of insufficient utilisation, other terms like 'e-commerce' or 'e-busi- fast enough. So far, because of high solutions have to be found. ness' focuses on the electronic trans- technical and financial requirements, Certainly the use of telemedicine mission of medical information. videoconferencing has been used can reduce the problem of inadequate Comparing it with 'telemedicine', J. mainly under very distinctive geogra- health-care in remote areas. Through Mitchell gave the following defini- phical and economic circumstances. telemedicine, medicine by distance, it tion of 'e-health': Via web sites, chat rooms, message is possible to save time and money for E-health is […] a term which des- boards or e-mail, the Internet facilita- patients and therapists, as only the cribes the increasing use of electronic tes a variety of communication possi- medically relevant information bet- communication and information bilities in psychiatry. Although one ween those involved and not the indi- technology in the health sector. Tele- can hardly doubt that presently the viduals themselves has to be transfer- medicine is the term used to describe potential of electronic telecommuni- red. Although the term 'telemedicine' the use of telecommunication for the cations is not exploited fully, the has been defined frequently, most provision of medical services to obstacles and limits in all their tech- definitions differ just marginally. As distant locations. E-health is a more nical, organisational, political, geo- an example S.W. Strode’s very com- general term that describes the use of Sulzenbacher, Bullinger, Senn, Bekiaris, Meise 65 both telecommunication and infor- conferencing and the Internet, is neit- in post-discharge care. mation technologies for the delivery her categorised as 'telepsychiatry' nor Still pictures: These can be trans- of health services both at a distance 'e-mental health', if rigid definitions mitted via television, web sites or and locally. Hence, e-health is an are used. e-mail. Telemedical transfer of still umbrella term that encompasses tele- pictures is used primarily in radiolo- medicine and telehealth. [83] gy, pathology and dermatology for diagnostic purposes. With the increa- From the psychiatric viewpoint Basics of electronic tele- sing diffusion of the Internet new both definitions are problematic, due communication uses, such as medical education, have to the way electronic telecommunica- recently emerged [28], although in tions became involved in psychiatry Each communication medium can psychiatry there are hardly any possi- historically. The term 'telepsychiatry' be characterised by several technical bilities to exploit these. was first used for interactive video- parameters which determine its possi- Audio-visual data: Such informa- conferencing in psychiatry [31] in ble uses. In this chapter some impor- tion can be transmitted via television, 1973 and since then both terms have tant parameters will be described with web sites or e-mail. In psychiatry been used synonymously. Although regard to the most common electronic audio-visual data transfer is used for there have been repeated attempts to media and their use in psychiatry. diagnosis and psychotherapy, but also define 'telepsychiatry' in a broad sen- in supervision, psychiatric education se similar to 'Telemedicine', collo- and administration. quially but also in scientific literature Type of information transferred the term is used almost exclusively for psychiatric interactive videocon- Physiological data: The monito- Direction of information transfer ferencing. A. Buist et al. expressed ring of physiological functions over a this usage explicitly: distance is called 'telemetry'. Teleme- Unidirectional information trans- Telepsychiatry is a specialist form try was probably first used by NASA fer enables the transmission of data in of telemedicine in which videoconfe- for terrestrial surveillance of astro- only one direction, from one defined rencing is used by psychiatric practi- nauts' blood pressure, respiration and transmitter to one or more defined tioners to communicate with other body temperature [112]. More recent- receivers. This form of data transfer is mental health service providers and ly this technology was used for used in radio and television broad- with patients. [15] instance for ECG-monitoring [87], casts and on simple non-interaktive electro-physiological observance of web sites. In psychiatry unidirec- And also the term 'e-health' is not mountaineers [50, 88] and divers tional data transfer can be used for usually used in the comprehensive [60], and SIDS-risk infants [4]. From transmitting general information and sense suggested in the definition the psychiatric view, the possible uses psychiatric education. above. G. Eysenbach gave a defini- seem to be limited. Bi-directional information trans- tion which considered the term’s Written text: The classical form of fer: Here the position of transmitters Internet origin: storing information and the most and receivers changes during the e-health is an emerging field in important form of communication in communication. Such an interactive the intersection of medical informa- science. Although each optical com- form of communication is made pos- tics, public health and business, munication medium is able to trans- sible by telephone, videoconferen- referring to health services and infor- mit written texts, for this sort of infor- cing and e-mail. As bi-directional mation delivered or enhanced mation transfer mostly web sites, data transfer allows information ex- through the Internet and related tech- message boards, chat rooms, and change between two people, psychia- nologies. [37] e-mail are used. In psychiatry written tric diagnosis, counselling and psy- text is used for general information chotherapy is possible. This conceptual vagueness was transfer and education, but also for Multidirectional information the reason we chose to use both psychotherapy. transfer: This form allows more than terms, 'telepsychiatry' and 'e-mental Spoken text: is mostly transmitted two people to communicate with each health', in this article as the psychia- via radio and telephone, but is also other. Every participant can act as tric use of all important telecommuni- transferable through web sites and transmitter as well as receiver. Multi- cation media will be presented. The e-mail. In psychiatrie telecommuni- directional telecommunication occurs compromise made here is clear when cations spoken text is used mostly for in audio- and videoconferences and we consider that the telephone, the organisational and administrative Internet, mediated in message boards most important communication me- purposes, in emergency medicine and and chatrooms. This form of informa- dium in psychiatry, alongside video- crisis intervention, and occasionally tion transfer allows discussions and Telepsychiatry and e-Mental Health: Electronic Telecommunication in Psychiatry 66 exchange of ideas between more or articles on the use of these media in Very soon these new communica- less selected groups of communica- psychiatry have been published, for tion possibilities were also used in tion partners. instance about television spots within medicine. The fast and uncomplica- the Anti-Stigma campaign of the ted information exchange via tele- World Psychiatric Association [94] or phone allowed its use in organisation Synchronicity about the diagnostic reliability of the and administration as well as in emer- fax [10]. Because of their restricted gency medicine and crisis interven- Synchronous communication de- psychiatric use, a description of these tion. Until today the telephone has mands simultaneous attention of all communication media has been been an indispensable part of these communication partners. Radio and excluded in this article. medical fields. television broadcasting, telephone, Given the telephone's omnipre- real-time-videoconferencing, and In- sence and manifold usability, there is ternet chat rooms are based on this Telephone a surprising shortage of scientific lite- form of communication. Synchroni- rature on its medical use. This short- city allows immediate interaction of Overview age is alarming mainly in terms of communication partners, as required psychiatry, as here, more than in any for instance in crisis intervention and The first telecommunication other field of medicine, quality and diagnostic interviews. medium, electromagnetic telegraphy, therapeutic success are based to a was already developed in the first half similar extent on verbal interaction, a Asynchronous communication: of the 19th century. Telegraphy allo- form of interaction which can easily The transmitted information is stored wed asynchronous bi-directional be carried out over the telephone. and available for the receiver when transmission of written information, needed. This form of communication however, efficient utilisation was Utilisation in psychiatry is used in telephone mailboxes, store- restricted by technical inadequacies: and-forward videoconferencing and First the text which was to be trans- Psychiatric diagnosis by telepho- in various Internet-mediated techno- ferred had to be encoded into a (deve- ne is problematic: The reliability of logies like e-mail, web sites, and mes- loped by S.F.B. Morse in its original telephone based diagnoses is partially sage boards. Asynchronous commu- form) binary sign system, and after – dependent upon the disorder in nication is used for example in orga- transmission the receiver had to deco- question – lower than in face-to-face nisation and administration, educa- de the text. For this en-/decryption interviews [91]. However, psychiatric tion and discussions. specialists skilled in the use of the screening by means of standardised Morse-alphabet were required, who screening instruments, for which a were placed at telegraphy offices. So lower diagnostic reliability is accep- not only was the use of the new table, is feasible by telephone [8]. Communication Media communication medium restricted Compared with its limited dia- in Telepsychiatry and mainly to larger communities, fur- gnostic possibilities, the telephone E-Mental Health thermore it was very expensive. has a great potential in view of post- Compared with telegraphy the discharge care. With medical after- In terms of their use for psychia- telephone, for which A.G. Bell recei- care by telephone, it is possible to tric purposes telephone, videoconfe- ved the patent in the year 1876, had the reduce the dosage of prescribed rencing and Internet play a prominent advantage that no encoding and deco- medication, the accumulated costs, role. These three communication ding of the transmitted text was requi- and the frequency and duration of media can be used for psychiatry in a red. As the users of the new medium further hospital admissions [96, 108]. number of ways: for education, were not dependent on en-/ decryption While the telephone's possibilities exchange of ideas, diagnosis, therapy, specialists, the telephone could be have been little used in psychiatric organisation and administration as installed directly at the users' homes. after-care so far, the telephone has well as for crisis intervention and Furthermore the telephone allowed the been serving for decades in psychia- psychiatric emergencies. The utilisa- communication partners a synchro- tric crisis intervention as an inestima- tion of these media in psychiatry is nous bi-directional interaction, by ble – often underestimated – tool. described below. which direct conversations over large Since the first telephone helpline was Certainly there is a multitude of distances were made possible. As a established in London in 1953, an other widespread communication result, it is no surprise that the new extensive network of telephone crisis media, but there is comparatively medium spread rapidly: In 1922, the intervention has developed [30]. Fur- limited use for any these in psychia- year Bell died, 14 Million telephone thermore informal crisis intervention try. As a result, just a few sporadic lines were registered in the USA alone. is probably offered by most psychia- Sulzenbacher, Bullinger, Senn, Bekiaris, Meise 67 tric divisions and outpatients depart- usable as an asynchronous communi- dicine [53], as it is made possible ments. A certain suicide preventive cation medium too, it is used in through the telephone or the Internet. effect of telephone crisis intervention psychiatry almost exclusively as a could be proved [27]. synchronous bi- or multidirectional Utilisation in psychiatry The telephone is the most impor- communication medium. So, similar tant communication medium in to the telephone, an immediate inter- Psychiatric videoconferencing rescue services and an essential com- action between all communication has always been seen as a chance to ponent of practices and hospitals. On partners is possible. But the additio- improve mental healthcare in remote average, a physician spends approxi- nal transmission of visual informa- areas. However, because of high costs mately one whole workday per month tion provides the important advantage such systems have succeeded mainly with phone calls [40]. of a better diagnostic reliability com- in rich countries with sparsely popu- Moreover the telephone has been pared with the telephone. If a suffi- lated remote areas, such as Australia playing a significant role in synchro- cient quality of picture and sound can [15, 21, 24, 29, 45, 52, 73, 104], nous forms of telemedicine, and was be guaranteed, videoconferencing is Canada [48, 105], the USA [14, 36, consequently esteemed as "the most able to achieve the diagnostic relia- 46], or the Scandinavian states [33, important part of telemedicine" [58] bility of a face-to-face interview 43, 82]. Several projects were concer- and as "the most basic unit of a tele- [6, 35]. ned with the problematic situation of medicine equipment" [112]. Despite However, the quality of the trans- psychiatric healthcare on smaller the fact that in scientific literature the ferred audio-visual information islands [26, 49, 76, 98]. As problems telephone has been neglected in depends on the transmission speed. If of mental healthcare also occur in big favour of the more spectacular video- a transmission speed of 384 kbit/s or cities, some inner-city projects have conferencing, it should be examined faster is available, highly reliable also been set up [13, 78]. whether, considering the video quali- psychiatric diagnosis is possible; The possibility of performing ty achievable, this method really adds lower transmission speed reduces the psychiatric and psychological dia- anything compared with a simple diagnostic reliability [113, 115]. This gnosis via videoconferencing was telephone connection, particularly if means that videoconferencing, if it used quite often in recent years, and no broadband connection is available should be used for diagnosis, requires for most mental disorders. Usually [100]. high acquisition costs as well as high the diagnoses are based on psychia- operating expenses. These high costs tric interviews, occasionally using are probably the main reason why so standardised tests which have been Videoconferencing far psychiatric videoconferencing adapted to the requirements of the could only be practised under very medium [9, 16, 84, 116]. Overview specific circumstances: As an integra- Continuing psychiatric care after ted routine service, videoconferen- the first diagnostic interview has been Videoconferences were used in cing exists presently almost exclusi- offered rather rarely: Considering the psychiatry for the first time in the vely in rich developed countries with high prevalence of chronic and recur- 1950’s, when C. Wittson established large sparsely inhabited regions ring mental disorders, various studies an interactive audio-video link bet- which are therefore difficult to provi- enumerate surprisingly low numbers ween the Nebraska Psychiatric Insti- de for medically. of follow-up sessions [64, 97, 105]. tute in Omaha and the Norfolk State The high costs of interactive tele- Videoconferencing has not only Hospital, 180 km away. Already in vision have caused a second impor- been used as a communication tool this early period a broad spectrum of tant difference compared with the between patients and experts, but also uses was found such as psychiatric telephone: As such a system is hardly for the exchange of information bet- education [110], group therapy [111], affordable for private households, ween therapists, education, admini- and psychiatric consultation [11]. potential users usually cannot be con- stration, supervision and training [43, In the year 1973 the term 'telepsy- tacted at their homes. Although in 54, 62, 64, 73, 89]. Psychologists and chiatry' was coined for psychiatric some Telemedical projects videocon- psychiatrists, nursing staff, social videoconferences [31] and, although ferencing systems were installed workers or occupational therapists until today videoconferencing has directly at the users' homes [85, 106], participated in such sessions [15, 33]. been used in nearly all medical fields, the services were usually – and as Numerous studies showed high psychiatry frequently was seen as routine services exclusively – instal- satisfaction among patients and thera- 'native application' of interactive led in public institutions. Of course pists [15, 26, 34, 57, 67, 81, 84, 90, telemedicine by means of video- the possibilities for use of such office- 98, 109]. The reservations, mostly conferencing [3]. /hospital-based telemedicine differ among therapists, can probably be Although videoconferencing is very much from home-based teleme- explained with frequently occurring Telepsychiatry and e-Mental Health: Electronic Telecommunication in Psychiatry 68 technical problems [42, 43, 51, 65, Although the foundations for Utilisation in psychiatry 75, 79, 84, 99]. computer networks were set up, the Although usually in psychiatric enormous diffusion of the Internet The World Wide Web offers an videoconferencing modern high-tech could not have happened without the immense and continually increasing equipment is used, the interaction development of the Personal Compu- amount of information. It has been itself is rather traditional: Because of ter. The first stages of development estimated that there are approxima- the concentration on diagnosis and date from the sixties, while the great tely 100,000 websites dealing with therapy, normally only patients and breakthrough took place in the late health questions [39], from which a therapists participate in videoconfe- 1970’s. Until then mainly large considerable segment is concerned rencing sessions. Apart from parents university computers were connected with mental health. These websites in child-psychiatric projects [34, 35, in the network, after a huge new are offered by a wide variety of ow- 67], the patients' relatives are rarely market emerged with new interests ners: organisations operating world- involved. Consequently the social- and demands (simple performance, wide as well as national, regional and psychiatric demand for integration of appealing design, entertainment local psychiatric institutions, and also family members in the therapeutic programmes). individuals such as patients, their process hardly seems to be realisable In the following years the number families and therapists. Consequently with interactive television. of computers connected with the net- the information offered is impressive- Half century ago, when videocon- work doubled nearly once a year and, ly diverse: Descriptions of mental ferencing was used in psychiatry for although the speed of the spread disorders are available as well as the first time, many people expected a slowed down recently, the Internet is information on psychiatric stigma, great success of the new communica- the fastest expanding technology in legal questions and presentations of tion medium. Instead a slow and hesi- history. However, the spread of the personal experiences of patients and tating development took place. Internet is extremely uneven: While their relatives. The search for relevant Depending upon various geographi- in many developed countries the information can be facilitated by cal, technical and economic circum- Internet is used at least occasionally categorised link lists [12, 74]. Fre- stances, psychiatric videoconferen- by more than half of the population, quently the quality of Internet infor- cing has only succeeded in a few in some of the poorest countries not mation has been doubted, and some regions. However, the increasing dif- even one in a thousand has Internet scientific articles indicate that a cer- fusion of webcam and broadband- access [22]. All in all men use the tain scepticism towards medical Internet could well lead to a funda- Internet more frequently, but health information on the Internet seems to mental change in this situation in the websites are visited more often by be reasonable [5, 68]. Nevertheless, a near future. females; the typical Internet user is systematic search for harm caused comparatively young, lives in an through inadequate Internet informa- urban environment and has an above tion brought very few definite results Internet average income and education [41, [23]. 72, 95]. Although in principle psycho-dia- Overview The Internet is the most complex gnosis via the Internet is possible, the communication medium ever develo- diagnostic reliability can be too low, The idea of the Internet was con- ped. It allows the transfer of most dif- if inadequate bandwidth is used ceived not later than 1962 when ferent information in uni-, bi- and [115]. In view of the Internet's conti- J.C.R. Licklider published his des- multidirectional ways, synchronous nuously increasing transmission cription of a "galactic network": a as well as asynchronous. Websites, speed, however, it is to be anticipated global network of connected compu- message boards, chat rooms, web- that this could be overcome in the ters, each computer able to send and cams, file sharing programmes, near future. No reliability problems receive data and programmes to and e-mail and mailing lists are such dif- caused by low bandwidth exist for from all others. The first data transfer ferent forms of information transfer psychiatric screening: Psychiatric over a large distance took place in that in fact each of these can be seen screening is a form of provisional 1965 [71]. Beginning in 1969, a as a communication medium sui diagnosis by means of standardised scientific department of the US-Mini- generis. In this article, however, the screening tools, which indicates a stry of Defence developed a network Internet is presented as a composite, certain likelihood for the presence or between originally just four universi- as normal Internet access allows the absence of a mental disorder. It has a ty computers: the Arpanet. This was user to employ all those single media significantly lower reliability than a presented to the public successfully and to decide, to which degree and to diagnostic interview [107]. Psychia- in 1972 and already had forty connec- which purpose those media will be tric screening is able to make people ted computers [114]. used. afflicted aware of their possible men- Sulzenbacher, Bullinger, Senn, Bekiaris, Meise 69 tal disorder. The Internet currently However, it has to be considered that tion, and therefore the carriers are offers such tests for various frequent even more potential users are exclu- dependent upon financial support mental disorders, for instance for ded from Internet access because of from the local, regional, or national alcohol-related disorders [56, 63], economic, social and even medical government. It is not surprising there- anxiety disorders [1, 77], or depres- reasons. So it is one of the most fore, that videoconferencing services sive disorders [25, 86]. important technical and political are typically orientated towards poli- The fact that the Internet is also challenges of our time to enable as tical borders and that transnational usable for therapeutic purposes is litt- many people as possible to access the projects are rare [92]. This orientation le known, although for psycho-thera- probably most important communi- is the reason that language barriers peutic methods it is absolutely feasi- cation medium of the future. play a more important role only in ble. There are several websites which multiethnic societies. offer CBT programmes, some of The Internet on the other hand is them with integrated diagnosis and Discussion hardly influenced by political boun- outcome testing by means of scree- daries: The Internet offers world- ning instruments [17, 18, 47]. Beside After the separate presentation of wide access to websites and e-mail such fully-automatic therapy pro- the telephone, videoconferencing and addressees. While videoconferencing grammes, the Internet also offers Internet in the previous section, in services are mainly installed in rural individual psychotherapy. Here the this final part some aspects of psychi- areas, in terms of the Internet the communication between client and atric telecommunication will be inhabitants of such remote regions therapist usually takes place via e- explored, which are significant for all are disadvantaged compared with mail or in a private chat room [2]. these communication media. people living in urban environments Formally standardised psychotherapy [72]. Even though for the Internet over e-mail is also available [59, 69]. political borders don't play a particu- The chances of success for Internet- Technical aspects and network larly significant role, there is still one based psychotherapy have been architecture important limitation for Internet assessed very differently. Undoubted- access: Language boundaries can hin- ly patient selection, which is not easy Although a separate description der the access to relevant informa- to make over the net, is of great of those telecommunication media tion, particularly if the user does not significance here [19, 20, 70]. which play an important role in psy- master the predominant English lang- Although synchronous multidi- chiatry was preferred in this article, it uage [102]. rectional telecommunication in the has to be emphasised that current far- The system architecture of the form of telephone and videoconferen- reaching technical developments are telephone network stands between cing already existed before the deve- leading to increasing convergence in videoconferencing and Internet: On lopment of the Internet, the widespre- the possibilities of telecommunica- the one hand the telephone allows ad use of this form of telecommuni- tion media. Webcams, Internet-tele- one, at least theoretically, to get in cation did not start before the inven- phone or picture-telephone are pres- contact with other people connected tion of the Internet chat room. The ently still new and little used forms of with the telephone network world- asynchronous multidirectional tele- data transfer, but it is certainly imagi- wide; so the communication is si- communication of Internet message nable that these media will be a com- milar to the Internet and restricted boards is an entirely new form of tele- mon part of everyday communication mainly through language barriers, communication, made possible first in a few years, as, for example, the less through political structures. On by the Internet. Currently multidirec- mobile phone and the SMS are al- the other hand different charges for tional telecommunication is used pri- ready today. calls at home and abroad cause a poli- marily by patients and their families It should be noted, however, the tical influence, too. and allows exchange of ideas, talking possibilities of a telecommunication about personal experiences and mutu- medium do not only depend on its al support; psychiatric message technical parameters, but also on the Home-based telemedicine & boards are usually moderated to pre- structure of the network used. office-/hospital-based telemedi- vent personal injuries or suicide pro- Psychiatric videoconferencing is cine paganda of participants [66, 103]. mostly used to improve the situation The various forms of communica- of mental healthcare in remote rural With regard to the psychiatric usa- tion, which are offered by the present regions. Typically small regionally bility of different communication Internet, can be used for psychiatry in connected networks are used. Video- media, one must distinguish between a wide variety of ways, and millions conferencing is currently a very home-based telemedicine and office-/ of people are able to participate. expensive form of telecommunica- hospital-based telemedicine [53]. Telepsychiatry and e-Mental Health: Electronic Telecommunication in Psychiatry 70

While in the first form the telecom- are open to the patient. However, in And finally psychiatric illness is munication system is available for the other situations anonymity is not just able to restrict the use of telecommu- user directly at his home, the second acceptable, but moreover desirable: nication: Dementia, substance abuse, form requires the user to move to an Undoubtedly the success of crisis depressive episodes or schizophrenic institution in which the system is intervention via telephone is at least psychoses can affect the acting, thin- installed. partially caused through the callers' king and feeling so much, that the use Office-/hospital-based telemedi- possibility to stay anonymous. The of a telecommunication medium be- cine is mainly used just to speed up situation is similar in Internet chat comes absolutely impossible. And so the information transfer between phy- rooms and message boards. Even for finally psychiatric disorders set the sicians for diagnostic purposes. It is carriers of websites, in some cases the limits of telepsychiatry and e-mental presently the most important function wish for anonymity has to be accep- health and determine their role: as a of telecommunication in radiology, ted, for instance, for patients suffe- worthwhile complement to the perso- pathology and dermatology, for ring from a mental disorders and for nal communication between patients, example. In psychiatry office-/hospi- their family members [93]. relatives and therapists – but not as its tal-based telemedicine is practised Confidentiality and data security: substitute. mostly as psychiatric videoconferen- Although these issues play an impor- cing. tant role in the personal interaction Home-based telemedicine allows between patient and therapist too, the Literature the user to communicate directly at use of telecommunication requires his/her home. For this form of tele- particular attention. Before the ex- [1] ADAA – Anxiety Disorders Association communication mostly the telephone change of confidential information, it of America: Anxiety Screening Tools. Last Update 2004. http://www.adaa. and Internet are used. has to be assured that the data is not org/Public/screeningtool.cfm available to anyone except the desi- [2] Ainsworth M: Metanoia. Turn toward gnated addressee. Stored data also the light. Last Update 2004. Ethical aspects has to be protected against unautho- http:// www.metanoia.org/ [3] Allen A: Telepsychiatry background and rised access. activity survey. Telemedicine Today In connection with medical tele- Crisis intervention: If patient and 1998; 6 (2): 34-7. communication there are various therapist use telecommunication [4] Aly AF, Afchine D, Esser P, Joos M, Nie- ethical-juridical questions. Some of media, it should be clarified already werth HJ, Wiater A, Meier M, Padeken D, Pericas A, Schwartmann D, Weber T, the most important problems are before a possible emergency situa- Wendrix V, Wirtz M: Telemetry as a new discussed below. Ethical guidelines tion, which intervention possibilities concept in long term monitoring of for the use of telecommunication in are open to the therapist. In a crisis SIDS-risk infant. Eur J Med Res 2000; medicine were proposed, for instance situation the therapist should be able 5 (1): 19-22. [5] Athanaselis S, Stefanidou M, Karakou- by eHealth Ethics Initiative [32], to contact an emergency service near kis N, Koutselinis A: Asphyxial Death Health on the Net Foundation [55], the patient's residence immediately. by Ether Inhalation and Plastic-bag Suf- and MEDEM & eRisk Working focation Instructed by the Press and the Group for Healthcare [80]. Internet. Journal of Medical Internet Research 2002; 4 (3): e18. Anonymity: This telecommunica- Social and medical aspects http://www.jmir.org/2002/3/e18/ tion problem has been known about [6] Baigent MF, Lloyd CJ, Kavanagh SJ, the telephone for a long time. Howe- The influence of social factors on Ben-Tovim DI, Yellowlees PM, Kalucy ver, whether the principle only to give the access to the Internet is obvious: RS, Bond MJ: Telepsychiatry: 'tele' yes, but what about the 'psychiatry'? J Tele- personal information about patients In poor countries there are fewer med Telecare 1997; 3 (Suppl 1): 3-5. to definitely identified people is Internet connections than in rich, and [7] Ball C, Franco A, Tyrrell J, Couturie P: obeyed consistently may be doubted. within each society the socially Videoconferencing and the hard of hea- For patients, anonymity is mostly disadvantaged have less access than ring. J Telemed Telecare 1998; 4 (1): 57-9. problematic in view of the Internet. people with higher income [38]. [8] Ball C, McLaren P: The tele-assess- So frequently the carriers of websites Rural population, elder people and ment of cognitive state: a review. J and their medical qualification are ethnic minorities are underrepresent- Telemed Telecare 1997; 3: 126-131. insufficiently specified or not speci- ed too [41, 72, 95]. [9] Ball C, Puffett A: The assessment of cognitive function in the elderly using fied at all [61]. Particularly for signi- Somatic illness and disability can videoconferencing. J Telemed Telecare ficant interaction like psychiatric dia- also reduce the possibilities of tele- 1998; 4 (Suppl 1): 36-38. gnosis or psychotherapy via telecom- communication: Sight defects, poor [10] Ball C, Tyrrell J, Long C: Scoring writ- munication, it must be guaranteed hearing and immobility can – depen- ten material from the Mini-Mental-Sta- te Examination: a comparison of face- that all relevant information about the dent on the communication medium to-face, fax and video-linked scoring. 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[99] Sorvaniemi M, Santamäki O: Telepsy- tance and reliability. J Clin Psychiatry chiatry in emergency consultations. J 1997; 58(1): 22-5. Telemed Telecare 2002; 8 (3): 183-4. [116] Zaylor C, Nelson E-L, Cook DJ: Clini- [100] Squibb NJ: Video transmission for tele- cal outcomes in a prison telepsychiatry medicine. J Telemed Telecare 1999; 5 clinic. J Telemed Telecare 2001; 7 (1): 1-10. (Suppl 1): 47-49. [101] Strode SW, Gustke S, Allen A: Technical and Clinical Progress in Telemedicine. JAMA 1999; 281 (12): 1066-8. [102] Sulzenbacher H, De Col C, Lugger K, Meise U: Ist das www für die Anti-Stig- ma Kampagne nutzbar? Neuropsychia- Hubert Sulzenbacher trie 2002; 16 (1/2): 110-4. Dept. of Psychiatry [103] tapir – the Anxiety Panic internet resource. Last Update 2004. Medical University Innsbruck http://www.algy.com/anxiety/ Anichstrasse 35 [104] Trott P: The Queensland Northern A-6020 Innsbruck Regional Health Authority telemental health project. J Telemed Telecare Austria 1996; 2 (Suppl 1): 98-104. E-mail: [email protected] [105] Urness DA: Evaluation of a Canadian telepsychiatry service. Stud Health Technol Inform 1999; 64: 262-9. [106] Valero MA, Arredondo MT, del Nogal F, Rodríguez, Torres D: Using cable tele- vision networks for interactive home telemedicine services. J Telemed Tele- care 1999; 5 (Suppl 1): 91-2. [107] Wancata J: Screening für psychische Krankheiten. Psychiatr Prax 2004; 31: 43-47. [108] Wasson J, Gaudette C, Whaley F, Sauvig- ne A, Baribeau P, Welch HG: Telephone care as a substitute for routine clinic fol- low-up. JAMA 1992; 267(13): 1788-93. [109] Williams TL, May CR, Esmail A: Limi- tations of patient satisfaction studies in telehealthcare: a systematic review of the literature. Telemed J E Health 2001; 7 (4): 293-316. [110] Wittson C, Dutton R: A new tool in psy- chiatric education. Mental Hospitals 1956; 7: 11-4. [111] Wittson CL, Afflect DC, Johnson V: Two-way television in group therapy. Mental Hospitals 1961; 12: 22-3. [112] Wright D: Telemedicine and developing countries. A report of study group 2 of the ITU Development Sector. J Telemed Telecare 1998; 4 (Suppl 2): 1-85. [113] Yoshino A, Shigemura J, Kobayashi Y, Nomura S, Shishikura K, Den R, Waki- saka H, Kamata S, Ashida H: Telepsy- chiatry: assessment of televideo psychi- atric interview reliability with present- and next-generation internet infrastruc- tures. Acta Psychiatr Scand 2001; 104 (3): 223-6. [114] Zakon RH: Hobbes' Internet Timeline v7.0. Last Update 2004. http://www.zakon.org/robert/internet/ timeline/ [115] Zarate CA jr, Weinstock L, Cukor P, Morabito C, Leahy L, Burns C, Baer L: Applicability of telemedicine for asses- sing patients with schizophrenia: accep- Neuropsychiatrie, Volume 18, S 2, 2004, page 74-78

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

1Telecommunication Engineering School, Technical University of Madrid 2Center for Research and Technology Hellas, Hellenic Institute of Transport, Thessaloniki

Key words (Fundación Vodafone, TRUTh, Inter- circulation of citizens. The problem Telepsychiatry, system architekture axon, MMU), and end users (Servicio of people medical disadvantage is of Canario de la Salud, University greater relevance in the numerous On the Integration of Telepsychi- Hospital Fort-de-France, Eginition islands within the EU. atry Services in European Remo- Hospital) to build a platform aimed to Epidemiological data suggest that te Areas: the ISLANDS Project deliver long distance psychiatric ser- anxiety disorders (post traumatic Case Study vices. stress disorders (PTSD), agoraphobia There are some regions in the In this paper, several aspects rela- and other phobias, etc.), depression, European Union – predominantly ted to the aforementioned problems drug addiction and psychosomatic islands – with particular characteri- are analyzed and a real case study, disorders (tinnitus, eating disorders, stics, which are responsible for their drawn from ISLANDS project, is and chronic pain syndromes) often being behind the average socio-eco- presented. occur in any population. Those disor- nomic development in Europe. They ders have an important impact on have an economic as well as medical societal development and economic logistic disadvantage. They are remo- aspects. tely located with a lack of access to Introduction The socio-economic development modern healthcare facilities, especi- of the European regions lying remote ally psychiatric and cognitive-beha- The need for health services rises from the main stream can be stimula- vioral therapies. As a consequence, because of the ageing in Europe as ted by reducing the impact of mental quality of life of patients living in the- well as in other industrialized health problems. Their empowerment se areas is impaired. Since anxiety, regions, and because of the citizens’ will lead to more autonomy, can depression or other mental health health services quality expectancies. lower the necessity of financial sup- disorders cause progressive vocatio- Demographic factors and technologi- port from the European Union and is nal, emotional and even physical cal progress lead to higher costs for able to improve quality of life in impairment of individual functioning, health services [6]. But at the same remote regions. the ability to participate in societal time, there is a need in reducing those The use of telemedicine is activities and to support economic costs because of lower public bud- undoubtedly increasing across de development of the living area is alte- gets. Consequently, it is very impor- world, but it is still proving difficult red. Studies assessing the possibili- tant to use all possible resources to to embed firmly within normal clini- ties of positively influencing econo- bring together divergent interests. cal practice [5]. However, one of the mic and mental health problems in In the European Union (EU), dif- best ways of addressing the problem remote European areas are lacking. ferent types of healthcare (HC) of medical disadvantage of people Facing this reality, the European systems exist in the various member living in rural and remote regions is Union has funded ISLANDS (Inte- states and sometimes they differ even the use of modern tools and aids to grated System for Long Distance from region to region. Europe’s long overcome practical obstacles and to Psychiatric Assistance and Non-con- history of regional autonomy, strong disseminate mental health tools to ventional Distributed Health Servi- national feelings, and heavily defen- those remote populations, offering a ces), a Quality of Life (QoL) project. ded borders may well account for the significant chance for health services ISLANDS joins research groups diversity of such HC systems. This and quality of life improvement [1]. (UPM, ICCS, COAT-Basel, Universi- leads to non homogeneous medical On the basis of the before mentio- ty of Innsbruck, Charles University of treatments over the European territo- ned conditions, the objective of the Prague), companies and industry ry that limits, to some extend, the free last generation EU Fifth Framework Cabrera, Arredondo, Rodriguez, Bekiaris 75

Programme funded project tested in three pilot sites: the French appropriate content and service pro- ISLANDS [4] is to develop services Oversea Departments, the Greek vision media in a comprehensive, to provide modular, non-conventio- Southern Sporades and the Spanish modular, and integrative framework nal, remote psychiatric and psycho- western Canary Islands. At first sight for remote patients, relatives/infor- therapeutic assistance for remote are- there are some similarities between mal cares and professionals, making as. By these means quality of life of these sites, but in fact the differences use of innovative computerized tools the users, quality of mental health outweigh. The pilots are part of three with multimedia and multilingual care and the economic strength of the different countries, and three diffe- user interfaces, to offer these services region should improve and over- rent languages are spoken. Besides, a in an optimal way. weight the costs of implementation different historical and cultural back- The main outcome will be an ade- and service support. This project will ground has led to different social, quate treatment of psychological pro- try to reduce inequalities in mental economical, political, and medical blems in terms of quality assistance health services and status among structures. These locations represent delivery for the patients, as well as European regions. different service combinations, geo- support for the family and the local graphical regions and support needs medical practitioners. Each of the (but with homogenous user groups), ISLANDS sites involves a target using a common set of evaluation population of more that 100.000 citi- Methods parameters and data processing tools. zens, and each of them will aim to The cost effectiveness of each integrate the developed services. The The project started with a literatu- proposed services and tools are being following sections describe the requi- re review of the state of the art on analyzed. The guidelines on appropri- red functional and technological remote therapeutic psychiatric and ate service provision will be formula- infrastructure. psychotherapeutic interventions, ted and the recommendations for sup- complemented by field work with the porting policy interventions will be A) System architecture realization of questionnaires to issued. The platform is composed of: patients, families and doctors, and an As pilot application fields, five • Remote services in diagnosing, international workshop, to result in typical case studies of psychological counseling and treatment of appropriate service delivery scena- problems have been selected that can psychological disorders [2]. rios. In total, 164 questionnaires were be found quite often in normal popu- • Computerized tools with multi- filled in: 71 by patients, 59 by infor- lations and are of specific interest: media and multilingual user inter- mal careers and 34 by medical pro- • Post-traumatic stress disorder. faces. fessionals from Austria, Czech Repu- • Agoraphobia. • A distributed tele-psychiatry plat- blic, France, Greece, and Spain. • Depression. form, which allows transfer of cri- The scenarios specified, the diffe- • Problems of alcohol abuse and tical parameters in a secure medi- rent user group needs and the epide- concurrent violence in families. cal telecare network among miological findings led to the defini- • Psychotic disorders. patients, their family members tion of different remote service catego- All cases are applicable in all and stationary centers, enabling ries (diagnosis, counseling and thera- three pilot sites to evaluate the propo- virtual telepresence, remote py) for patients, informal careers and sed therapeutic content and tools monitoring and teleconsultation professionals, as well as an overall ser- under different geographical and with medical experts, irrespective vice layout. These services are suppor- environmental conditions. of location limitations. ted by interactive and user-friendly In order to offer these services and tools for service content presentation, tools, the architecture developed for namely: an interactive web chat tool, a such platform is based on the provi- database of reference case studies, an Results sion of a Multi-Access Server (MAS) expert tool for therapy guidance, a tool that comprises full range of widely for service confidentiality, and the The ISLANDS project belongs to accepted information technologies necessary communication tools and the last generation of the QoL pro- offering to the users a universal, easy service delivery platforms. jects, and it started operating at the to use, on-line and cost-effective All the above developments (con- beginning of 2003. The main goal of access to the provided services. The tent, tools, and delivery platforms) ISLANDS, which has been proposed MAS allows users to access remotely are integrated into modular service by the relevant partners, is to develop regardless of the access terminal they typologies, taking into account rele- remote services in diagnosing, coun- choose. The integrated platform will vant security, legal and ethical issues. seling and treatment of psychological embed several technical implementa- The proposed services will be disorders. The project will establish tions 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, profes- system. The KMO receives a messa- • The ISLANDS database. The sionals and family members already ge from each agent whenever an information that has to be shared to mentioned. event happens and checks which is allow the interoperability between all The architecture is open and the next action to be done and the the agents and applications is classi- distributed, able to integrate different agent that should perform it. After- fied according to its nature: user’s functional modules from different wards, the KMO sends a message to information, profiles, medical data developments using heterogeneous the final agent containing the infor- and treatments, centers of excellence, software and hardware solutions. It mation to perform the action. access rights and reference cases. allows each clinical site to configure • The ISLANDS agents. These are • The user applications. These are the number of services they want to Web Services (3) that have to collabo- the software modules that allow the offer to their own users depending on rate to guarantee a homogeneous user to interact with the system and the local healthcare organization. In access of the users to the services. They access to the available services. addition, the ISLANDS architecture are divided into two different catego- • The user terminals to access the facilitates the integration of existing ries: Communication Servers (CS) and system. applications that could be adapted. Application Servers (AS). Each CS is The telecommunication infra- The architecture (see figure 1) in charge of managing the communica- structure is a state of the art one, cal- allows the interoperability of diffe- tion process between the platform and ling for no further research, being the rent modules that perform the func- one specific user terminal. They have main added value the integration of tionality of the ISLANDS services in the responsibility of performing the already validated solutions. a distributed way. The general com- security policies for user access con- Security is also a critical aspect ponents are: trol, data confidentiality and data inte- that has been taken into account due to • The Knowledge Management grity during data transfers. Each AS is the nature of the managed information. Organizer (KMO). This is the central in charge of performing the kind of Mechanisms for authentication, confi- element of the platform in charge of data analysis that requires the presenta- dentiality, data integrity and access coordinating the interoperability bet- tion of the results accessible from dif- control are being implemented. ween the agents integrated into the ferent user terminals. Cabrera, Arredondo, Rodriguez, Bekiaris 77

SERVICES AND SCENARIOS DESCRIPTION REQUIREMENTS DEFINITION

Type of content Major chapters Data Data urgency Telecommunicatio transmitted n Services

• Anxiety symptoms Screening • Depressive symptoms Text Low SMS, WAP, chat, • Alcohol abuse e-mail • Psychoticdisorders • Anxiety in general Psycho-education, • PTSD counseling • Depression in general Text Low SMS, WAP, chat, • Alcohol e-mail • Psychoticdisorders • Self-exposure in anxiety disorders through professional guidance SMS, WAP, chat, Guided therapy • PTSD therapy through standard writing Text, speech, High e-mail, MMS, • Self-management techniques in depression conferencing speech, • Motivational therapy in alcohol abuse / conferencing. dependence Help in screening for a • Anxiety symptoms disorder in a friend, part- • Depressive symptoms Text Low SMS, WAP, chat, ner, family member, etc. • Alcohol abuse e-mail • Psychoticdisorders Psycho-education, • Anxiety in general counseling • PTSD Text, speech Low Speech, SMS, WAP, • Depression in general chat, e-mail, MMS, • Alcohol conferencing • Helping others in self-exposure in anxiety disorders

NFORMAL CARER PATIENT Guided advice • PTSD therapy through standard writing Text, speech, High Speech, chat, e-mail, • Helping others in self-management techni video MMS, videoconfe- ques in depression rencing • How to support someone in motivational therapy in alcohol abuse/dependence

Supervision and advice in Text, speech, Speech, chat, e-mail, screening Intermediate SMS, MMS, WAP PUSH, • Post-traumatic stress disorder video videoconferencing Supervision and advice in • Agoraphobia and other phobias Text, speech, Intermediate Speech, chat, e-mail, SMS, psycho-education, counseling • Depression video MMS, videoconferencing • Alcohol abuse Supervision and advice in • Psychoticdisorders Text, speech, High Speech, chat, e-mail, SMS, treatment MMS, WAP PUSH, PROFESSIONAL video videoconferencing

Table 1: Service layout and requirements definition

B) Service layout The various services to the principle is the integration of specific The service delivery is based patients, their families and the local interactive and situational informa- upon a multi-screening and a multi- professionals, although reliable as tion with standardized and validated step approach addressed to three tar- stand-alone, are planned to be also neuropsychological assessment tools, get groups: patients, family members offered in coordination. leading to specific pathways of hand- and local professionals. Three service ling the respective situation, delive- batches are discerned, according to ring the appropriate sessions and in the user group to whom they should C) Tools and media general managing the service. benefit, as shown in table 1. As des- The need to offer generic, easy to In order to deliver the web-based cribed in the table, the first column use and low cost remote services has interventions and evaluate their pro- identifies the service content for each lead to the choice of a web portal as gress, a set of computer assessment of the end users. The second column the basic service delivery platform. It and training tests have been designed. relates the type of services with the includes a user-friendly interface and An automatic system has been deve- different type of content. The third navigation tools, which can be perso- loped, which analyze the user’s ans- one shows the type of the information nalized according to level of services wers, compute scale scores, compare transmitted. and patient types. The overall design them with the inclusion cut-off scores On the Integration of Telepsychiatry Services in European Remote Areas: the ISLANDS Project Case Study 78 and inform the participants if they are any negative influence on their part of diagnostic, counseling and therapy accepted. the patients’ (remote) therapy and, on purposes. Each of these components A database of case studies has the other hand, to further supplement is being successful and will continue. been defined. It contains a description it by consulting also the patient’s rela- The project will, it is hoped, provide of the existing remote treatments and tives and medical doctor accordingly. leadership, enhance information tools, and a collection of particular The development of a knowledge- about mental health problems, and cases. Its structure is behind the web based expert tool to guide the relevant undertake research in cost-effective platform and can be accessed by nor- services application aims to avert policies to improve the mental disor- mal web browsers, being compatible erroneous application of such servi- ders addressed. with various computer types. ces, by inexperienced medical per- Acknowledgements: We are gra- sonnel or the users themselves and teful for the valuable contribution of D) Communication framework their relatives. the ISLANDS project consortium to The communication systems The psychotherapeutic services this work. This project is partially employed for each service use alter- differ to a high extent in the various funded by the EU Quality of Life Pro- native and redundant means to gua- European areas. Also the role of the gramme. rantee global coverage at the best family and the local doctor is much cost-efficiency ratio. Although the more important in Southern than in relevant telecommunication frame- Northern Europe. In order to be able work is state of the art, its integration to support a Europe-wide service net- References and use pose a number of challenges, work, that will be able to be integra- such as: ted in the medical and psychological [1] Barry DK: Web Services and Service- • proper communication signal support services of different countries Oriented Architectures. San Francisco, operation and transfer in remote areas and cultures, ISLANDS targets a Elsevier Science 2003 with poor telecommunications infra- modular service, that will be offered [2] Burnett KF, Magel PE, Harrington S, structure; and validated in three different sites, Taylor CB: Computer-assisted beha- • real time transmission of poten- that follow completely different ser- vioral health counseling for high school tially high data content (e.g. physio- vice provision formats. In addition, as students. Journal of Counseling Psy- logical signals or images), with the they are applied to distant and remote chology, 1999; 36: 1-5 current limitations of browser interfa- populations of islands, the local cul- [3] Council of Europe. Demographic Year ces and network communications; tural specificities are also taken into Book. 2001 • seamless and reliable communi- account. The adaptation of these ser- [4] European Commission, Quality of Life, cation, when transferring from one vices to such a wide cultural and ISLANDS: Integrated System for Long medium (e.g. Web) to another (i.e. organizational spectrum will make Distance Psychiatric Assistance and satellite communication); the service content and media open Non-conventional Distributed Health • service cost viability, since satel- enough for pan-European adoption. Services, Project QLG5-CT-2002- lite communications especially are 01637. 2003 still quite expensive. [5] Hawker F, Kavanagh S, Yellowlees P, The above issues are gathered in Kalucy RS: Telepsychiatry in South table 1 where the last two columns Conclusions Australia. Journal of Telemedicine and represent the communication techno- Telecare 1998; 4: 187-194 logies proposed in relation to the The potential benefits of telepsy- [6] Wootton R, Yellowlees P, McLaren P: importance and urgency of the trans- chiatry, especially for European Telepsychiatry and e-mental Health. mitted data. remote areas, are considerable. Tele- Royal Society of Medicine Press Ltd, psychiatry has the capacity to enhan- 2003 ce, support and increase the efficien- cy of mental health services; reduce Discussion inequalities of access to health servi- ces and information for individuals The project seeks wide user and communities, particularly in rural Maria Fernanda Cabrera PhD acceptance of the defined remote and remote locations; and support, ETSI Telecommunicación psychological support services, from educate and train isolated health prac- Ciudad Universitaria all user types (patients, families and titioners where they live and work. 28040 Madrid, Spain local professionals). The support of Over the past 12 months, the E-mail: [email protected] services for the family and the local ISLANDS consortium has focused in professionals is proposed to avoid the development of feasible tools for Neuropsychiatrie, Volume 18, S 2, 2004, page 79-88

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 Center of Applied Technologies in Mental Health, Dept. of Psychiatry, University Basel 4 Center for Research and Technology Hellas, Hellenic Institute of Transport, Thessaloniki

Key words ISLANDS system along with the com- Radiology Telepsychiatry, services, architecture, ponents description will be presented Mature Pathology system, screening, diagnosing, therapy, and thoroughly analysed in this paper. Psychiatry e-mental health, technology Cardiology Maturing Services and Architecture for the Dermatology ISLANDS system: Towards a Introduction Ophthalmology Modular Non-Conventional Tele- Surgery psychiatry System Telemedicine has been applied Pediatrics Emerging Quality of life of patients living in nowadays in practically every area of Emergency medicine remote areas is impaired. Since anxiety, the clinical medicine as well as medi- Rare Diseases depression, substance use disorders or cal education. However, although other mental health disorders cause telemedicine is represented in the Table 1: Telemedicine applications catego- progressive vocational, emotional and vast majority of medical advances rised by the level of maturity [2]. even physical impairment of individual and specialties, the stages of develop- functioning, the ability to participate in ment and maturity vary significantly In contrast, telemedicine has only societal activities and/or to support eco- from specialty to specialty. The follo- recently been applied in other cases nomic development of the living area is wing table (table 1) presents a num- such as in surgery, pediatrics, and rare altered. Modern technologies, such as ber of telemedicine applications in diseases. This is reasonable to an the Internet, the telephone, the video- relation to the level of maturity. extent, since the difficulties that arise conference and other kind of communi- in the second case are more complex. cations, software tools, multimedia trai- Maturity depends on several fac- Maturing clinical applications ning packages, can provide feasible tors, including the quantity and quali- include telepsychiatry, teledermato- tools for diagnosis, counseling and the- ty of research that has taken place for logy, telecardiology, and teleophthal- rapy. In this paper the services that will the specific application, the degree to mology, as issued in Table 1, since be delivered to the three different target which the application has been accep- there has been held a primitive rese- groups (i.e. professionals, patients and ted by the professionals, and the arch and development work in these their informal carers) within the development of standards and proto- specialties. The most recent evidence, ISLANDS will be discussed. Patients, cols for this application. Other para- however, do not indicate the accep- their families and professionals will be meters that are related to the develo- tance of the relevant technology in able to interact with each other in diffe- ping field of telemedicine applica- the aforementioned applications. This rent ways. Mobile phones, web-based tions are namely technical feasibility, situation results partly from the unde- coaching, newsgroups, chats, video diagnostic accuracy, sensitivity, spe- veloped national and international conferences and many other devices cificity, clinical outcome, and cost standards for technology and clinical can support the communication bet- effectiveness. Taking a look at table protocols. Specifically, telepsychiatry ween the three aforementioned groups, 1, it is obvious that teleradiology and has primarily been realized through e.g. to find support and help in scree- telepathology are on a high rank on videoconference and similar techno- ning and diagnosing a patient [1]. The- the maturity scale when evaluated on logy [2, 3]. Even at an early stage, refore, the architecture of the the basis of the attributes listed above. there were challenging experiments Services and Architecture for the ISLANDS System: Towards a Modular Non-Conventional Telepsychiatry System 80 in the field of psychiatric teleconsul- ge is bound to increase in the follo- the services and the architecture of tation in Boston, Massachusetts, and wing years, since the cost of telepsy- the ISLANDS system will be tho- Omaha, Nebraska, that proved the chiatric equipment is continuously roughly analysed. This paper is orga- clinical efficiency of telepsychiatry. declining. What is more, research and nized as follows: the following sec- Today, telepsychiatry is one of the study on the acceptance of and satis- tion is an analysis to the services that most frequently used clinical applica- faction with telepsychiatry systems will be delivered through the tions of telemedicine, and it is estima- suggest that both patients and provi- ISLANDS project to the three target ted that more than 12,000 telepsychi- ders are content with this type of deli- groups namely the general practitio- atric consults are conducted annually vering psychiatric facilities. It is com- ners, the patients and their carers. The in the United States. Moreover, rese- mon knowledge that acceptance is clo- next section provides details concer- arch in this field has illustrated a high sely associated with frequency of use. ning the design of the ISLANDS degree of accordance between tele- Therefore, enhancing the interaction system architecture. In this section, psychiatric and traditional in-person with this kind of technology will result except for describing the different consults regarding the clinical assess- in the users’ wider acceptance [2]. components that compose the system, ment [2]. The ISLANDS project aims at the state of the art technology for con- Similar to other clinical applica- developing services to provide modu- ducting and establishing e-mental tions, cost analyses in telepsychiatry lar, non-conventional, remote psychi- health sessions is also presented. suggest that large amounts of money atric and psychotherapeutic assistan- Finally, the main concerns and obsta- have been invested to the maturing ce for people who live in remote are- cles along with the conclusions are field of e-mental health. This percenta- as. Therefore, in the following units being put forward.

Data urgency Service End User Service Type of content Data transmitted (high, inter- Service No Type mediate, low) frequency • Anxiety symptoms I Screening • Depressive symptoms Text Low Daily • Alcohol abuse Psycho- • Anxiety in general II education, • Schizophrenia Text Low Daily counseling • Depression in general • Alcohol • Self-exposure in anxiety disorders through professional guidance Text, speech, High Daily Patient • Schizophrenia therapy conferencing Guided through standard writing (exposure III therapy and cognitive restructuring) • Self-management techniques in depression • Motivational Therapy in alcohol abuse / dependence Help in scree- • Anxiety symptoms IV ning for a • Depressive symptoms Text Low Daily disorder • Alcohol abuse Psycho- • Anxiety in general V education, • Schizophrenia Text, speech Low Daily counseling • Depression in general • Alcohol • Helping others in self-exposure Informal in anxiety disorders Carer • Schizophrenia therapy through Guided advi- standard writing (how to support Text, speech, VI ce for therapy someone) video (films, High Daily • Helping others in self-management conferencing) techniques in depression • How to support someone in Motiva tional Therapy in alcohol abuse / dependence Amditis, Lentziou, Panou, Bullinger, Bekiaris 81

Data urgency Service End User Service Type of content Data transmitted (high, inter- Service No Type mediate, low) frequency

VII Supervision Text, speech, Intermediate Daily and advice in video (films, screening conferencing) Supervision • schizophrenia and advice in • agoraphobia and other phobias Text, speech, VIII Professional psycho- • depression video (films, Intermediate Daily education, • alcohol abuse conferencing) counseling Supervision Text, speech, IX and advice in video (films, High Daily treatment conferencing)

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 Videoconference/ Text, Speech, Conferencing High computer conference

Text, Speech, Video (films, conferencing) Intermediate/High Videoconference/ Computer conference

Table 3: The recommended technology in relation to the different services

Services be diagnosed, while for their family toms and alcohol abuse. The sixth members it means that he will receive column shows the urgency (namely The ISLANDS project aims to the support and help in screening and for high, intermediate or low) in the The ISLANDS project aims to the professionals that he will accept transmission of the required data in address four different mental health supervision in screening. These are relation to the type of service while problems, namely schizophrenia, analytically presented below. the previous column identifies which depression, phobia and (ab-)use of As described in the following format (i.e. text, speech, conference, alcohol through the use of electronic table, three service batches are discer- and video) of the transmitted data can means. For each of the aforementio- ned for the benefit of the three diffe- cover the relevant need. This means ned categories a series of modules rent end users as indicated by the that dependent on the importance and will be set and integrated in order to three different shadings in the colour the urgency in the transmission of the help users suffering from or concer- of the table along with the second medical data the technology that will ned with this problem. column (namely the general practitio- be used is defined. For example, a Mainly, there are three types of ners, the patients and their carers). In low importance service delivery can services (i.e. screening, counselling the third column the type of service is be supported by text, whereas the and therapy) that will be delivered to identified for each one of the end most urgent cases require the trans- the three different types of end users. users (i.e. screening, counseling and mission of video (audio and visual This means that substantially the therapy for the three aforementioned contact). This issue will be discussed ISLANDS project aims at providing target groups). In the forth column the analytically in the following section. nine different services for the users type of content that corresponds to Finally, in the last column the requi- (i.e. professionals, patients and their the different type of services are pres- red frequency of the delivered service informal carers). For instance, the ented. For instance, screening a is described and defined as daily, sin- screening service has different mea- patient within the ISLANDS project ce it is crucial for a psychiatrist to ning for each user; for the patient it involves examining a person for have a daily contact with his patients means that he will have the chance to anxiety symptoms, depressive symp- or other professionals. What is more, Services and Architecture for the ISLANDS System: Towards a Modular Non-Conventional Telepsychiatry System 82 patients with mental disorders • Cost efficiency issues. area and this clinic is directly connec- demand a frequent diagnosing and • Liability. ted through one communication treatment. In order to sum up all the • Risk analysis. channel to the general hospital, whe- above mentioned technologies in • Security issues and confidentia- re not only the patient but also the comparison to the importance of the lity for the safety of the users. general practitioner can be guided transmitted data, a supplementary Additionally, the ISLANDS and consulted on how to handle a pro- table is being put forward: As descri- system will be able to integrate diffe- blem. This is an ideal solution for tho- bed in this table an incident with low rent functional modules from diffe- se who despite the fact that they are importance (e.g. following up a rent development using heterogene- not close to a psychiatric clinic, they patient’s condition after he/she has ous software and hardware solutions live near a general hospital and there- been diagnosed and treated) can be and it will allow each clinical site to fore the travel time and related issues conducted via mail, since the required configure the number of services they are no hindrance. amount of information can be delive- want to offer to their own users in On the other hand, the home red by transmitting a written text. The dependence to the local Health Care based technology supports many same rationale corresponds to the Organisation. information channels, is used for edu- need of high importance data transfer. The ISLANDS system will sup- cation and information purposes and Further details on the usage of each port both home based and is handled through telephone and above mentioned technology (namely office/hospital based infrastructure Internet. In this case the technology is mail, telephone, videoconference and for the delivery of the various servi- usually paid by the user. The picture computer conferencing) are provided ces. The difference between these two that follows illustrates the idea of the in the last section of this paper. Follo- infrastructures is that the hospital home based e-mental health. wing, an elaborate description of the based technology supports one infor- This picture conveys the idea that ISLANDS system is being given. mation channel, is handled mainly the psychiatric clinic or the psychia- through videoconferencing, is used trist connects directly to each one of for diagnosis and therapy and does the end users. This means that that the not demand the presence of family patient, for instance, does not have to Architecture of the members or other informal carers of travel to the nearest hospital in order ISLANDS system the patient. In this case the costs are to be treated, since he/she can be dia- paid by the provider. In the following gnosed and treated whilst in his/her Building such a complicated picture the general concept of the home. In this case, the user overco- system that will be able to combine hospital based e-mental health is mes the travel expenses and other the delivery of nine different services presented: relevant problems that moving to to three different target groups and at It is obvious from this figure that another place may mean. However, the same time be compatible with the there is a psychiatric hospital (or a he/she must be able to cover the standards and the situation that exists private clinic of a psychiatrist) in the expenses for the purchase and the 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 require- ments of the various components and the peripheral devices of the overall system is needed. This analysis leads to an elaborated design of the propo- sed system for the ISLANDS project, the description of which is extensive- ly 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. Figure 1: Hospital based telepsychiatry Amditis, Lentziou, Panou, Bullinger, Bekiaris 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 informa- tion 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 ser- vices (namely screening, counseling and therapy) for patients, professio- nals 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 Figure 2: Home based telepsychiatry Eginition Hospital (Greece), the Ser- vicio Canario De La Salud (Canary Islands-Spain) and the University Hospital Fort-de-France (Martinique- France) have already a certain equip- ment at their disposal for handling some kind of communication with those patients who live in remote are- as. 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 func- tions of the existing components in these three European areas. In this way, each pilot site will have the pos- sibility to define the number of servi- ces that it will offer to its users (according to their needs that are strongly related to the location’s spe- cial characteristics) in dependence to Figure 3: The general architecture of the ISLAND system the local Health Care Organisation. Therefore, the design of the archi- maintenance of the telecommunica- services. The idea is that the IMAS tecture of the ISLANDS system was ting equipment. will allow users to access the remote conceived so as to allow the interope- The ISLANDS system is liable to services whatever access terminal rability of different modules that per- support both ways of telepsychiatry (namely phone device, PDA, PC, lap- form the functionality of the (home and hospital based). The basic top or digital TV) they choose (or ISLANDS services in a distributed concept is that the ISLANDS system combination of them). In the follo- way, as thoroughly discussed earlier. will primarily consist of the ISLANDS wing picture the aforementioned The ISLANDS center will comprise Multi-Access Server (IMAS). This view is presented: the following components: server will comprise a wide range of As it is shown in this picture any information technologies and will user can have access to the IMAS • The Knowledge Management offer to the users the opportunity to regardless of whether he is using Organiser (KMO), which is responsi- have a universal, user friendly and GPRS, telephone connection, ISDN ble for handling and operating all the cost-effective access to the ISLANDS lines, Internet connection or some incoming and outcoming data. Services and Architecture for the ISLANDS System: Towards a Modular Non-Conventional Telepsychiatry System 84

• The ISLANDS agents. Some of the ISLANDS agents are in charge of communications with the different user terminals integrated within the ISLANDS centre (named communi- cation server agents) and other agents are in charge of data analysis and pro- cessing (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 ran- ge of potential users. The access rights will differ for each user group. Figure 4: Initial approach of the ISLANDS system architecture Therefore, only medical doctors will have access to the reference cases, so which is accordingly converted into a Telephone as to prevent other users from making WSP response. wrong assumptions for their own In both cases the user can have This type of connection will be case. However, everyone will have access to the ISLANDS services and, applied to services I,II, IV and V (as access to the included lists of availa- thus, be consulted on-line from the indicated in table 1) where the impor- ble treatment, tools and Centres of project’s web portal. In this way the tance of the data transfer is low and Excellence at worldwide scale. user will have the opportunity to find the communication between the doc- • The various user terminals. all the required information for scree- tor and the patient or the informal The following figure describes ning, counselling and treating people carer can be held through speech. the functionality of the different with mental disorders, help their Additionally, the telephone has the agents and generally illustrates the families to be able to support them advantage of being interactive and operation of the ISLANDS system. In and give the professionals the neces- therefore can be extremely useful in this picture two different ways of sary tools to cope with a similar situ- cases of emergency such as a crisis accessing the ISLANDS center are ation. incident. presented: Telepsychiatry and e-mental The telephone is a common, but • Using high computing power health in general can be accomplis- underrated, communication technolo- through ISDN or PTSN connection. hed using various technologies. A gy. Despite the availability of a varie- In this case the user is connected via number of services can be delivered ty of sophisticated systems that can the web browser to the ISLANDS through a web portal (such as access support telemedicine applications server by making an XML, HTTP, to a database of case studies). Howe- such as conference calls, voice mail, HTTPS request (URL). The server ver, the ISLANDS project aims at good quality global audio connec- gives an HTTP response (HTML) to providing additional services as well tions and other forms, the plain old the user. to the end users. Among the most telephone system is the first line of • Using low computing power important and useful ones are those defense for handling clinical opera- through wireless network such as that can be handled through the com- tions. Unfortunately, this kind of GPRS, GSM connection etc. In this mon technologies, such as the tele- communication lacks in visual con- case the user sends a WSP request phone, the Internet, the Computer tact and the patient’s rehabilitation (URL) to the ISLANDS center, which conferencing and the videoconferen- consultations often require visual is converted into an HTTP request cing. Following more information feedback before an informed decision (WML) by the WAP Gateway Proxy, about the aforementioned technolo- can be made. However, as already in order to gain access to the gies are presented analytically [4]: mentioned above the telephone can ISLANDS server. The server provi- be essentially useful in crisis situa- des the user with an HTTP response tions) [3]. Amditis, Lentziou, Panou, Bullinger, Bekiaris 85

Regarding the technical characte- program, transfer data files between the message, and can be configured ristics the telephone provides optimal sites and some kind of conversation by sending a reply confirming that the function in many cases. In other namely chat [5, 14]. message has been opened [6, 16]. cases, noise in long-distance telepho- The number of functions availa- When it comes to conferencing ne lines can cause the system to fre- ble on a system depends on the com- through Internet several issues are quently lose the connection. The tele- puter hardware and software. Almost raised. One of the main factors that phone usually comprises the follo- all desktop conferencing solutions affect communication system perfor- wing features: can display still images, receive audio mance is the type of connection that • Supports home-based e-mental and live-video, provide a share work exists among the computers. A local health. space, and allow you to type messa- call to an Internet provider can result • Has a low cost regarding instal- ges between sites. Let’s have a closer in a more reliable connection since lation, equipment and maintenance look at these conferencing features. data lines for Internet traffic are often issues. better than long-distance telephone • The installation is usually paid lines. People with a faster Internet by the user. connection can take advantage of the Internet Ð Mail better performance while still being able to connect to people with a slo- This type of connection will be wer communication link. An Internet Desktop / Computer applied to services II and V where the connection also has the advantages of Conferencing importance of the data transfer is low allowing multipoint conferencing and what is usually required is the (i.e. more than two people participa- Recent technological advance- exchange of text between the profes- ting in the meeting) [7, 8]. ments in computer graphics, enginee- sional (doctor) and the patient or Generally, the use of the Internet ring, video production, and Internet informal carer. Internet and specifi- technology comprise the following communications can be used to pro- cally email can be used for the cases features [9, 15]: vide visual feedback and multimedia of screening a patient or helping in • It is mostly store-and-forward. clinical interactions. Computer screening a patient’s condition. In no • It has usually low quality while systems that provide these features case, can this type of connection be transmitting videos. are often referred to as computer con- used for diagnosing or therapy purpo- • It is easy to access and use. ferencing systems or desktop con- ses. • It is mainly home-based. ferencing systems. Emails do not interrupt research • The costs either for installing or Personal computer-based con- meetings or patient consultations. for using it are medium. ferencing systems are the most cost They do not need an immediate reac- • The installation is usually paid effective way of sharing video and tion as a phonecall does, even for by the user. audio information between sites. extremely incidents that do not requi- Even the lowest cost, new, personal re direct and immediate treatment. computers are capable of handling Emails can cope with a prompt type live video and sharing software appli- of communication with no interrup- Videoconference cations. In fact, the main limitation tion at all. It is mainly for informato- for desktop conferencing is the tele- ry purposes, such as notifying the This type of connection will be communication line capacity – not doctor about the patient’s condition applied to services III, VI, VII and IV the capabilities of the computer or requesting advice from a profes- where the importance of the data system. Desktop computer conferen- sional on how to proceed with a spe- transfer is intermediate or high and cing systems should handle most of cific problem. Email content can be there is a very urgent need for the the tasks associated with a remote noted without having to reply imme- exchange of text, speech and video. consultation; however, high-end diately, something which is very use- These cases aim mostly at helping the video conferencing systems are cur- ful in cases where thinking time, or professional to handle a situation and rently required to display full-screen, communication with someone else include giving advice in screening/ television like, video. before replying, is worthwhile. Addi- diagnosing a patient, counseling and Most desktop conferencing pro- tionally, putting together an email giving therapy/treatment according to ducts have the same basic function gives many more potentials for prio- the patient’s condition. set; such as show live video from the ritising, both information and There are mainly three types of other site, capture and display still demands for input. Most email videoconferencing [3]: images, annotate images on a shared systems have the ability to send a Person to Person: This is the sim- work space, jointly use a computer report if there is a problem delivering plest form of conference where two Services and Architecture for the ISLANDS System: Towards a Modular Non-Conventional Telepsychiatry System 86 computers connect directly with each where it is very difficult to reach ble for connecting the Hospital with other using a specific conferencing otherwise, such as countries where the remote area. The terabit network software. All that one has to do is type telecommunications are unavailable router (TNR), which intermediates in the IP address of the person or class or unreliable. The M4 service is opti- between the hospital and the local he would like to connect with for a mized to work with the Integrated server, achieves terabit-level aggre- conference. Much the same way one Services Digital Network (ISDN) gate routing capacity in a carrier-class would dial up a friend on the phone. available in many countries providing system. It distributes the path of pak- Group Conference: This is where high-speed data connectivity at 64 kets between large numbers of rou- many people can participate and col- kbps from the individual mobile ting engines connected via a distribu- laborate. To do this, each person or satellite terminal linked through the ted, linearly scalable switch fabric. It class has to connect to a site that is ISDN to the final destination. can house 16 K processing nodes in running a specific software. The con- Through an ISDN connection the 64 open racks arranged in four rows nection is made by typing in the IP inherent problems of analog circuit- to achieve an aggregate routing capa- address of that software. The soft- switched data transmission are avoi- city of 2.4 Tb/s. The local Lotus ser- ware receives everything that is trans- ded and at the same time much higher ver has the capability to connect mitted by the group and then trans- data throughput is achieved. Surely, through ISDN or Internet or even mits it to the others in the group the possibility of analogue connec- through an analogue network to anot- Broadcast: This is way of con- tion through the INMARSAT satellite her Lotus server and retrieve infor- ferencing is much like television. One still exists. In short, Inmarsat-M4 ser- mation from it. computer which is running a particu- vice extends a company's (or a hospi- The TT-3080A Messenger is a lar software transmits audio and tal’s in our case) WAN (wide area net- suitable for a portable high-speed video to all those who are connected. work) via satellite to the world's most data terminal, which enables fast Generally, the use of the video- remote regions, allowing worldwide worldwide communication. The 64 conferencing technology comprise accessibility. kbps bandwidth of the TT-3080A the following characteristics: In figure 5 the overall connection Messenger and the ISDN interface • It is singularly interactive, which of a remote area with a psychiatric makes it possible to browse on the means that the psychiatrist can have a clinic (or the psychiatric department Internet, connect to the Local or Wide direct contact with the patient and the of a general hospital) through the Area Network, transfer large files, person who is responsible for looking INMARSAT satellite is analytically transmit real time and store and for- after him. presented. This figure is taken as an ward video conferencing, send pictu- • It allows both document and example from Following, a descrip- res and images and broadcast quality record sharing and thus can be used tion of the various components that voice. This can be accomplished rela- not only for cases where the visual are necessary to manage the commu- tively easy by plug and play applica- contact is important but also for cases nication takes place. tions, which are easily connected to where the exchange of files (i.e. The satellite is actually responsi- the Messenger. 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/hospital- based. • The cost for the purchase and the installation of the equipment is often rather high. • The installation is paid by the provider.

Satellite

Infosat’s Inmarsat M4 service extends the functionality to places Figure 5: Overall connection through the INMARSAT satellite Amditis, Lentziou, Panou, Bullinger, Bekiaris 87

A portable station is needed in system. Therefore, it is extremely € (53 € for only communication order to manage the communication important to conduct a survey on the costs). The relevant cost through with the remote hospital. This station state of the art on the relevant techno- ISDN or PTSN connection is much has to fulfill some requirements such logy, before building the architecture lower, depending on the national pri- as to be a lightweight and easy-to-car- of telepsychiatry system. The pro- ce list. In Greece the relevant cost is ry terminal and to give the users the blems that are raised and that have to approximately 0.50 euros/minute for opportunity to get high-speed data be discussed and solved, to an extend, distant phone calls (without including services and PSTN (public switched before designing the system architec- a monthly fee of 5 euros). For wire- telephone network) quality voice ture are delays in the transaction of less telephony (e.g. PDAs, cellular connectivity. data due to the bad networking con- phones etc) this price is 0.10 nections and generally inefficiencies euros/minute (without including a in the functionality of the telecommu- monthly fee of 7.50 euros) on avera- nication systems, inadequate existing ge. Of course, in the aforementioned Concerns and obstacles: applications in the telemedicine area cases one has to add the expenses for Issues to be taken into that could be used as term of referen- the purchase of the equipment, its account ce, lack of existing relevant telecom- installation and its maintenance. For munication infrastructure and user videoconferencing systems these There are multiple and various friendly interfaces and nihility of expenses are extremely high and can- constraints and obstacles related to tele-support systems flexible enough not be paid by the patient. However, the introduction of e-mental health to cover the various needs and featu- even in this case the expenses are out- into the remote areas of Europe, res of the different end users. balanced from the face-to-face ses- which have to be taken into conside- Additionally, there are issues rela- sions between the psychiatry and ration while setting up an e-mental ted to the installation of the telematic people who leave in remote places, health support system [10]. While the equipment that have to be taken into since then travel expenses are high introduction of e-health is not recent, account. Setting up and installing a enough and must also be encounte- since its implementation has started system like this in remote areas and red. What still has to be examined is many years ago, e-mental health is specifically in unapproachable who will have to pay for the equip- still in an early stage of its evolution. islands is a complicated and at the ment i.e. the patients and their fami- This means that there are various same time challenging subject, which lies or the hospital and the Health restrictions and practical problems however provokes a number of pro- Ministry and the related public sec- that arise from the establishment of e- blems. Most of the pilot sites within tors? mental health sessions. Namely, there the ISLANDS project are areas that Regarding the Human related are constraints related to the installa- can only be accessed by boat, which issues that were previously mentio- tion of the relevant equipment, the makes the installation of the relevant ned, statistically, patients appear wil- cost-effectiveness, the reliability of system even more demanding and ling to accept e-psychiatry, after the system while transmitting the rough. What is more, the various geo- having used a telepsychiatry or rele- data, the e-mental health acceptance graphical scenarios and characteri- vant system [12]. However, the pro- not only by the average people but stics of the different areas pose a lot fessionals (in our case the psycholo- also by the professionals, the need for of problems that have to be thorough- gists/psychiatrists or the general prac- telepsychiatry in the specific pilot ly examined before purchasing the titioners) are reluctant to accept the sites along with the assessment of the different components and construc- introduction of the concept of e-men- potentials and advantages that come ting the telepsychiatry system. tal health. Their concerns focus main- from its use and the different needs Moreover, there are cost related ly on the ethical issues having to do that the different target groups have. issues that have to be taken into con- with the medical data security and Above all however, the national and sideration [11]. An appealing and confidentiality and the fact of recei- international legal, ethical and orga- attractive system has to be cost effec- ving hardly any compensation for the nizational framework should be ensu- tive, which mainly means that it will effort they devote to their work red. All the aforementioned ideas will provide the users with services that in through the tele-appointments. Sure- be thoroughly explained in the follo- comparison to face-to-face psychia- ly, a significant part of their resistance wing lines. try will be economically preferable. to the e-mental health applications As resulted from the aforementio- As already examined and experien- occurs due to their inability to con- ned topics, the existing equipment in ced by one of the ISLANDS pilot front with the new rules and general- terms not only of hardware, but also sites (i.e. the French Pilot in Martini- ly to their inflexibility to comply with of software, predefines the structure que), the cost of a tele-consultation by the technological evolution, which in and the design of a telepsychiatry INMARSAT M4 satellite today is 78 many cases corresponds to time con- Services and Architecture for the ISLANDS System: Towards a Modular Non-Conventional Telepsychiatry System 88 suming training lessons [10, 13]. tions have been given regarding the [8] Kennedy C, Yellowlees P. A community Thus, a telepsychiatry system should various ways of establishing e-mental based approach to evaluation of health outcomes and costs for telepsychiatry in be designed in a way to attract mostly health. Finally, an extensive reference a rural population: preliminary results. J the professionals’ interest more than has been given to the different kind of Telemed Telecare 2000;6:S1:155–157. alluring the patients or their carers. technology, namely the Internet, the [9] Evolution Of Telehealth To Ehealth And Finally, the ethical, legal and telephone, the videoconference and Onto The Internet Why It Must Happen! Linda Weaver, P.Eng., M.B.A, F.E.I.C, organisational framework that was the computer conference. C.C.E Chief Technical Officer, TecK- mentioned in the first paragraph of In the short-term future the work nowledge Healthcare Systems, Inc. this section involves issues related to will be centered on examining the [10] Deliverable 1.2: “Treatment scenarios the security and the confidentiality of various users’ needs and characteri- and preliminary specifications” of the ISLANDS project, A. Bullinger, K. the medical records and data in gene- stics within the different pilot sites Estoppey, M. Kottlow, C. De las Cuevas ral, the policy and the strategy that and defining the different key actors’ Castresana, U. Meise, H. Sulzenbacher, will be followed and that in many role towards the design of a modular P. Doubek, A. Kott, A. Charles Nicolas, telehealth applications it is not well and flexible telepsychiatry support M. Michalon, N. Ballon. [11] Trott P, Blignault I. Cost evaluation of a defined, the insurance conditions system. A risk analysis study and an telepsychiatry service in northern towards the safeguarding of the analysis of the security-related issues Queensland. J Telemed Telecare 1998; patients rights in case that the tele- will also take place towards the deve- 4: 66–8. sessions do not result in the desired lopment of the system. Finally, the [12] Zarate CA Jr., Weinstock L, Cukor P, Morabito C, Leahy L, Burns C, Baer L. outcome, the legal consolidation of communication services definition Applicability of telemedicine for asses- the professionals that will be using and requirements, the access services sing patients with schizophrenia: the telepsychiatry systems and finally specifications and the geographical Acceptance and reliability. J Clin Psy- issues that deal with the financial scenarios will be thoroughly analysed chiatry 1997;58: 22–25 [13] Mielonen ML, Ohinmaa A, Moring J, matters, such as the high cost of the and described. Isohanni M. The use of videoconferen- relevant equipment. cing for telepsychiatry in Finland. J Telemed Telecare 1998;4:125–131. [14] http://www.rcpsych.ac.uk/college/ sig/comp/docs/connectJune02.pdf References [15] http://www.rcpsych.ac.uk/college/ Conclusions sig/comp/docs/connectMay03.pdf [1] Using Communication Technology to [16] http://www.coh.uq.edu.au/coh/ resour- The establishment of psychiatry Enhance Rehabilitation Services, A ces/reports/Email%20Guidelines.pdf Solution Oriented Manual, Edward sessions through the use of electronic Lemaire, PhD Institute for Rehabilita- means, such as e-mail, Internet, tele- tion Research and Development, Terry phone, videoconference and other Fox Mobile Clinic, The Rehabilitation Dr. Angelos Amditis Centre, Ottawa, Ontario, Canada technologies is a complicated task, Institute of Cummunication and [2] State-of-the-Art Telemedicine/Telehe- since it raises many questions regar- alth: An International Perspective, Computer Systems ding its feasibility and faces many RASHID L. BASHSHUR, Ph.D., Irron Polytechniou 9, Str. SALAH H. MANDIL, Ph.D. and problems that have mainly to do with 15773, Athens the users’ needs and acceptance and GARY W. SHANNON, Ph.D. [3] Wittson, Cecil L, and Benschotter, RA: Greece several technological constraints and Two-way television: Helping the medi- e-mail: [email protected] barriers. Issues related to legal and cal center reach out. Am J Psychiatry ethical matters come also in light. It is 1972;129:136–139. very crucial that all the aforementio- [4] Yellowlees P. The use of telemedicine to perform psychiatric assessments under ned parameters be well studied and the Mental Health Act. J Telemed Tele- defined before building the architec- care 1997;3:224–226. ture of the ISLANDS system. [5] Dongier M, Tempier R, Lalinec- Michaud M, et al. Telepsychiatry: Psy- chiatric consultation through two-way The discussion was focused on television: a controlled study. Can J giving information about the services Psych 1986;31:32–34. that will be delivered to the end users [6] Houston MS, Myers JD, Levens SP, through the ISLANDS project and McEvoy T, Smith SA, Khandheria BK, Shen WK, Torchia ME, Berry DJ. Clini- providing details concerning the des- cal consultations using store-and-for- cription of the architecture of the ward telemedicine technology. Mayo ISLANDS system. The state of the art Clin Proc 1999;74: 764–769. of the telemedicine applications was [7] Grigsby B, Brown N. Report on US tele- medicine activity. Am Telemedicine analytically presented and many solu- Service Provider 1999. Neuropsychiatrie, Volume 18, S 2, 2004, page 89-92

Original Towards the Development of Tools for Remote Interventions

Maria Panou1, Evangelos Bekiaris2 and Angelos Amditis3

1TransEuropean Consulting Unit of Thessaloniki, Thessaloniki 2Center of Research and Technology Hellas, Hellenic Institute of Transport, Thessaloniki 3Institute of Communication and Computer Systems, Athens

Key words cognitive-behaviour therapy. Also, it tools, case studies database and expert tool, database, case studies, PC is possible to build an excellent thera- expert tool. tests, interventions. peutic alliance in videoconference Tools for remote [1]. interventions Towards the Development of Tools for Remote Interventions Therefore, tools to support tele- The users of the tools are divided In this paper the need for com- psychotherapy are needed, such as in two groups: puter-based tools to support web and the computerized ones developed - Informal Assistant or Patient teleconference-based interventions is within ISLANDS project and descri- (IAP); presented, followed by the short spe- bed. - Professional Assistant (PA). cification of three such tools, namely PC-based assessment and training As informal assistants, members tests, a case studies database and a of the family of the patient may be knowledge-based expert tool. These Islands project considered, while professional assi- tools are appropriate for professional stants are the psychologists or other assistance of patients with light Some regions in the European experts. degree psychiatric disorders (anxiety, Union are behind the average socio- depression, etc.). Specifically for the economic development of Europe. As it is expected, different user database, the content, search criteria, They are in remote areas, where with types will not have access to the same data collection forms and fields are a lack of access to modern health care tools, in order not to allow patients or explained. Also, the concept and pro- facilities, especially psychiatric and their family members make wrong cedure to develop the knowledge- cognitive-behavioural therapies are transfers and extrapolations to their based tool is analysed. Finally, the lacking. Furthermore, epidemiologi- own case. Below follows the descrip- paper presents in a schematic dia- cal data suggest that anxiety disor- tion and architecture of assessment gram format the interrelated use of ders, depression, drug addiction and and training tools, the database of these tools, for the operation of the psychosomatic disorders often occur case studies and the expert tool being remote intervention, including dia- in any population. developed within ISLANDS. gnosis, counseling and therapy. ISLANDS is a EU co-funded pro- ject, encompassing 12 partners form Introduction 12 European countries, including Computer assessment experts in expert tools development, and training tools Studies have shown feasibility of remote clinics, and communication telehealth for mental health in gene- media providers. The project aims to A set of computer assessment and ral. Specifically, a research in Mani- cover the gap of healthcare in the area training tests will be designed, to waki, Canada aimed to compare the of psychiatry in remote areas, through deliver the web-based interventions effectiveness of a validated treatment the development of remote services and evaluate their progress. The ove- delivered through videoconference in diagnosis, counselling and treat- rall design principle will be the inte- and in face to face. Results revealed ment of relevant disorders. One of its gration of specific interactive and that telepsychotherapy seems as main objectives and innovations is situational information with standar- effective as face to face for panic the development of computerised dised and validated assessment tools, disorder with agoraphobia and for tools, i.e. assessment and training leading to specific pathways of hand- Towards the Development of Tools for Remote Interventions 90 ling the respective situation, delive- ring 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 deli- ver 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: Figure 1: ISLANDS services diagram. - 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 appro- priate for people without good PC knowledge and expertise) and navi- gation tools. Currently, the develop- Figure 2: Start page of the database. ment work is focused on the inclusion of different UI’s to support different - Description of tools to deliver levels of services and categories of those interventions (especially the users (i.e. different patient types, ones to be developed within family members, local doctors). Both Case studies database ISLANDS) and a short Manual password and security software and for them. public domain areas and chat forums It is about an on-line database, - Use cases. are foreseen. accessible via the project web site. - Centres of Excellence. This database is under development, Finally, an automatic system will encompassing a userfriendly and The role of the database in the be developed, to analyse the user’s modular interface and a multi-criteria complete services concept of IS- answers, calculate their scores, com- search engine, to be useful to the PA. LANDS is depicted in the following pare them with the inclusion cut-off A search engine software is included, scheme (in the diagram, it is also cle- scores and inform the participants if allowing the user to search the data- ar how the expert system is involved they are accepted. This will continue base by selecting a specific keyword – see next section) (Figure 1). to monitor their progress and will from a predefined list. report it to their carers. Thus, the Personal Assistant will The database includes: have to login (emphasis is given to - Description of existing and new the security of the system) and if assessment/training interventions. accepted by the system, he/she will be Panou, Bekiaris, Amditis 91

and pencil, PC-based database of test cases) and treatment assessment indi- cators, 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 formula- ted 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.

The reason that an expert tool is useful, especially in the area of medi- cine, is that it can support the local Figure 3: Centres of excellence ‘results’ user interface. and maybe nonspecialised psycholo- gist and can compose the knowledge and experience of more than one experts, offering better reliability [3]. Furthermore, such a system can pro- vide the explanation for its decision, offering to the user an understanding and resolving possible questions.

The expert system will be consti- tuted by a team of programs that can be separated in three categories: • the core, • the interconnection and, • a set of support programs.

The structure of the ISLANDS expert tool is shown in the diagram of Figure 4: Graphical presentation of the structure of the ISLANDS expert system. Figure 4 [2]. able to access the following areas: with available information. The follo- The core of the Expert System - expert tool; wing figure shows the result page for constitutes of the knowledge base and - database of patients and PA data; the field ‘Centres of Excellence’ the inference engine. The knowledge - discussion forum for PA only; (Figure 3). base stores facts (data, information) At the end of the project, the data and rules regarding the knowledge’s - discussion forum for IAP; field of a specific particular disorder - diagnosis; base will be available in three that it will help in the proposition of a - counselling; languages (English, French and Ger- specific treatment and use of certain - therapy; man). tool(s). The inference engine deals - case studies. with the solution of the problem and constitutes of various subsystems. The introductory user interface of This engine is in charge of the the database is shown below (Figure 2): Knowledge-based expert management and the knowledge con- tool trol that is found stored both in the After selecting one of the four knowledge base and in the working possible fields, the user has access to One of the major project risks is to memory of the program, aiming at the the ‘search’ page of the selected field, offer to the expert an abundance of configuration of conclusions. Its or he/she can view all entries in this communication media (i.e. voice and main parts are the interpreter and the field. Then, the ‘result’ page appears face-to-face contact) tools (i.e. paper scheduler. The interpreter deals with Towards the Development of Tools for Remote Interventions 92 the implementation of selected - definition of the intervention design of the tools may be indicated actions applying in the knowledge success criteria and subcriteria and appropriate modifications will be base corresponding rules, aiming at (per intervention phase); realised for their optimisation. the production of knowledge. The - definition of the intervention scheduler is the sub program in char- phases for each service; ge of deciding the strategy for the - definition of thresholds for the control of the system. It deals with the above criteria; References observation of the order of imple- - specification of measurements mentation of ac-tions and calculates of those criteria; [1] ISLANDS 1st International workshop, the results of the application rules, - correlation of each intervention Stephan Bouchard presentation, Prague, September 2003. based on determined priorities given with relevant reference case from [2] John Durkin, “Expert Systems Design or other criteria (a list that contains the case studies database; and Develop-ment”, Prentice Hall Inter- their rules to be executed). - correlation of this intervention national, inc 1994, USA. with any other relevant one (i.e. [3] Vasiliki Dimitroula, “Expert system for the diagnosis of eye diseases”, Master The interconnection with the user check if also the relatives of the dissertation, December 2000, Thessalo- implements the communi-cation bet- patient or his/her local doctor are niki, Greece. ween the user and the system. The using the relevant services of [4] Donald A. Waterman, “A Guide to data is imported to the system based ISLANDS and synchronisation / Expert Systems”, 1986. on questions and answers from the correlation of those services and system to the user, i.e. questions their out-comes); about the symptoms of the patient and - application of best practice and Dr. Evangelos Bekiaris the result of specific tools that the knowledge-based rules for the Posidonos 17, patients have been examined with, as intervention, from a group of 17455 Athens, paper&pencil tests, PC-based tests, selected experts of the Partners. Greece etc. Also, information may be acqui- E-Mail: [email protected] red through specific databases of The above expert tool will be patients data and progress status. All firstly developed, based upon the cur- these are called the ‘Support tools’. rent level of knowledge and then it The communication is implemented will evolve with the project. Of cour- through the use of a friendly graphi- se it is not aimed to substitute the cal user interfaces. carer or even totally guide each type The successive stages of the de- of service, but only to assist the carer velopment of the ISLANDS ex-pert in managing the service progress and system is given below [4]: monitor key service assessment para- 1. Analysis and determination of meters and milestones. the main parameters of the pro- blem. 2. Knowledge Acquisition. - Knowledge Elicitation. Conclusions - Knowledge of Analysis. 3. System Design. All the tools described above will 4. Implementation. be validated in three countries, namely - Prototype development (know- France, Greece and Spain, with 70 ledge verification from the patients, 35 family members and 7 specialist). local doctors in each one and an equal - Debugging. number of persons to act as the control 5. System final validation. group. The selected users will suffe- - Validation by the developer. ring from the following disorders: - Users Evaluation (during the - psychotic disorders, project pilots). - agoraphobia and other phobias, 6. Final system optimisation. - depression, and - alcohol abuse. For the expert tool to be devel- oped , a list of actions has to be reali- Based on the results, some proble- sed in advance, namely: matic areas on the functionality or the Neuropsychiatrie, Volume 18, S 2, 2004, page 93-99

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 Center of Applied Technologies in Mental Health, Dept. of Psychiatry, University Basel 2 Center for Research and Technology Hellas, Hellenic Institute of Transport, Thessaloniki 3 Center for Online Mental Health, Dept. of Psychiatry, Medical University Innsbruck

Key words Introduction recommendations are available from eMentalHealth, eHealth, telepsychiatry, a number of public websites such as telemedicine The ISLANDS project forms a http://www.realage.com. part of the field of eMentalHealth, While the “first generation” of The ISLANDS Treatment Scena- which itself is embedded in the rather eHealth applications primarily offe- rios and Service Batches wide field of eHealth. red information and support, at pre- Traditional eHealth applications The technical term “eHealth” sent increased access to practitioners followed the classic top-down appro- refers to all forms of electronic and direct service delivery is offered ach: from medical authority to the healthcare delivered over the internet [3, 4, 5]. patient. With the Internet coming into (e-mail, chat room and interactive Internet-based technologies are the equation, patients gained immedi- websites), through the telephone, by now converging with satellite and ate access to global medical databa- television and videoconferencing, fax cable television for full interactive ses and information sources. Conse- and message boards, ranging from broadcast capabilities delivered quently, patients are taking more inte- informational, educational and com- through one, seamless technology. rest in and more responsibility for mercial products to direct services Professionals and patients are able to their health-related decisions while offered by professionals, non-profes- interact over the Internet in a secured relying less upon individual medical sionals, business or consumers them- environment. With continued impro- professionals. selves. With telemetry even the moni- vement in security and quality of Also mental health patients are toring of physiological functions healthcare websites, consumers and increasingly presenting themselves (blood pressure, respiration, and body practitioners were able to increasin- for diagnostic advice or even treat- temperature) has become possible. gly rely upon eHealth to provide ment, sometimes literally armed with Telemedical transfer of images (tele- accurate clinical data and support. information they found in web-based radiology, telepathology, telederma- EMentalHealth is not only one of sources. Furthermore, patients as well tology) has as a purpose for medical the main applications of eHealth [6], as their significant others are also hel- data interpretation and diagnosis. but moreover, one of its most suc- ping themselves and each other, with Furthermore, the development of new cessful applications [7, 8]. It mostly or without the involvement of profes- technologies within the last years led consists of diagnosis, screening, sionals. to some new fields of application as, counselling, consultation, education The ISLANDS project is directly for example, medical education [1]. and therapy through telephone, vide- aimed at providing relevant tests and A central focus of eHealth is the oconferencing and internet-based tools for these mental health patients, development of low-cost and conve- eMentalHealth. together with experts’ knowledge, nient supportive communities that diagnostical and supervisional exper- focus on a wide range of issues [2]. Specialized groups offer support tise for professionals working with People can anonymously join a sizea- for almost every type of mental disor- these patients. ble online community to share perso- der (e.g. trichotillomania) or life cir- As patients do change, so will nal information to a depth that is cumstance (such as divorce), as well professionals have to change further. unprecedented in the face-to-face as support for friends and family [9]. They will need to become more spe- world. Behavioural healthcare practitio- cialized and learn to accommodate Some websites provide virtual ners are already using computers to their newly empowered patients, rat- communities, chat rooms for personal take histories, fine-tune diagnoses, her than expecting to be the unque- issues and discussion hours with pro- monitor progress, and maintain thera- stioned expert. fessionals. Behavioural and lifestyle peutic contact through email. The The ISLANDS Treatment Scenarios and Service Batches 94

Internet is used as a virtual office to provide interactive consultations [10]. User Diagnosis Counselling Therapy EHealth is including more and more interactive services and the vir- Patients Service No. I Service No. II Service No. III tual office will become an integral part of psychiatric practice. Informal carers / Service No. IV Service No. V Service No. VI The aim of the ISLANDS project, family Seeking… Information on… Information on… Information on… concerning eMentalHealth, is to crea- te and distribute services that add Professionals Service No. VII Service No. VIII Service No. IX value to the field of eHealth, especial- Seeking…. Expert opinion Supervision on… Expert opinion ly the delivery of resources that sup- on… and/or supervision on…. port the development and manage- ment of psychiatric services for Table 1: Mapping of ISLANDS user groups and service levels 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 psychothera- peutic 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 over- weight the costs of implementation and service support by far. The pro- ject will reduce inequalities in mental health services and status among European regions.

Description of the ISLANDS service batches Figure1: General Scheme of ISLANDS Treatment Modules

The treatment scenarios consist in Login, access and use rights to be validated by the administration the specification of nine categories of the ISLANDS services system which will address the needs of possi- To give a thorough description of prior to the assignment of specific ble users in the psychiatric and/or this scheme, we will start with the access rights to the then known user. psychotherapeutic field (see next box on the left upper corner: As soon These specific access rights will table): as an unknown user tries to log into always be restrictive in part, as for According to different mental the ISLANDS system, an automated example a patient has no business of health problems (phobia, depression, screening process will start. This scanning the information given in the alcohol-related disorders and psycho- screening will be unspecific and ser- supervision submodule of the tic disturbances) each category will ve as an identifying process with ISLANDS services and vice versa. comprise modules to help users suffe- respect to the unknown user. Next to ring from or concerned with this pro- all personal unique identifiers (name, As soon as a known user identifies blem. Within this paper the numbe- date of birth, residence, etc.) clarifi- her-/himself via a pre-assigned login ring of Table 1 will be followed to cation will be sought to the essential procedure, this user will undergo spe- facilitate for the reader orientation question, whether the unknown user cific screening in case of first login and oversight within the various ser- seeks access to the system as patient, into the system or in case progression vice batches (Figure 1 shows). as informal carer or as professional. tests are due. Afterwards the user will The general scheme of the treat- As eMentalHealth applications hold be re-directed to the respective sub- ment modules foreseen for the most sensitive data, the information module (therapy, counselling or ISLANDS project. given by an unknown user will have supervision). Bullinger, Senn, Bekiaris, Meise, Mager, Müller-Spahn, Sulzenbacher 95

In a sense the user forum is an informal carers and/or family mem- As disorder-specific self-report exception to this re-direction process, bers) she or he will be directed to this screening measure for depression we as this will be an exchange forum Information Library where the des- recommend the BDI, alternatively mainly for the users themselves. In ired information can be looked up via also the CES-D or the Zung SDS this forum different user groups decision trees as well as via search could be used. might meet each other. In order to options comparable to those known We suggest using the AUDIT as prevent spreading of unwanted know- from web-based search engines. In disorder-specific screening instru- ledge (for example information on addition to that pre-categorized links ment for alcohol-related disorders, deadly eatable substances exchanged to further information on the respecti- which can be used as a clinician- between highly depressed and poten- ve subject in question will be offered. administered or a self-report test; if tially suicidal users) as well as gua- the test is clinician-administered, an rantee adherence to netiquette this Another subset of service batches optional clinical screening procedure forum will be moderated via the (concerning the batches VII to IX, containing a physical examination, a ISLANDS expert pool. services of professionals) can be set blood test, and two questions about The ISLANDS Experts Pool will aside separately insofar as these ser- traumatic injury can be added. The feed in knowledge into the therapy vices have to be real-time and require AUDIT is able to identify harmful or module, the counselling module and a individual counterpart at the respec- hazardous alcohol consumption, is the supervision module. The Experts tive ISLANDS center of excellence. highly correlated with other self- Pool will also moderate the user A professional seeking help with dia- reports of alcohol problems, such as forum, as mentioned above. In addi- gnostic or therapeutic problems, the MAST, and also significantly cor- tion to that, the ISLANDS experts requiring supervision in a therapeuti- related with biological indices. An will have the right to interact directly cal or counselling setting can not be AUDIT cut-off of 11 or higher with the ISLANDS database on two pointed to a referenced article or a (recommended by WHO) yielded different levels: mere database entry. These service sensitivity and specificity scores for a • Write data on themselves (fields batches therefore have to be capable DSM-III alcohol-related disorder of expertise, etc.) and users they of multimedia streams over the inter- assessed by the DIS of 0.84 and 0.71, take care of net (audio and video). respectively; a cut-off of 13 or higher • Read data stored in the database The service batches I to III, dea- yielded a sensitivity and specificity of - In clear text (open) data related ling with patients directly, have to be 0.70 and 0.78, respectively, which to users they take care of described individually: may be better for screening purposes. - Anonymised data related to all We recommend using the BAI as other users a reliable and well-validated measure of somatic anxiety symptoms found Service batch I: Diagnosis across the anxiety disorders and also Description of Service Batches for patients in depression. It is a short, self-admi- nistered scale and is simply scored. The numbering of the service bat- For diagnostic purposes disorder- The BAI is well suited for monitoring ches follows the numbers given in specific as well as disorder-unspeci- change with treatment. Because it is table 1. fic screening and testing instruments easy to administer and because data are needed. on non-clinical individuals are availa- A variety of these service batches ble, the BAI may be a useful scree- in terms of content deals with specific ning tool for unselected individuals in information and psychoeducational Disorder-specific screening instru- a general medical setting. Its simpli- materials rather than with direct and ments city also supports its potential as an specific advice for the respective administrative tool for documenting user. Within the ISLANDS project Basically most disorder-specific the performance of health care delive- these information-based service bat- self-report screening instruments ry systems in treating anxiety. – ches will be pooled into an Informa- show similar strengths and weaknes- However, it is important to note that tion Library: All materials dealing ses: They are usable for both scree- the BAI does not assess worry, a key with mental-health – related informa- ning and outcome measurement; they symptom of generalized anxiety tion as well as with psychoeducatio- show an overemphasis on so-called disorder, nor does it focus on other nal material in a more narrow sense core symptoms of the respective DSM-IV symptoms of generalized goes into this library. If a user of the disorder while underweighting the anxiety disorder, such as difficulty ISLANDS services requires access to more atypical symptoms of the with concentrating, irritability, or service batches IV to VI (services for respective condition. sleep disturbance. Therefore, it can- The ISLANDS Treatment Scenarios and Service Batches 96 not be considered a specific measure one-page Patient Questionnaire (PQ), Disorder-specific outcome measu- for generalized anxiety. It does not which is completed by the patient rement discriminate well among anxiety before he or she sees the physician, disorders or distinguish anxiety disor- and the nine-page Clinician Evalua- We propose to use the BDI not ders from anxious depression. tion Guide (CEG), which is a structu- only as a screening instrument, but No disorder-specific self-report red interview that the physician uses also as a disorder-specific self-report screening instrument for psychotic to follow up on items checked positi- outcome measure for depressive disturbances is available. As a clinici- ve on the PQ. The PQ is an initial disorders. an-rated tool the BPRS is frequently symptom screen for the mental disor- Our proposal as a disorder-speci- used, a scale which was initially desi- ders covered by the CEG. It consists fic alcohol outcome measure is the gned to measure symptom change in of 25 yes/no questions about signs RTCQ. This self-report test is easy to patients with psychotic illness. Thus, and symptoms experienced by the handle and does not require much the items on the BPRS focus on patient in the past month, plus an item time. It can show a change in a perso- symptoms that are common in referring to the patient’s overall n's perception of alcohol consump- patients with psychotic disorders, health. Fifteen items cover the majo- tion. As an alternative or complement including schizophrenia and other rity of somatic complaints seen in pri- the TLFB could be used. However, psychotic disorders, as well as those mary care; one item refers to abnor- the TLFB has to be clinically admini- found in patients with severe mood mal eating behaviour, two to symp- stered and requires more time. An disorders, especially those with toms of depression, three to anxiety advantage of the TLFB is its thera- psychotic features. The BPRS is desi- symptoms, and four to problems with peutical component, as it increases gned to be administered by experien- alcohol-related disorder. The PRI- the alcohol-related disorder’s aware- ced clinicians on the basis of infor- ME-MD is able to measure following ness of her or his pattern of alcohol mation obtained during a clinical ISLANDS-related disorders: depres- consumption as well as of the amount interview and from patient observa- sion (major depressive disorder, par- of consumed alcohol. tion. The BPRS has been successfully tial remission of major depressive As self-report tool for anxiety used to evaluate both inpatients and disorder, dysthymic disorder, proba- measurement we recommend the outpatients. The BPRS contains seve- ble minor depressive disorder), BAI. This scale allows us to measure ral general items (e.g., anxiety, ten- anxiety (panic disorder, generalized the intensity of anxiety symptoms the sion) and some relatively schizophre- anxiety disorder), and probable alco- patient is suffering from. Generally, nia-specific items (e.g., hallucinatory hol abuse or dependence. Finally, anxiety can be stratified in three behaviours, mannerism and postu- three rule-out (R/O) diagnoses are levels. A grand sum between 0 – 21 ring). included: R/O bipolar disorder; R/O indicates very low anxiety. A grand depressive disorder due to general sum between 22 – 35 indicates mode- medical condition, medication, or rate anxiety and a grand sum that Disorder-unspecific screening other drug; and R/O anxiety disorder exceeds 36 indicates high anxiety. instruments due to general medical condition, As the BPRS was initially desi- medication, or other drug. The final gned to measure symptom change in We suggest using the BSI as well diagnoses are checked off on a dia- patients with psychotic illness, we as the PRIME-MD as non-disorder- gnostic summary sheet. recommend its use also for measuring specific screening instruments for all During ongoing therapy outcome outcome. disturbances taken care of in the measures should be used to quantify ISLANDS project. The BSI is a short changes of the severity of symptoms version of the SCL-90-R, contains 53 and the treatment effects. We think Disorder-unspecific outcome self-report questions, and is able to that the interval between the single measurement measure depression as well as anxie- measurements should be approxima- ty disorders and schizophrenia (by tely 3 months, respectively. Conse- We recommend using the GAS means of the subscales "Paranoid ide- quently a person who will take part in and, alternatively or complementari- ation" and "Psychoticism"). The only our project over 3 months should be ly, the CGI as clinician-administered ISLANDS-specific disorder which tested two times, and a person who non-disorder-specific outcome mea- the BSI cannot measure is alcohol will take part over a year should be sures for all patients. A global assess- abuse. tested five times. Similar to the dia- ment of the patient's situation is pos- As an administered non-disorder- gnostical tools also in outcome mea- sible by using a Quality-of-Life mea- specific screening instrument we surement a distinction can be made surement. We propose the use of the recommend the PRIME-MD. PRI- between disorder-specific tools and QOLI for all patients. ME-MD has two components: the the unspecific ones. Bullinger, Senn, Bekiaris, Meise, Mager, Müller-Spahn, Sulzenbacher 97

Service batch II: Counsel- ded (e.g. marital and family counsel- offered during the ISLANDS project ling for patients ling, bereavement counselling, is not decided so far and needs to be school counselling, addictions coun- answered in D2.2 (ISLANDS service Counselling is a process that ena- selling, HIV/AIDS counselling, etc.). delivery content). There are several bles a person to sort out issues and At advanced levels of training, coun- manualised therapeutic approaches reach decisions affecting their indivi- selling has a greater overlap with on the market that can be easily trans- dual life. It involves talking with a Psychotherapy than at base levels. formed into net-based applications. person in a way that helps that person solve a problem or helps to create conditions that will cause the person Guided therapy for psychotic to understand and/or improve his Service batch III: Therapy disturbances behaviour, character, values or life for patients circumstances. It is important to The ISLANDS consortium will understand that counselling is not In this context therapy for patients not offer a guided – therapy module about giving directional advice. It is means self-help approaches. Thera- for these disturbances. Due to the spe- about helping and supporting a per- peutic approaches with a professional cifications of the illness itself, this son to find an understanding and ans- therapist available, the latter seeking seems to be not only prone to secure wers that work for that person. As advice or supervision concerning the failure but also unethical. there is a tendency to mix up counsel- therapy, are described in Services VII ling with psychotherapy, the follo- to XI. wing clarifications are needed: • Psychotherapy and counselling Limitations and specific are professional activities that utilise Guided therapy for depression risks an interpersonal relationship to ena- ble people to develop understanding One has to be cautious with gui- Although eHealth applications as about them and to make changes in ded therapy and other self-help a whole have proliferated in the their lives. approaches to depressive symptoms recent years, their diffusion and • Professional psychotherapists due to the comparably high risk of distribution has often remained quite and counsellors work within a clearly self-harming or even suicidal beha- low11, especially in the Mental contracted, principled relationship viour in these patients. Furthermore, Health area. The actual use of eMen- that enables individuals to obtain efficacy of internet-based self-helped talHealth has in many cases been far assistance in exploring and resolving programs without supervision by a less than what was anticipated. This issues of an interpersonal, intrapsy- local Medicare professional is que- led to the discussion of main cons- chic, or personal nature. stionable, to say the least, with major traints or barriers, which could contri- depression. There seems to be a bute to problems of implementation So although psychotherapy and favourable effect with mild to mode- and usage of eMentalHealth systems counselling overlap considerably the- rate depressive syndromes. and services. re are also some differences. The work with clients may be of consider- While patients appear willing to able depth in both modalities; howe- Guided therapy for alcohol-related accept eMentalHealth after they have ver, the focus of counselling is more disorders had some experience with it, (potenti- likely to be on specific problems or al) service providers show consider- changes in life adjustment. Psycho- There is a variety of internet – ably more reservations. The reasons therapy is more concerned with the based self-help programs for alcohol- for professional wariness are quite restructuring of the personality or related disorders [Toll et al., 2003, complex and range from self. Furthermore: Both, psychothera- Lieberman, 2003]. One of them will • ethical concerns about network pists and counsellors, work with a be adopted for the ISLANDS pro- security and privacy or the possi- wide variety of clients. Psychothera- gram. bility of harming patients with tre- pists are more likely to work very atment model/tools so far intensively, with more deeply distur- unknown bed individuals who are seen more Guided therapy for anxiety disorders • technophobia and lack of training frequently over a longer period of and familiarity with computer time. Counsellors are more likely to Similar to alcohol-related disor- aided systems work in specific areas where speciali- ders, the question which self-help • problems with time schedules and sed knowledge and methods are nee- program for anxiety disorders will be convenience The ISLANDS Treatment Scenarios and Service Batches 98

• problems with reimbursement for health care professionals have been effects. For the relationship between online work found to be inherently conservative. quality and eMentalHealth it is hel- to challenges to fundamental views Technological changes such as eMen- pful to consider Donabedian`s on professional roles within the Men- talHealth may contribute to conflicts, distinction between medicine’s tech- tal Health field. arising from the move towards the nical and interpersonal components. Because the challenges for eMen- emphasis on teamwork and collabo- The technical dimension refers to cli- talHealth are of human rather than ration. nical processes of care (e.g. diagno- technological variety the main focus Effective eHealth consultations sis, treatment or follow up) and out- in the following consideration is on require a degree of collaborations and comes (e.g. health status or quality of this topic. teamwork between different occupa- life); the interpersonal dimension As a new medical practice, eHe- tional groups. An organization which refers to social and psychological alth can be conceptualised as an inno- is small, complex and decentralized aspects of treatment (e.g. user satis- vation. Innovation literature can be has a potential to introduce eHealth faction and acceptance or doctor used to study why the diffusion or services, while a highly formalized patient relationship) [15]. eHealth remains comparably low. structure and centralization would Roger’s “Diffusion of Innovation have an opposite effect; especially if Theory” suggests that organizational, it is associated with a lack of resour- structural and cultural aspects affect ces and limited management support Conclusion health professionals perception of [13]. eHealth. The introduction of these Some countries require certifica- EMentalHealth made a mere start services affects existing work practi- tion for eMentalHealth practitioners in Europe so far. Nevertheless there ces and work flows. Therefore it is to be able to claim payments for their seems to be a reliable infrastructure at necessary to develop strategies for consultations. This certification pro- hand for its delivery and a broad ran- the introduction of eHealth applica- cess should be focused on ensuring ge of potential services has been iden- tions, which take into account the par- that clinicians have a good understan- tified. ticular structures and cultures of the ding of prevailing clinical, technolo- The main criticism of eMentalHe- individual organisations within the gical, and ethical practices. alth applications as well as eHealth different Mental Health care systems. EHealth supports also a cultural applications in general is that there Roger argues that an innovation is change, which is driven by the global would not be enough evidence of suf- more likely to be adopted, if it has consumers’ movement, where ficient substance to back assertions relative advantages and is compatible patients are insisting as being part- that it is safe, efficient and cost-effec- with existing values and needs. ners in their own care and being kept tive. These criticisms have to be met Tanrivedi and Iacono [12] explain fully informed. This new paradigm of by further specific research. with their “Extended Knowledge empowered clients requires also a Within the ISLANDS project the Barrier Metaphor”, which is based on substantial change of role and attitu- consortium opted for a more proactive Attwell`s “Theory of Knowledge de. Medical knowledge does not lon- strategy between the partners involved Barrier” that in addition to economic, ger represent the powerbase of health in order to ensure the consistency and organizational and technical know- professionals. In future they also have compatibility not only of infrastructu- ledge barriers also Mental Health to act as coach and consultant to their re, equipment and technological stan- professionals may resist the use of a patients. dards but also of data acquisition, new technology, which they do not Security and privacy are two core screening/testing methods/tools and understand, whose effectiveness on a requirements for any eMentalHealth evaluation methodologies, which will range of outcome variables requires consultation. All systems must keep allow comparisons not only between more research. For health professio- patient data secure; privacy is crucial the pilot sites but also across geogra- nals eMentalHealth is also associated for real-time data management, data phical regions and other eMentalHe- with a novel way of working and alte- storage and data forwarding proces- alth approaches from outside the rations of traditional roles, practices ses. There exist a number of docu- ISLANDS project. and relationships. This requires sub- mented ethical and clinical guideli- That way one of the major challen- stantial attitudinal changes. nes, which have been published by ges after the pilot phase of ISLANDS There are a number of structural different groups, covering this field will be to determine a way in which characteristics common to most [14]. eMentalHealth advocates could work health-care organizations, which together in the future, bring together affect technological innovations. Numerous eHealth evaluation fra- their experience and merge their data These organizations are usually cha- meworks have been proposed inclu- pools into a convincing and persuasive racterised by a hierarchical structure; ding comparisons of costs and body of evidence. Bullinger, Senn, Bekiaris, Meise, Mager, Müller-Spahn, Sulzenbacher 99

In addition to that we have to sta- [7] Hailey D, Roine R, Ohinmaa A. Syste- te, that besides cost, ethical, legal or matic review of evidence for the bene- technical issues, the implementation fits of telemedicine. J Telemed Telecare 2002; 8 Suppl 1: 1-7 of eMentalHealth services needs to [8] Hersh W, Helfand M, Wallace J, Krae- take account of the idiosyncrasies of mer D, Patterson P, Shapiro S, Green- the health service sector and the par- lick M. A systematic review of the effi- ticular structures and cultures of indi- cacy of telemedicine for making dia- vidual organizations; particularly if gnostic and management decisions. J Telemed Telecare 2002; 8(4): 197-209 the distribution of resources and [9] Salem D, Bogat GA, Reid, C. Mutual power is affected and potential chan- help goes on-line. Journal of Communi- ges in work practices may contribute ty Psychology 1997; 25(2): 189-207 to behavioural barriers between the [10] Maheu M, Whitten P, Allen A. E-health, Telehealth & Telemedicine: A compre- participating working groups or even hensive guide. New York: Jossey-Bass, individuals. 2004 (in press) In order to be successful, general- [11] Walker J, Whetton S. The Diffusion of ly speaking eMentalHealth providers Innovation: Factors Influencing the must focus on the needs of Mental Uptake of Telehealth. Journal of Tele- medicine and Telecare 2002; 8 Health professionals instead of for- (Suppl.3): 73-75 cing to fit existing technologies and [12] Tanrivedi H, Iacono CS. Diffusion of contents on these services, so not to Telemedicine: A Knowledge Barrier replace a consumer focused approach Perspective. Telemedicine Journal by a product focused approach. 1999; 5,3: 223-244 [13] Bullinger AH. Information Systems and The introduction of eMental- Organisational Structure. Dissertation Health services should follow a step- for the Master of Business Administra- by-step approach. EMentalHealth tion (MBA), University of Wales, Aca- should fit into the Mental Health care demic Press, Great Britain, 2001 system and be introduced in a balan- [14] Wootton R, Blignault I. Guidelines for Telepsychiatry and e-Mental Health. In: ced way. Therefore tailor-made solu- Wootton, Yellowlees, McLaren. Tele- tions have to be developed for each psychiatry and e-Mental Health; Royal cultural / geographical region in Society of Medicine Press Ltd., Lon- question. don, 2003 [15] Dillon E, Loermans J. Telehealth in Western Australia: the challenge of eva- luation. Journal of Telemedicine and Telecare 2003; 9 (Suppl. 2): 15-19 References

[1] Diepgen TL, Eysenbach G. Digital images in dermatology and the Derma- Dr. Alex H. Bullinger, MBA tology Online Atlas on the World Wide Center of Applied Technologies in Web. J Dermatol. 1998 Dec; 25(12): Neu roscience (COAT-Basel /PUK) 782-787 University of Basel [2] Wellman B, Gulia M. Net surfers don't ride alone: Virtual communities as com- Wilhelm Klein-Strasse 27 munities. 1995. HTML document avai- CH-4025 Basel lable on WWW at http://www.sscnet. Switzerland ucla.edu/soc/csoc/cinc Email: [email protected] [3] Borowitz SM, Wyatt JC. The origin, content, and workload of e-mail consul- tations. JAMA (United States) 1998; 280(15): 1321-1324 [4] Eysenbach G, Diepgen TL. Labeling and filtering of medical information on the Internet. Methods Inf Med. 1999; 38(2): 80-88 [5] Sleek S. Providing therapy from a distance. APA Monitor 1997, 1-38 [6] Lessing K, Blignault I. Mental health telemedicine programmes in Australia. J Telemed Telecare 2001; 7(6): 317-323 Neuropsychiatrie, Volume 18, S 2, 2004, page 100-105

Original Process Quality Analysis of Telepsychiatry: Contributions of Statistical Control Process and Critical Pathway Analysis

Carlos De Las Cuevas1 and Justo Artiles2

1Department of Psychiatry, University of La Laguna, Santa Cruz de Tenerife 2Economic Analysis Service, Canary Islands Health Service, Santa Cruz Tenerife

Key words Conclusions: The continuous try is worth the cost or whether it pays Statistical Control Process, Control Chart, quality improvement approach mini- for itself is more controversial, but Quality, Critical Path Analysis, Telepsychia- mised the working time and increa- the review of the literature have try, Telemedicine sed, in a systematic way, the produc- demonstrated that telepsychiatry can tivity of the telepsychiatry service be cost-effective in selected settings Process Quality Analysis of Tele- These achievements can diminish the and can be financially viable if used psychiatry: Contributions of Sta- total cost of the service, improving beyond the break-even point in rela- tistical Control Process and Criti- the relative cost effectiveness with tion to the cost of providing in-person cal Pathway Analysis respect to the conventional model. psychiatric services (Hyler & Gangu- Purpose: To describe the results of re, 2003). an innovative process quality analysis With the primary goals or benefits in a telepsychiatry routine service. of: improve access; reduce costs; Methods: The process assessed Introduction reduce isolation; and improve quality was “the teleconsultation of psychia- of care, the Canary Island Health Ser- try” along an evaluation frame time Telepsychiatry is the use of elec- vice (CIHS) developed a Telepsychi- of 1 year. A continuous quality impro- tronic communication and informa- atry Program, that began in year vement approach was applied, using a tion technologies, originally develo- 2001, to complement the mental statistical control process and critical ped to provide or support clinical psy- health care of the citizens living at El pathway analysis. The statistical con- chiatric care at a distance, that enhan- Hierro island The purpose of this trol process was developed using an ce access to mental health care for paper is to describe the results of an individual control chart. rural and underserved populations innovative analysis of process quality Results: The mean number of (APA, 1998). With the development after the first year of operation. The teleconsultations per session increa- of more technology and increasing process assessed was “the teleconsul- sed from 3.3 (SD = 1.2) in the first experience, it has become evident tation of psychiatry”. The quality of stage to 6.1 (SD = 2.4) in the second that the goal of telepsychiatry is much this process was evaluated through a stage. This improvement process did broader than originally designed and continuous quality improvement not have an important effect on the nowadays this welfare alternative is approach, of which the variables stu- variability of the process. The critical used in many countries and several died were the variability of the con- path implied 179 minutes per session mental health frameworks (De las sultation workload and the staffing and 33.81 (CI 95%: 32.58-34.96) Cuevas et al., 2003a). level rate of the telepsychiatry servi- minutes per consultation. The total In telepsychiatry, consumer and ce. The workload (of consultation or labour hours required by Telepsychi- provider satisfaction has consistently patients) is one of the variables that atry Service would be 172 hours for shown that this mode of clinical ser- most affects the cost effectiveness each professional (psychiatrist and vice delivery is widely accepted relationship (Bergmo, 2000; Mielo- nurse). Accordingly, labour require- (Gammon et al., 1996; Clarke, 1997; nen, 2000; Davis, 2001; Harno, 2001; ments were 0.104 of a Full-Time Urness, 1999), although only a few Lamminen, 2001; Simpson, 2001; Equivalent for each professional. number the studies carried out inclu- Wootton, 2001; Bjorvig,2002; Braca- This indicated that there was no addi- ded a measure of preference between le, 2002; Cabrera, 2002; Ohinmaa, tional impact of telepsychiatry servi- telemedicine and face-to-face consul- 2002; Valero, 2002), and therefore ce on staff requirements. Full-Time tation (Williams et al., 2001; De las this is a variable that must be monito- Equivalent of the psychiatrist in the Cuevas et al., 2003b). red. To do this, a statistical control conventional model was 0.116. The issue of whether telepsychia- process (SCP) was applied. SCP has De Las Cuevas, Artiles 101 been applied to the health sector in other instances and its use has resul- ted in improvements in efficiency and productivity (Laffel & Blumenthal, 1989; Benneyan, 1998; Alemi & Sul- livan, 2001; Caron & Neuhauser, 2001; Amin, 2001). In addition, the staffing level rate of the telepsychia- try service was evaluated using a cri- tical pathway analysis (CPA). CPA is an analysis tool, which helps to iden- tify the minimum length of time, nee- ded to complete a process with improved productivity and diminis- hed costs. Telemedicine provides an opportunity to implement a continu- ous quality improvement process.

Description First region Second Region Mean 3,3 6,1 Material and Method Standard deviation 1,20 2,40 Variation Coefficient 36% 39% Setting and description The Canary Islands form a Spa- Upper Control Limit 6,9 13,6 nish archipelago 700 miles far from Lower Control Limit * 0 0 mainland Spain. The Canaries consist * If the control limit < 0, then set the LCL = 0 of seven islands which have about 1.8 million inhabitants, 85% of them Table 1: Statistical description of control chart living on the major islands of Teneri- addressed by the SCP was: Can tele- (four sessions per month). fe and Gran Canaria. El Hierro, the psychiatry produce the same number 3. Data was recorded in SPSS smallest and most westerly of the of consultation than conventional 10.0. islands, has over 7,000 inhabitants. face-to-face model. 4. The control chart was construc- Until the introduction of telepsy- The Statistical Control Process ted using the following information: chiatry, the conventional model was a was developed using an individual 4.1. The mean value for the num- psychiatrist who travelled to the control chart. Figure 1 shows the ber of teleconsultations per session island every 2 weeks (2 visits per general format of control chart. In was calculated. month) to face-to-face consultations. general, the control limits are situated The telepsychiatry service provides above and below of the central line of psychiatric consultations through a distance of three times the standard videoconference to individuals based deviation (sd). For interpretation where, on a referral from general practitio- rules, the control chart is divided into ners via email. Telepsychiatry ses- six equal zones that fall between the Teleconsulation’s mean per session sions took place every Thursday (four Upper Control Limit and Lower Con- Number of session per year sessions per month). trol Limit. In our study, the target variable is Number of teleconsulation in the session i Statistical Control Process the “number of teleconsultations per Statistical Control Process is a session” and the statistical control is standardising technique used to redu- the mean number of teleconsultations 4.2. A moving range average was ce variations and achieve performan- per session. The steps taken in con- calculated by taking pairs of data ce benchmarks. In this way, a telepsy- structing the control chart were: (X1,X2),(X2,X3)…(Xn-1, Xn), chiatry service will be stable when it 1. First, the variable to be charted taking the annual sum of the absolute produces, in a consistent way, the was identified (number of teleconsul- value of the differences between them number of teleconsultations that tation per session) and dividing this sum by the number satisfies the demand of the resident 2. Second, the appropriate fre- of pairs. This is shown mathematical- population of El Hierro. The question quency of sampling was determined ly as: Process Quality Analysis of Telepsychiatry: Contributions of Statistical Control Process ... 102

or extraordinary occurrence in the Critical Pathway Analysis where process. Examples of special cause The Critical Pathway Analysis for might include changes in clinical pro- the telepsychiatry service was deve- Moving range average cedures, skill degradation, equipment loped through a multidisciplinary failure, new staff, etc (Bennayan, teamwork that includes psychiatrist, 1998). The interpretation rules used nurse and health economist. The Cri- 4.3. Upper control limit (UCL) and to detect special causes of variation tical Pathway was developed through low control limit (LCL) were calcula- are: the next steps: ted; where 2.66 is the constant used • One or more data points can be 1) Devise the protocol’s activities found above a UCL or below an of teleconsultation using the relevant LCL literature (Tachakra et al., 1997; Ben- •7 or more consecutive points eit- ger, 1999). her above or below the CL 2) Discuss, improve and prepare when individual measurements are • 14 or more consecutive points the definitive list of teleconsultation’s plotted. alternating up and down in a saw- activities. 4.4. Plot the data point, mean and tooth pattern. 3) Determine which activities control limits on the same graph •4 of five successive points on the immediately precede and follow each (Note: If the LCL < 0, then set the same side of the CL in zone b or activity. LCL = 0) beyond. 4) Identify the staff in charge to 5. The process was monitored •2 of three successive points on the perform each activity. distinguishing special from common same side of the CL in zone a 5) Estimate the duration time of causes of variation. Common cause • 15 or more consecutive points each activity. variation is the naturally occurring alternating above and below the 6) Draw a network with activities fluctuation or variation inherent in all central line, all of which fall wit- connected using numbers and arrows. process. Some examples of common hin zone c cause are: the time of the day, hospi- 6. Taking into account the above The times were measured using a tal case-mix, physical condition of (step 5), corrective action was taken job-cost sheet to record the duration patients, etc. Special cause variation to control the process and improve of the protocol’s activities. Finally, is typically caused by some problem productivity. the Full-Time Equivalent was calcu- De Las Cuevas, Artiles 103 lated. Full-Time Equivalent is the Results psychiatry were on a particular side percentage of time a staff member of the central line during February worked. A full-time person valued as Figure 2 and table 1 show the sta- and March. The special cause of this 1.00, a half-time person as 0.50 and a tistical control process using control variation was identified: The patients quarter-time person as 0.25. Full- chart analysis. Reference lines inclu- forgot to go to the consultation since Time Equivalent was calculated divi- de the mean value, ±1 standard devi- it was a new service. Once this was ding labour hours required per year ation (SD), ±2 SDs, and upper and identified as the special cause of vari- over total hours available per year. lower controls. The control chart was ation, it was eliminated by introdu- The standard of total hours available based on data from 166 teleconsulta- cing a reminder call to the patients. per professional was 1645 hours per tions developed through 40 sessions When the statistical control was esta- year. The questions addressed by the over a twelve-months period. blished, a productivity analysis was workload analysis were: 1) what is There are several points to note. performed taking as a reference the the minimum time necessary to deve- An out-of-control signal was detected annual activity level of the travelling lop a telepsychiatry session? 2) What in the first six-months of the evalua- psychiatrist (305 consultations/year); staffing level is required by a routine tion period (Figure 2: first region): this fixed the standard performance telepsychiatry service? seven consecutive sessions of tele- value at 6 teleconsultations per ses-

Protocol Activities Mean Confidence Interval Standard Deviation Code Lower Upper Limit Limit Recall patient and sending email to psychiatrist 1,22 1,14 1,35 0,72 A confirming teleconsultations Setup equipment and establish contact with the 0,73 0,66 0,79 0,43 B nurse C Planning the session according email information 1,24 1,10 1,32 0,69 D+E+F Videoconference * 25,01 24,0 28,03 6,63 G Reassert the treatment to patient 4,40 4,24 4,56 1,04 H Commenting the session 1,21 1,06 1,37 0,70 Time per teleconsultation 33,81 32,58 34,96 7,76

Table 2. Time of protocol activities per teleconsultation (minutes) Process Quality Analysis of Telepsychiatry: Contributions of Statistical Control Process ... 104 sion. The effect of the improvement process was observed from August to Production Planning the final evaluation period (second - Teleconsultations per session = 6,1 region). In this way, the mean number - Sessions per year = 50 of teleconsultations per session incre- - Performance results = 305 teleconsultations per year ased from 3.3 (SD = 1.2) in the first stage (first region) to 6.1 (SD = 2.4) Workload Planning in the second stage (last months of the - Duration of teleconsultations = 33,8 minutes year.) This improvement process did - Duration of the session = 3,4 hours not have an important effect on the - Contracted hours staff: variability of the process, measured by the variation coefficient. The con- Psychiatrist = 172 hours/year sultation workload was controlled by Nurse = 172 hours/year fixing the performance of telepsychi- Table 3. Management guidelines for telepsychiatry service atry to 6 teleconsultations per session through 50 sessions over the year, i.e. the protocol is considered, the total conventional care was determined 305 teleconsultation per year. time per teleconsultation rise to 33.81 with the use of a Critical Pathway The results of Statistical Control (CI 95%: 32.58-34.96) minutes. Analysis. The continuous quality Process are tied in with the network Assuming the earlier performance improvement approach minimised analysis, which was developed results (305 teleconsultation / year), the working time and increased, in a thought the critical pathway analysis, the total labour hours required by systematic way, the productivity of which was shown to be useful for telepsychiatry would be 172 [(33.81* the telepsychiatry service. These minimising time and integrating and 305)/60] hours for each professional achievements can diminish the total reallocating activities. The network (psychiatrist and nurse). Accordingly, cost of the service, improving the analysis of the standard telepsychia- labour requirements were 0.104 relative cost effectiveness with try session is shown in Figure 2, [172/1645] of a Full-Time Equivalent respect to the conventional model: where the number next to each activi- for each professional. This indicated the minimization of work-time redu- ty represents the activity’s duration in that there was no additional impact of ces the variable cost and the increase minutes. Nodes 1 and 2 mark the TS on staff requirements. The Canary in productivity reduces the fixed cost beginning of the telepsychiatry ses- Islands Health Service information assigned to each teleconsultation. The sion and node 9 is the finishing node. system indicated that Full-Time results of the present evaluation pro- The network diagram indicates that Equivalent of the psychiatrist in the vide a management guidelines (Table activities A-B had to be completed conventional model was 0.116 3). These guidelines are the result of a before activity C began. Activities D- continuous quality improvement pro- E-F were integrated within the video- cess. conference itself (activities E-F were developed in parallel). The critical Discusion & Conclusion In summary, our approach has the path is the activities group A-C-D-E- following benefits: firstly, our recom- G-H. Activity E´ is a dummy activity: Industrial quality management mendations are based on realistic it is an artificial activity whose pur- analysis has been applied in other stu- assumptions: statistical control pro- pose is to distinguish between two or dies to the health sector and has cess shows that the telepsychiatry more activities that both begin and shown demonstrated improvements service has the capability of produ- end at the same node. Adding up all in efficiency and productivity (Laffel cing the same number of consulta- the minutes along this path results in & Blumenthal, 1989; Benneyan, tions as the conventional model. In a total of 179 minutes per session, 1998; Alemi & Sullivan, 2001; Caron conjunction, the critical pathway ana- where the activities D and E (telecon- & Neuhauser, 2001; Amin, 2001). lysis is an effective assessment sulting and reviewing the treatment In this paper we applied two plan- method that considers what tasks with the patient) consumes 132 minu- ning tools to conduct an analysis of must be carried out, what parallel tes (74% of the critical path time). the telemedicine process in the Cana- activities can be carried out, the role Table 2 shows the time spent on ry Islands. A Statistical Control Pro- of each team member as well as their different protocol activities in the cess was used to ascertain that the responsibilities and the resources that teleconsultation process. The average level of usage fell within an accepta- are used for each protocol activity. As time for teleconsultation videoconfe- ble (efficient) range. The feasibility a result of the entire previous one, the rencing activities was 25 (CI 95% = of achieving this range while using relative cost effectiveness of teleme- 24-26.03) minutes. When the rest of the same level of resources as under dicine telemedicine can be improved. De Las Cuevas, Artiles 105

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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 Europe [2]; Ethical code of conduct In conclusion, the consortium e-Mental-Health, e-Health, telepsychiatry, from APA [1]; Declaration from Hel- declares that ISLANDS does not telemedicine, ethical considerations sinki from the world medical associa- include any research involving the use tion). General ethical principles are of human embryos, human embryonic presented. Subjects have to be infor- tissue, human fetuses, human fetal tis- Ethical Conduct within the med about the experiment and give sue, other human tissues, genetic ISLANDS Project written assent to participate. Resear- information, people unable to give This paper indicates the issues to chers do only deceive subjects when consent, or pregnant women. There is which special sensitivity concerning this is justified by the study’s signifi- no animal experimentation. The test ethical aspects should be given cant prospective value. Deceived subjects will not receive any unlicen- throughout an eMentalHealth project subjects have to be clarified about the sed medication, legal or illegal drugs like ISLANDS. This means, first and real issues of the study. The privacy or any other substance other than that most important, to secure an ethical of the subjects is ensured through all normally required by their health con- treatment of the participants invol- steps of the project. The subjects are dition and prescribed by a doctor on ved, and secondly, to secure the high protected from harm. The psycholo- site. Personal data on subjects will be scientific quality of research conduc- gical tests are used in accordance to used in strictly confidential terms and ted within, suggested or even promo- legislative and contractual obliga- will be published as statistics (anony- ted by the ISLANDS project. tions. The professional knowledge for mously). General research ethics related to psycho diagnostic testing is ensured research with humans and research within ISLANDS. Personal informa- involving testing and assessments are tion is regarded as confidential. Dis- firstly presented. This ethical issue respect concerning the use of langua- Methodology concerns the proposed screening, ge should be avoided. counseling and treatment policies, as The ethical issues highlighted in well as the use of the research data, in One of the main objectives of this paper are based on information a way that guarantees privacy and sta- ISLANDS is to create the scientific gathered from various sources: te of the art therapy according to local base for appropriate tools that can be and European law. used in a modular, non-conventional • Convention on human rights and Cultural and personal elements remote psychiatric and psychothera- Biomedicine of the Council of cannot always be totally dismissed; peutic supply for remote European Europe however, they can and should be cri- areas. Cost effective services (inclu- • American Psychological Associa- tically examined. ding its evaluation) are offered to dif- tion’s ethical Principles of ferent consumers (patients, signifi- Psychologists and Code of Con- cant others, professionals). All test duct methods will be non-intrusive. A • Universal Declaration on the Introduction medical practitioner is present during Human Genome and Human each study. All used assessment tools Rights of the UNESCO [3] The ethical considerations within and protocols are verified by COAT • Declaration of Helsinki: Recom- the ISLANDS project are based on Based (ISLANDS partner, psychia- mendations Guiding Physicians in information gathered from different tric clinic) regarding their impact to Biomedical Research Involving sources (Convention on human rights users’ well-being before being app- Human Subjects from the World on biomedicine from the council of lied. medical association [4] Senn, Sulzenbacher, Meise, Estoppey, Mager, Müller-Spahn, Bullinger 107

• National legal and ethical require- Researchers explain any decep- citly regulated) should also be follo- ments of the Member States tion that is an integral feature of the wed as part of good practice. (Greece, Spain, France, Austria) design and conduct of an experiment where the research is performed. to participants as early as feasible, preferably at the conclusion of their Professional competence participation, but no later than at the The professional knowledge that conclusion of the data collection, and the use of assessment and diagnostic General ethical principles permit participants to withdraw their tools (i.e. tests) requires, is guaran- on research with human data (American Psychological Asso- teed within ISLANDS. Partly the law subjects ciation, 20021). already regulates this; e.g., certain tests are available only for psycholo- gists’ use. Informed Consent Confidentiality Previous to any intervention the Privacy and confidentiality is a subjects have to be informed about central concept in the conduct of ethi- Instruments the aims of the study, procedures, and cal research within ISLANDS. Used assessment instruments are methods in a clear and comprehensi- The privacy of the subjects is valid and reliable. Eventual limita- ve way. All of the subjects are volun- ensured through all steps of the rese- tions will be taken into account when teers. They are clearly informed that arch project, including data handling, communicating test results. they are allowed to stop participating data analyses, and research commu- at any time during the experiment. nications. It is also ensured that all the After ensuring that the subject has persons involved in research work Personal information understood the information about the understand and respect the require- Personal information must be study, the physician then obtains the ment for confidentiality. The subjects regarded as confidential. Custodian subject's freely-given written infor- should be informed about the confi- of a large research database or regi- med consent. Special attention should dentiality policy that is used in the ster must ensure they have each per- be paid in regard to recognizing and research. son’s explicit consent to obtain, hold upholding the rights of those subjects and use personal information. whose capability to give a valid con- Due to the confidentiality of test sent to research procedures may be Protection of subjects data and the anonymous nature of the diminished. Subjects with legal guar- Risks attend us every moment in performance, the researchers are not dian aides as well as subjects who can life and thus a totally risk-free setting allowed to inform any authorities not rationalise the test course and is impossible. However, subjects about the participant’s performance, goal based on any impairment of their should not be exposed to or induced even if the subject’s performance cognitive abilities will be excluded to take risks that are greater than tho- might indicate for example safety from the study. se they would normally encounter in problems in activities of daily life like their life. The subjects participating road traffic. in ISLANDS are protected from Deception harmful physiological and psycholo- Researchers do not conduct a stu- gical effects that might be caused. All dy involving deception unless that the risks (both to physical and mental Ethical perspective on they have determined that the use of appearance of the participant) related language deceptive techniques is justified by to research procedure are minimized. the study’s significant prospective scientific, educational, or applied Disrespect value and that effective non-decepti- Both overt and hidden disrespect ve alternative procedures are not fea- Ethics conduct in assess- should be avoided in all research sible. This is clearly not the case for ment and tests communications and materials. The the reseach done within the terms used should be politically cor- ISLANDS project. Some of the work packages of rect, e.g., the expressions “disorder” Researchers do not deceive pro- ISLANDS include testing and assess- or “substance use” should be used spective participants about research ment of research subjects. The com- instead of “illness” or “abuse”. Also that is reasonably expected to cause mon psychological tests are used in any images of otherness should be physical pain or severe emotional accordance to legislative and contrac- avoided when describing people. distress. tual obligations. Principles (not expli- That is, all kinds of “us” vs. “them” Ethical Conduct within the ISLANDS Project 108 arrays should be strictly avoided in all References communications. Finally, in all rese- arch communications and materials, [1] American Psychological Association it should be kept in mind that having (2002). Ethical Principles of Psycholo- gists and Code of Conduct. American problems is not equal to sickness and Psychologist, 57, 1060-1073. infirmity but is a kind of life that [2] Council of Europe, Convention on should be addressed with the same human rights and Biomedicine, 1997. respect as others, too. [3] UNESCO, Universal Declaration on the Human Genome and Human Rights, Language that equates persons 1997. with their condition or that has nega- [4] World Medical Association, Declaration tive overtones should be avoided. of Helsinki: Recommendations Guiding Physicians in Biomedical Research Involving Human Subjects, 1996.

Sexism Similarly, overt and hidden sexism should be avoided in research communications and materials of Dr. Alex H. Bullinger, MBA ISLANDS. The language used should Center of Applied Technologies in be gender neutral: the pronoun he Neuroscience (COAT-Basel /PUK) should not be used to refer to both University of Basel genders, and the masculine or femini- Wilhelm Klein-Strasse 27 ne pronoun should not be used to CH-4025 Basel define roles by gender. Also the word Switzerland “man” should not be used to refer to Email: [email protected] all human beings. The use of the generic “he” can be overcome for example in using plural nouns or plu- ral pronouns, replacing the pronoun with an article or dropping the pro- noun.

Other Labeling people should be avoi- ded when possible. Researchers should carefully consider when – if ever – it is adequate to use broad cate- gories, such as “the alcoholic”, that tend to present the subjects in the stu- dy as objects without individuality or heterogeneity. The language in all research com- munications 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 sub- jects or objects, regardless of the rese- arch setting or methods. Neuropsychiatrie, Volume 18, S 2, 2004, page 109-111

Report Potential Constraints and Obstacles relevant to the Introduction of e-Mental Health and Telepsychiatry

Ullrich Meise1, Hubert Sulzenbacher1 and Alex H. Bullinger2

1Center of Online Mental Health, Dept. of Psychiatry, Medical University Innsbruck 2Center of Applied Technologies in Mental Health, Dept. of Psychiatry, University Basel

When implementing e-mental actual use of telepsychiatry has in questions about responsibilities health services in the different pilot many cases been less than anticipated. towards the patients, if the risks sites it seems to be necessary to deter- The main constraints or barriers, will be covered by insurance com- mine different factors (Wright 1998): which can contribute to problems of panies and state licensing require- implementing e-mental health fall ments - define the needs for telepsychia- into the following categories: human, - the often non-existent telemedici- try, assess the potential and ethical, legal business and technolo- ne policy and strategies also defi- advantages of these applications gical issues ning the roles of the different - define the needs and priorities of players the different players; ensure that - financial problems like the high diverse players are involved (pro- expenses for hard- and software fessionals, patients, telecommuni- 1. Human issues - difficulties to reimburse physici- cation companies and operators, ans for their telework health authorities …) While patients appear willing to - the general lack of third party - define which telecommunication accept telepsychiatry after they have reimbursement and of a business infrastructure is available or could had some experience with it, provi- model supporting e-health activi- be made available; assess the ders exhibit considerably more resi- ties or the uncertain long-term accessibility of these structures stance. The reasons for professional funding of e.g. pilot projects - determine the most appropriate wariness are complex and range from -a lack of cost effectiveness since technologies (telephone, www, - ethical concerns about network e-mental health can enhance the email, videoconferencing) security and privacy or the possi- services or may multiply demand - determine factors like costs, bility of harming patients with for previously inaccessible mental financing and other resources unknown treatment models health services or necessary - professionals technophobia and - legal difficulties arising from the - raise awareness about potential lack of training and familiarity possibilities of cross-boundary telepsychiatry applications among with equipment consultations. health care professionals and other - problems with time and conve- relevant players nience - ensure adequate legal, organisa- - problems with reimbursement for tional and administrative arrange- their online work and 3. Technological issues ments are established and sustai- - challenges to fundamental views nable on professional roles. These include technical and - establish a telepsychiatry databa- scientific difficulties like: se to monitor outcomes - inadequate telecommunication - identify socio-cultural factors, networks legal considerations and potential 2. Ethical , legal and -a lack of user friendly information barriers relevant to the introduc- business issues systems and interfaces tion of this technology. -a lack of satisfactory bandwidth These include: -a rapid development of technolo- Although e-health applications - concerns about telecommunica- gy have proliferated in recent years, their tion network security and privacy -a scarcity of evaluation data about diffusion has often remained low. The standards the effects of telepsychiatry Potential Constraints and Obstacles relevant to the Introduction of e-Mental Health and Telepsychiatry 110

“There is currently a substantial roles, practices and relationships. been published by different groups. gap between the widespread This requires substantial attitudinal demand for telehealth and the changes. Some countries require certifica- scientific evidence supporting its tion for telepsychiatry practitioners efficacy and cost effectiveness” There are a number of structural to be able to claim payments for their characteristics common to most consultations. This certification pro- healthcare organisations which affect cess should be focused on ensuring technological innovations. These that clinicians have a good understan- Considerations of these organisations are usually characteri- ding of prevailing clinical, technolo- barriers sed by a hierarchical structure and gical, and ethical practices. health care professionals have been Because the challenges for e- found to be inherently conservative. Numerous telemedicine evalua- mental health are of human rather Technological changes such as e- tion frameworks have been propo- than technological Variety, we will mental health may contribute to con- sed including comparisons of costs focus on this topic. flicts, arising from the increasing and effects. For this relationship bet- As a new medical practice, e- emphasis on teamwork and collabo- ween quality and telepsychiatry it is health can be described as an innova- ration. “ The use of telehealth requi- helpful to consider Donabedian’s tion. Innovation literature can there- res the development of new routines, distinction between medicine’s tech- fore be used to study why the diffu- which alter the traditional practices nical and interpersonal components. sion of telemedicine remains low. and relationships.” The technical dimension refers to cli- Rogers’ nical processes of care (e.g. diagno- “Diffusion of Innovation Theory” Effective telehealth consultations sis, treatment or follow up) and out- suggests that organisational structu- require a high degree of collaboration comes (e.g. health status or quality of res and cultures will affect health pro- and teamwork between different life); the interpersonal dimension fessionals’ perception of telehealth. occupational groups. An organisation refers to social and psychological which is small, complex and decen- aspects of treatment (e.g. user satis- The introduction of these services tralised has a potential to introduce faction and acceptance or doctor affects existing work practices and telehealth services, while a formali- patient relationship) work flows. Therefore it is necessary sed structure and centralisation would Besides cost, ethical, legal or to develop strategies for the introduc- have a negative effect; especially if it technical issues, the implementation tion of telehealth applications, which is associated with a lack of resources of telepsychiatry services needs to take into account the particular struc- and limited management support. take account of the idiosyncrasies of tures and cultures of the individual the health service sector and the par- organisations within the different E-health also supports a cultural ticular structures and cultures of indi- mental health care systems. Rogers change, which is driven by the global vidual organisations; particularly if argues that an innovation is more consumers’ movement, in which the distribution of resources and likely to be adopted, if it has relative patients are insisting on being part- power is affected and potential chan- advantages and is compatible with ners in their own care and being kept ges in work practices contribute to existing values and needs. fully informed. This new paradigm of behavioural barriers. empowered clients also requires a Tanrivedi and Iacono explain in substantial change of role and attitu- In general, to be successful tele- their “Extended Knowledge Barrier de. Medical knowledge no longer psychiatry providers must focus also Metaphor”, based on Attwell’s “The- represents the power-base of health on the needs of mental-health profes- ory of Knowledge Barrier”, that in professionals. In future they also have sionals and not be forced to fit their addition to economic, organisational to act as coach and consultant to their services to existing technology. and technical knowledge barriers, patients. “Consumer focus must not be mental health professionals may also replaced by product focus” The intro- resist the use of a new technology Security and privacy are two duction of e-mental health services which they do not understand. More core requirements for any e-mental should follow a step-by-step appro- research is necessary on a range of health consultations. All systems ach. Telepsychiatry should fit into the outcome variables which may must keep patient data secure; priva- mental health care system and be influence effectiveness. For health cy is crucial for both real-time and introduced in a balanced way. There- professionals e-mental health is also store and forward approaches. A fore tailor-made solutions should be associated with a novel way of wor- number of documented ethical and developed for each region in king and alterations of traditional clinical guidelines exist which have question. Meise, Sulzenbacher, Bullinger 111

Literature Walker J, Whetton S (2002): The Diffu- Univ. Prof. Dr. Ullrich Meise sion of Innovation: Factors Influencing Dep. of Psychiatry Hsiung RC (2003): E-therapy: Opportu- the Uptake of Telehealth. Journal of Tele- Medical University Innsbruck nities, Dangers and Ethics to Guide Prac- medicine and Telecare 8;S3:73-75 tice (in: Wootton, Yellowlees, McLaren. Wootton R, Blignault I (2003): Guideli- Anichstrasse 35 nes for Telepsychiatry and e-Mental Telepsychiatry and e-Mental Health); pp 6020 Innsbruck, Austria 73-82 Royal society of Medicine press Health. (in: Wootton, Yellowlees, McLa- E mail: [email protected] Ltd., London ren. Telepsychiatry and e-Mental Tanrivedi H, Iacono CS (1999): Diffu- Health); pp 293-304 Royal society of sion of Telemedicine: A Knowledge Bar- Medicine press Ltd., London rier Perspective. Telemedicine Journal Wright D (1998): Telemedicine and 5,3:223-244 Developing Countries. Journal of Tele- medicine and Telecare 4;S2:1-87

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 men- experiences of real-time telepsychia- comprehensive companion to all tal health care in the 21stcentury is try gives the reader first-hand infor- mental health professionals: Trainee considerable, both in the industriali- mation about how diagnoses and and qualified psychiatrists whether zed and developing world. This is the patient management can be achieved. practising or considering using tele- fist book to cover the emerging prac- In addition, the authors explain how psychiatry and the Internet, nurses, tice of telepsychiatry and e-mental the Internet can provide advice and psychologists, social workers, mana- health. Focusing on both clinical and information to doctors, plus self-help gers, mental health service planners educational applications, the interna- or even therapy to patients. The futu- and administrators, and IT staff wor- tional team of authors demonstrate re of mental health provision, inclu- king in the mental health sector. the broad spectrum of technologies ding the economics of such services currently available to health profes- and the particular challenges faced by sionals including video, Internet and health professionals in the developing telephony. world, is discussed through experi- This book presents a unique and mental ideas such as the development Royal Society of Medicine Press Ltd formidable overview of current aca- of commercial online clinics and 1 Wimpole Street, demic literature which complements automated diagnosis. London Q1G OAE UK a comprehensive selection of practi- Written by experts with substan- 207E Westminster Road, Lake Forest cal ideas and advice on technical, cli- tial experience from across the world, IL 60045 USA nical and medicolegal areas. Direct this book is designed to provide a http://www.rsm.ac.uk Neuropsychiatrie, Volume 18, S 2, 2004, page 112-115

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 provider acceptance and satisfaction specified or understood place”. For Presence, Telepresence, Telepsychiatry, (Gammon et al., 1996; Clarke, 1997; these authors, the sensation of presen- Virtual Reality. Urness, 1999; De las Cuevas et al., ce is unstable and oscillates around 2003). However, when a telepsychia- three senses of place. From moment- Some Considerations about the try videoconference system is used to to-moment the user may feel present Concept of Presence in Telepsy- bridge remote locations, a virtual in the physical environment (Distal chiatry environment is created and it is likely Immediate), the virtual environment The authors reflect about the con- that some information cues present in (Distal Mediated), or the imaginal cept of presence and its relevance in the physical environment are not environment (Reduced Attention to the practice of telepsychiatry consi- available in the virtual environment Distal Stimuli, i.e., the space of dering the use of videoconferencing (Turner, 2001). Since this fact could daydreams, dreams, and hallucina- technology as a mean of providing have unknown effects on decisions tions). As individuals experience sen- mental health consultations across made in these environments, the stu- sations coming from the physical distances. This brief paper stresses dy and analysis of the concepts of environment or the virtual environ- the importance of examining the new presence and telepresence become ment, their sense of presence, or context created by new communica- necessary in an attempt to clarify the being there, may oscillate moment- tion technologies, and of understan- possible limitations of this new wel- to-moment between these two senses ding of the novel practitioner-patient fare modality. of place, or they may withdraw their relationships created, paying atten- Virtual reality created by video- attention to these stimuli and retreat tion to secondary and peripheral con- conferencing means that users expe- into the imagination. Therefore, at texts that could potentially be ignored riences a mediated environment as if any moment users might feel "pre- because of telepresence. it were real and that this virtual envi- sent" in one of three places, but when ronment can give rise a subjective the incoming information from the sensation of being in a remote or arti- unmediated physical space is techno- ficial environment, but not the sur- logically or attentionally diminished According to Bashshur (1995), rounding physical environment (Held or suppressed, and the media interfa- telepsychiatry can be conceived as an & Durlach, 1992; Sheridan, 1992; ce allows the mind to focus on infor- integrated system of mental health Steuer, 1995; Kim & Biocca, 1997). mation coming from the virtual envi- care delivery that employs telecom- This "illusion of nonmediation" whe- ronment, a person may experience munications and computerized infor- re psychiatrist and patient "...fails to telepresence. mation technology as an alternative perceive or acknowledge the existen- In a face-to-face psychiatric con- to face-to-face contact between psy- ce of a medium in their communica- sultation the mental health professio- chiatrists and patients. Videoconfe- tion environment and responds as nal has access to much more of the rencing is the central technology that they would if the medium were not patient’s context, while in a telepsy- is currently used in telepsychiatry, there" (Lombard and Ditton, 1997) is chiatry session the psychiatric has since it permit live, two-way interac- called telepresence or “virtual presen- access only to the context that is vie- tive, full-colour, video, audio and ce” (Barfield & Weghorst, 1993; She- wable on the videoconference, being data communication (Janca, 2000). ridan, 1992), a facet of presence the presence very different. A wide variety of studies concer- which is a more wide concept. Turner (2001) considers three dif- ning telepsychiatry, interactive video According to Kim and Biocca ferent contexts influencing presence consultations, have been performed (1997), presence could be defined as in telepsychiatry. Primary context showing high rates of consumer and “a person’s perception of being at a refers to the immediate presence of De las Cuevas, González de Rivera 113 the participants. It refers to what we need to have in mind that the qua- From the point of view of counter appears salient to the participants. lity of the videoconference is a com- transference issues, Kaplan (1997) Within telepsychiatry, the primary bination of hardware, transmission signals that some psychiatrist are context is the image on the video speed and room environment, alt- reluctant to carry on mediated monitor. Within a traditional encoun- hough debate on quality has however psychotherapy, and the perception of ter, the primary context is the imme- centred on the transmission speeds as this reluctance may deter the patients diate distance around the participants. the most significant of these factors. from asking or exploring for this pos- Within that primary context, some For telepsychiatry purposes, and con- sibility. On commenting on this issue, secondary context is available, but is sidering presence as the goal to achie- Joyce Aronson (2000), in the intro- not the focus of participants. Within ve, videoconference rooms can be duction to her excellent book on the telemedicine encounter, this may thought of as one-half of a pair; each Psychotherapy by Telephone makes include sounds that give information room is an extension of the other. the, probably accurate, sexist remark regarding what is occurring outside Videoconference rooms that share the that “Men often confine their telepho- the image displayed on the video same interior design help all partici- ne use to the accomplishment of spe- monitor. Within traditional encoun- pants feel that they are in the same cific tasks, and women are usually ters, secondary context refers to the room. This removes the natural sense more comfortable in relating over the room within which participants meet. of distance and promotes a sense of phone”. Peripheral context is the ancillary closeness and privacy, An adequate Relationship is, in fact, a key issue context that is not a part of the tele- lighting that ensure the transmission on psychotherapy. Counselling and medicine encounter at all. Within the of good quality images and a room some forms of psychotherapy, such as traditional encounter, the peripheral design that take into account the cognitive-behavioural techniques, context may include the walk into the required acoustical needs also facili- seem more appropriate for telepsy- building, the walk down the hallway, tate the sense of presence. The appea- chiatry than the more empathic and the impromptu meeting with nur- rance of the telepsychiatry room can methods. However, Saul (1954) ses outside of the patient's room. affect the way participants feel about published the first report on the use of We propose to distinguish bet- teleconsultations. The surroundings the telephone as an adjunct for ween three main applications of tele- should be warm and comfortable. The psychoanalysis, and Robertiello, as psychiatry a) clinical, concerned colours selected for the interior walls, soon as in 1972, was reporting the use mainly with diagnostic interviewing floor and furnishings should be plea- of this same media in conducting and treatment supervision, b) consul- sant; avoid saturated colours. Colours psychoanalytically oriented psycho- tation with family practitioners and such as taupe, blue and salmon therapy sessions. paramedics and c) psychotherapy. In remain "truer" after video transmis- McLaren et al. (1995) found the review conducted by Hilty et al. sion than do greens, reds or browns. increased interpersonal distance (2003) the degree of satisfaction The issue of “presence” is particu- appeared to enhance communication among users of the clinical applica- larly important in psychotherapy, on some patients who felt more com- tion was very high, albeit satisfaction where the mediated interaction bet- fortable self-disclosing at a distance. among the nurses and family practi- ween patient and therapist introduces However, they also noted that the tioners who consulted a psychiatrist new parameters more relevant to con- technology limited ability to perceive expert was not so evident. The dia- sideration about the setting. In fact, certain nonverbal behaviours. In gnostic reliability of telepsychiatry the American Psychiatric Association addition, both the patients and the was high, with good interrater reliabi- Resource Document on Telepsychia- psychiatrists were somewhat distrac- lity for a wide range of psychiatric try (1998), while clearly endorsing ted by the equipment and felt self- disorders in children, adults and geri- the usefulness of telepsychiatry for conscious viewing themselves on the atric populations. clinical interviews, emergency evalu- monitor. A significant technical considera- ations, case management, forensic In fact, diluting and controlling tion made by Hilty is that most positi- psychiatry and clinical supervision, the presence of the psychotherapist, ve studies use transmission speed is, albeit not negative, more reserved so as to feel less influenced by him, equal or higher than 128 kbs, which is in terms of its application for psycho- may be an important motivation to the minimal speed required to simula- therapy. seek telepsychotherapy by some te real life experience. In our expe- Lombard and Ditton (1997) defi- patients. In our own experience, rience, we prefer to operate at 384 ne the feeling of presence as the sub- (Gonzalez de Rivera, 2004) social Kbps. 384 Kbps is certainly more jective experience of 'being there' in phobics and obsessional patients are comfortable because of clearer pictu- mediated environments such as virtu- more likely to complete on line que- re resolution, smoother motion and al reality, simulators, cinema, televi- stionnaires on stress reactivity and to synchronicity of sound. Nevertheless, sion, etc inquire or solicit internet-mediated Some Considerations about the Concept of Presence in Telepsychiatry 114

psychotherapy. This trend may be one with nature. The hackers find Gammon D, Bergvik S, Bergmo T & related to Kraut et al. (1998) research soul in the machine”. Psychiatry has Pedersen S. Videoconferencing in psy- on internet users, which tend to feel now not only a new tool, but also a chiatry: a survey of use in northern Nor- way. Journal of Telemedicine and Tele- more lonely and depressed than con- new area worth exploring, that of care 1996; 2:192-8. trols, and to have lighter and more “Identity in the Age of Internet” (Tur- Gonzalez de Rivera, JL: Instituto de Psi- restricted interactions in the physical kle, 1995) coterapia & Investigación Psicosomáti- world. Excessive use of internet, they Although not seriously intended ca. http://www.psicoter.es/estres. asp Grolnick, SA, Barkin, L and Muenster- contend, has a negative effect on the for psychotherapy uses, the program berger, W: Between Reality and Fanta- socialization experience. If this is so, ELIZA, developed by Weizenbaum sy. Transitional Objects and Phenome- encouraging telepsychotherapy may (1976) in M.I.T. in the late 60´s as an na. Jason Aronson, New York, 1978 be a double-edged sword: In one experiment on artificial intelligence, Held, R. M., & Durlach, N. I. Telepre- sence. Presence, 1992, 1(1), 109-112. hand, it may facilitate therapy for so engages the user that some may Hilty, DM, Liu, W, Marks, S and Calla- people unable or unwilling to tolerate end up by experiencing a real feeling han, EJ: The effectiveness of telepsychi- the physical presence of a therapist. of presence, and treat the program as atry. A review. Bulletin of the Canadian On the other hand, this very physical a real therapist. Psychiatric Association, October 2003 Janca, A. Telepsychiatry: an update on presence and the interaction in the In order to finalize, the implemen- technology and its applications. Current real –non-mediated- world may be tation of telepsychiatry activity provi- Opinion in Psychiatry, 2000; 13: 591- the most important therapeutic tool des the opportunity for healthcare 597. for those patients, and telepsychiatry providers to understand the importan- Kaplan, E: Psychotherapy by telephone, videotelephone and computer videocon- psychotherapy would be, then, inap- ce of communication processes to the ferencing. Journal of Psychotherapy propriate. healthcare encounter. Professionals Practice and Research, 1997, 6:227-237 In our view, a medium term posi- involved in the practice of telepsychi- Kim, T & Biocca, F. Telepresence via tion will be to consider the virtual atry must be conscious of the impor- Television: Two Dimensions of Tele- relationship achieved by telepsycho- tant role that presence and telepresen- presence May Have Different Connec- tions to Memory and Persuasion. Jour- therapy as a Transitional Object, in ce play in providing information nal of Computer-Mediated Communi- Winnicott terms, and use it as and regarding the mental healthcare con- cation, 1997, 3 (2):http://www.ascusc. adjunct to facilitate and promote a text. org/jcmc/vol3/issue2/kim.html therapeutic relationship. Examples of Kraut, R, Lundmark, V., Patterson, M, Kiesler, S, Mukopadhyay, T and Scher- similar uses of objects and situations lis, W: Internet Paradox: A Social Tech- in psychotherapy are illustrated by nology That Reduces Social Involve- Grolnick et al. (1978). A case is repor- ment and Psychological Well-Being? ted by Aronson (2000) of the treat- American Psychologist, 1998, 53: 1017–1031 ment of a very fragile patient by inter- References McLaren, P., Ball, C., Summerfield, A. spreading consultation-room sessions B., Watson, J. P., & Lipsedge, M. with telephone sessions. APA Resource Document of Telepsychia- (1995). An evaluation of the use of In her two influential books, Sher- try via Videoconferencing. Approved by interactive television in an acute psychi- APABoard of Trustees 7/98. www.psych. atric service. Journal of Telemedicine ry Turkle (1984, 1995) contends that org/psych_pract/tp_paper.cfm and Telecare, 1, 79-85. the irruption of mediated communi- Aronson, J: Use of the Telephone in Lombard, M and Ditton, At the Heart of cation in our lives has introduced a Psychotherapy. New Jersey, Jason It All: The Concept of Presence. Journal new element not previously present: Aronson, 2000 of Computer-Mediated Communica- Barfield, W., & Webhorst, S. The sense tion, 1997, 3 (2): http://www.ascusc. the interaction with the computer of presence within virtual environ- org/jcmc/vol3/issue2/lombard.html itself –or, more precisely, with the ments: A conceptual framework. Pro- Robertiello, RC Telephone sessions. program the machine is running. Star- ceedings of the fifth International Con- Psychoanalytic Review, 1972, 59:633-634 ting by the simple observation of the ference of Human-Computer Interac- Saul, LJ. A note on the telephone as a tion, 1993, 699-704. technical aid. Psychoanalytic Quarterly, deep absorption of children on com- Bashshur, RL. On the definition and 1954, 20:287-290 puter-games, Turkle (1984) goes on evaluation of telemedicine. Telemed J Sheridan, T. B. Musings on telepresence analysing the mentality of hackers, 1995; 1: 19-30. and virtual presence. Presence, 1992, often isolated and ineffectual in the Clarke, PHJ. A referrer and patient eva- 1(1), 120-126. luation of a telepsychiatry consultation- Steuer, J. Defining virtual reality: real world, who become heroes when liaison service in South Australia. Jour- Dimensions determining telepresence. launched through internet. She nal of Telemedicine and Telecare In: Biocca, F., & Levy, M.R. (eds.), depicts well this ability to achieve a 1997;3(Suppl1):12-4. Communication in the age of virtual deep interaction with the computer in De las Cuevas C, Artiles J, De la Fuen- reality. Hillsdale, NJ: Lawrence Erl- her following sentence, worth quo- te J & Serrano P. Telepsychiatry in the baum Associates, 1995, pp. 33-56. Canary Islands: User Acceptance and Turkle, S: The second self: Computers ting: “The romantics wanted to esca- Satisfaction. Journal of Telemedicine and the Human Spirit. Simon & pe rationalist egoism by becoming and Telecare 2003; 9, 4: 221-224. Schuster, New York, 1984 De las Cuevas, González de Rivera 115

Turkle, S: Life on the screen: Identity in the Age of Internet. Simon & Schuster, New York, 1995 Turner JW. Telepsychiatry as a case stu- dy of presence: Do you know what you are missing. Journal of Computer- Mediated Communication, 2001; 6 (4): http://www.ascusc.org/jcmc/vol6/issue 4/turner.html Urness DA. Evaluation of a Canadian telepsychiatry service. Stud Health Technol Info, 1999, 64: 262-269. Weizenbaum, J. "Computer Power and Human Reason: From Judgement to Calculation". San Francisco. W.H. Free- man. 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: [email protected] Neuropsychiatrie, Volume 18, S 2, 2004, page 116-122

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 bers of Telemed are listed in Appen- The project consortium was di- Telepsychiatry, EU-funding, nonverbal dix I. Key results from Telemed have verse. This was stimulating but also communication, videoconferencing, bro- been published elsewhere [2, 7]. This generated considerable organisatio- adband. article will review the project process nal demands. The technical environ- and results from the Telepsychiatry ment at the time of inception of the work group within the project. project was rapidly changing, in Telemed was a multidisciplinary respect of communication options The Telemed Project (RACE- multi-professional project, with the and the videoconferencing kit. This Project R 1086): Lessons learned primary objective of developing led to lively debate between the tech- for Telepsychiatry from the first healthcare applications for emerging nical partners in the early phases, EU funded Telemedicine Project broadband telecommunication links. about the choice of communication ISLANDS is the latest EU funded Clinical applications included ima- carrier, whether the emerging broad- Telepsychiatry project. The Telemed ging in cardiology, radiographic ima- band network or satellite should be Project (RACE-1068) which ran bet- ge database management and Tele- used. The availability of broadband ween 1990 and 1994 was the first. psychiatry. The consortium contained links, at costs which had been built This paper reviews the technical and technical, clinical and research ex- into the project, was limited and organisational background to Tele- perts, managed by Detecon in Berlin. although a common platform was med and summarises key results. sought but it was soon recognised that High levels of acceptance were found this was not realistic to achieve among acute adult psychiatric pa- Telemed and Telepsychiatry within the timescale of the project. tients. Telemed was highly ambitious but failed to produce technical inno- Within Telemed Workgroup 5 had vation or to generate a marketable the tasks of first developing a Low Workgroup 5 videoconferencing kit. It did launch a Cost Videoconferencing system Telepsychiatry research programme (LCVC) and then a Medium Cost The aims for workgroup 5 were to which has continued in London. Videoconferencing System (MCVC) develop an LCVC for remote diagno- Research questions arising from the for remote diagnosis and treatment in sis and treatment, to perform a requi- project centred on the impact of the psychiatry. This workgroup had part- rements capture for the use of video- videoconferencing medium on the ners in France, at the Croix Rouge conferencing in mental health care clinical consultation. (Centre Pierre Nicole) in Paris and in France, Germany and the United subsequently the Centre Hospitalier Kingdom and then to build and test a Specialise de Ville-Evrard , the Free Medium Cost Videoconferencing University of Berlin, the United system (MCVC) in clinical psychia- Introduction Medical and Dental Schools of Guy’s try. The Cognitive Psychology Group & St Thomas’s hospitals and the at Birkbeck College studied the ef- The RACE-1068 Telemed Project Department of Cognitive Psychology fects of altering the image parameters was the first major telemedicine pro- at Birkbeck College in London. Tech- on the LCVC on laboratory recogni- ject funded by the European Com- nical support for the specification and tion tasks. mission. The driving force behind construction of the videoconferen- RACE was the search for clinical cing kit was provided by STC (Stan- applications for broadband communi- dard Telephones and Cables). cations links. The Consortium mem- Mc Laren, Charles-Nicolas 117

Method testing produced considerable delay social exchange. This was derived in which meant that the availability of turn from work by Morley and Ste- the leased line was limited for clinical phenson [10], on inter-party and The kit research. The leased line was expen- interpersonal exchange. Inter-party sive, £ 6000 for the year and its use exchange relates to acting out a role Three sets of the LCVC were could not be continued after the pro- and an agenda, interpersonal exchan- built. Two were installed at Guy’s ject funding ran out. ge is to do with developing a personal Hospital in an acute psychiatric unit relationship. The UCL group regar- and one was installed at Birkbeck ded social presence as being made up for the laboratory studies. The LCVC Evaluation of factors such as sociable-unsocia- was based on an Archimedes 310M ble, insensitive-sensitive, cold-warm, personal computer using a Watford Within the project a range of personal-impersonal. Media with a Archimedes realtime digitiser con- study designs were employed to eva- high degree of social presence are nected to a monochrome video ca- luate the use of the LCVC in clinical judged as being warm, personal, sen- mera. The software could run on settings. These included single case sitive and sociable. 1 Megabyte of memory and was con- studies, case series and comparative figured to load and run from disk studies. Qualitative and quantitative The LCVC was introduced into when switched on. It had a mouse- methods were used to collect data the routine operation of the ward at based interface and the image was through observation, participant ob- Guy’s. This was facilitated by the displayed in a quarter-screen window servation, user self-report on structu- senior psychiatrist on the project who (160 x 128 pixels). The user could red and semi-structured questionnai- was also the Consultant Psychiatrist select the image parameters of 16 res. A log was kept of individual on the ward where the LCVC was grey levels at 25 frames per second or interactions. Observers watched in- sited. The psychiatrists on the ward 64 grey levels at 12.5 frames per teractions initially by sitting in the and the nursing team were asked to second with an image of 128 x 128 room and then via a close circuit tele- consider using the LCVC to substi- pixels. The miniature camera was vision system into one of the LCVC tute for face-to-face communication mounted on top of the monitor. A self- rooms from an adjacent room. As in a range of clinical tasks. These view image was displayed on a sepa- confidence grew in the acceptability included senior doctors supervising rate local monitor. If the user sat and reliability of the system, patients junior doctors, the ward doctor com- about 1.3 m in front of the camera, were left on their own. municating with the nursing team and then a satisfactory head and shoulders The Cognitive Psychology group senior and junior doctors intervie- shot was obtained. In Guy’s Hospital at Birkbeck examined the relations- wing patients. Patients were offered the LCVC ran over a co-axial cable hip between picture parameters and the opportunity to see the LCVC and- between two floors in the psychiatric cognitive tasks such as the recogni- to use it informally before using it to unit. Sound was generated and trans- tion of facial expression using student talk to the psychiatrist. Informed mitted separately using two Technics volunteers. written consent was obtained from HiFi amplifier and loudspeaker sys- patients entering the study. tems connected with coaxial cable. A key assumption of the evalua- The kit from Guy’s was taken by car tion performed by the Guy’s group, Different approaches to collecting to Ville-Evrard in Paris for field was the need to understand the chan- subjective data were explored. This testing for two weeks. It was set up ges in the clinical interview process included the Personal Questionnaire between two rooms in an acute psy- caused by the medium, the LCVC. Rapid Scaling Technique designed by chiatric unit. The unit cost of the This was influenced by the Univer- Mulhall [11]. This is an ideographic LCVC at the time of construction was sity College London (UCL) Social technique but for the purposes of this approximately £ 1500. Psychology Research Group [12]. study statements were generated from This group was funded by the British service users and doctors who had The MCVC was also based on an Post Office, to study the social psy- used the LCVC. Key themes were Archimedes PC connected via a chology of the use of the new tele- identified and two versions of the Craycom multiplexer to a British communications media, audio con- questionnaire produced, one for Telecom Megastream leased line. ferencing and videoconferencing and professional users and one for pa- Two MCVC kits were built and used to identify factors that would improve tients. The statements in Table 1 were to connect the acute ward at Guy’s the efficiency of their use in business. used to collect data on professional with the Speedwell Mental Health These authors developed the con- user responses. Centre about 10 km away. The instal- struct of social presence to explain lation of the Megastream link and how different media might impact on The Telemed Project (RACE-Project R 1086) 118

Table 1 Table 3 Videotape recordings were made of the image transmitted over the PQRST statements for professional users Focussed Observation Scale for Health LCVC in a proportion of the interac- 1. My satisfaction was Professionals tions to facilitate the study of non- 2. My need to see the other today is 1. How easy did you find making contact verbal aspects of the communication. 3. My need to seek advice from a for this interaction ? colleague is 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? Results 6. The level of rapport I established was 3. How clear was it to you when to end 7. My frustration was the dialogue? 8. My enjoyment was 4. How much did the equipment interfere The French experience 9. My anxiety was with your ability to perform your inten- 10. The clarity of my explanations was ded task(s)? In the Telemed project France was 5. How confident are you to make deci- represented by the Centre Pierre- In Table 2 the PQRST items given sions on the basis of this interaction? Nicole in Paris and subsequently by to patients after they had used the 6. Do you think you need to talking per- the Centre Hospitalier Specialise de LCVC are listed. son to the other to complete your task Ville Evrard. Their task was to spe- effectively? cify and to test the impact of using a Table 2 7. Did the equipment you were using Low Cost Videoconferencing System interfere with the dialogue? (LCVC) for remote diagnosis and PQRST statements completed by patients 8. Do you think the equipment upset the treatment. 1. My anxiety was other? The clinical setting in Paris for the 2. The degree to which I feel better is 9. Did you find the equipment upsetting ? installation of a telephone equipment 3. My level of frustration was 10. How anxious did you feel using thee- combining the image with the voice 4. My disappointment was quipment? was prepared by Prof. A. Charles- 5. The extent to which my problems were 11. How self-conscious did you feel using Nicolas. One end of the link was understood was the equipment? located at the Centre Pierre-Nicole, a 6. My need to see the doctor today is drug addiction treatment and rehabili- 7. My ability to explain what I wanted was A version of this questionnaire tation center headed by Prof. Charles- 8. My satisfaction was was also developed for patients. This Nicolas. In this center, managed by 9. The reassurance was is in Table 4. The first two questions the Croix Rouge Française, there was guage the general response and the a unit caring for mothers who were last three relate to their reaction to the drug addicts and HIV positive toget- A rating scale, the Focussed LCVC. her with their new-born babies. The Observational Scale (FOS), was also other end was 2 kilometers away in developed for patients and health Table 4 the paediatrics and obstetrics depart- professionals. The FOS questions are ment of Cochin Hospital. This video- listed in Table 3. Each item was rated Focussed Observational Scale for Patients link included the delivering of dia- on a five point numerical scale from 1. Do you feel better after talking to the gnosis and a psychological support. 1 labelled ‘Not at all’ to 5 labelled doctor/nurse? It should allow the mothers, still preg- ‘Very’. The first three questions refer 2. Do you feel worse after talking to the nant or not, addicted to heroin to have to the ease with which a dialogue is doctor/nurse? interviews with the addiction staff of established. The next three questions 3. Do you now want to talk to your doctor Pierre Nicole Center. It allowed also refer to the task that needs to be per- in person? the latter to get advice from the formed during the interaction. The 4. Did you feel upset by the machine? Cochin paediatricians about the care final group of questions referred to 5. Did the machine make it easier to talk of the babies. This setting has been the interpersonal aspects of the ex- to the doctor or nurse? replaced by the Ville Evrard Psychia- change. 6. Would you be willing to use the machi- tric Hospital where two sets were ne again? 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 Mc Laren, Charles-Nicolas 119 translated into French and checked by General findings of the UK group champion within the nursing team. back translation. The focus of the Finding an appropriate room to posi- observational and self-report assess- The Birkbeck group completed tion the LCVC was challenging and ment was to determine whether the their deliverables on time and confir- demanded considerable attention. A medium interfered with the clinical med that basic facial expression balance had to be struck between task. Clinical tasks which were stu- recognition tasks could be completed accessibility in a clinical area and not died included: over the LCVC. There was consider- impeding access to that room for • Review of inpatients by a ward able delay in achieving the technical other professional users. Space was at doctor deliverables for the project. This was a premium and it was considered des- • Psychotherapy assessment in part due to technical difficulties in irable that the LCVC was kept close •Acomparison of face-to-face, linking the MCVC to the broadband to but separate from the nursing telephone and novel audio-video network, but also because the com- station. In one of the wards the LCVC conditions. munications costs for the use of bro- was in a room with a close-circuit adband in France and Germany far television link to an adjacent room. exceeded what had been put in the The rooms were in demand on the General findings of the French budget. The result was that most of busy wards. They also overlooked a group the clinical evaluation was performed courtyard and were not far from a on the LCVC connected with co-axial busy road. Extraneous noise someti- The Psychiatric patients (someti- cable between two rooms in the in- mes interfered with the sound quality mes from ethnic group highly depri- patient unit at Guy’s and in Ville- in the LCVC. ved) adapted very easily to the video- Evrard. While the original plan was to Over the first 15 months of the conferencing medium. Professionals test the MCVC in the United King- study there were no technical failures were much more wary and expressed dom, France and Germany, it was or delays in getting a satisfactory concerns that the medium would only tested in London. Considerable image. The high levels of patient ac- upset the patients. The psychothera- effort and resources went into a requi- ceptance were striking and not res- pists felt distanced by the medium. rements capture identifying patterns tricted to young users. One middle The French psychiatrists were of healthcare delivery in the areas to aged West Indian woman, with seve- concerned about the impact of the be studied but this bore little relevan- re schizophrenia and detained against consultation on the therapeutic re- ce to the final clinical study, which her will adapted, very quickly to lationship [4, 9]. Exploratory work had been demarcated before the pro- using the LCVC. When questioned was done on therapeutic processes, ject started by the project plan. she said that in her Pentecostal church looking at the impact on nonverbal The potential of the LCVC for a microphone was passed around behaviour. remote teaching and tutoring of stu- during the service and using the The most striking finding from dents and trainees was recognised at LCVC microphone reminded her this phase was the ease with which an early stage and the LCVC was church. No spontaneous complaints patients took the using of the system. used successfully for medical student were made about improving the ima- One of the more deplorable out- teaching [6]. ge. The LCVC image quality did not comes of this experience was the lack Professional users complained appear to observers to be limiting the of cross fertilization between work- that the PQRST was complicated, interaction but on occasions the groups. The groups came together for time consuming and difficult to com- sound quality did. Audio feedback project management issues but they plete. The PQRST system proved was a problem if users spoke softly were so disparate in clinical expertise over-elaborate and gave inconsistent and the amplifier had to be turned up. that there was little scope for scien- responses. It was abandoned after the One patient insisted on leaning for- tific collaboration. first phase of the study for the more ward to use the microphone which This first phase was technically concise FOS. moved his head out of the camera possible because the connection of range. Attention needed to be paid to the LCVC needed a coaxial cable. the relationship between the picture The Medium Cost Videoconferencing General observations from the parameters and ambient illumination. System (MCVC) to be tested in phase clinical trials of the LCVC In tasks with little movement 64 grey 2 of this project should be linked scales gave better image definition. across broadband links. Unfortuna- It was difficult to get the nurses on At this level there was still considera- tely, the high cost of broadband at this the ward to use the LCVC for com- ble glare off dark skinned users, time put an end to the French partici- munication. They had pressures on which mad it harder to see facial pation in this consortium. their time with high levels of patient expression. The frame rate at 25 fra- turnover and the project lacked a mes/s proved inadequate for captu- The Telemed Project (RACE-Project R 1086) 120 ring involuntary jerking movements. out of thirty-three such patients refu- The reactions of these Psychothera- Even at 64 grey scales writing on a sing. The protocol and link was pists, who were not actively involved page of A4 could not be interpreted at acceptable to even seriously ill psy- in Telemed, echoed the reservations the remote end. chiatric patients. Only one with Buli- of other professional users who re- Two patients, one with hypoma- mia Nervosa refused after a trial run. ported uncertainty as to the origins of nia and one with schizophrenia beca- She also reported discomfort talking feelings generated during an LCVC me focussed on the technology and on the telephone. consultation. Is a reaction during a this distracted them from the inter- Two experienced Psychothera- consultation determined by the view. A patient with schizophrenia pists were asked to use the LCVC to LCVC or the patient? The possible said, “I look better on the screen” and assess patients [5]. The rationale for contagion effect from telephone also , “It could be a temptation for this was that as Psychotherapists they ‘phobia’ is worthy of further investi- some people to take their clothes off”. would be sensitive to the effects of gation. One doctor reported getting fatigued the medium on the process. One felt In respect of the quantitative data, by the effort of concentrating on the the machine brought a quality of patients completed FOS questionnai- screen, after thirty to forty minutes of distance to the interaction. He descri- res on 47 consultations on the LCVC. continuous use. On further questio- bed wanting to ‘climb into the machi- High levels of acceptance were re- ning he explained that he found it ne to get closer’ to the patient. He felt flected by 35 scoring 4 or 5 when more difficult to leave periods of inhibited in asking questions about asked if they would use the LCVC silence and had to keep the dialogue sexuality and was confused if a fee- again to talk to their psychiatrist. For moving. ling of irritation was a countertransfe- the same interactions the degree to Not all patients admitted to the rence to the patient or the LCVC. He which the professionals thought the ward during the study were asked to reported that he had also felt uncom- patients were upset by the link (Ques- use the link but most were. Some op- fortable talking to patients on the tion 8 on the professional FOS) was portunities were missed because of telephone. A second, psychodynami- compared with the actual patient lack of room availability. Refusals cally orientated, psychotherapist felt response (Question 4 on the patient were given particular attention and that on the LCVC, he was having a FOS). In 25 of 44 interactions the details of the reasons for refusal to ‘nice chat’ with the patient rather than psychiatrists over estimated the participate in the study were recor- getting’ under the surface of the pro- degree to which the patient was upset ded. Most were due to illness rather blem’ He claimed that he could no by the LCVC. Six under-estimated than concerns about the link. One longer detect subtle nonverbal cues this distress and in 13 it was estimated patient with schizophrenia asked to such as pupillary changes. He felt correctly ( Figure 1) stop after he had started to use the that his nonverbal behaviour, which LCVC and the observers thought he would usually put the patient at ease Exploratory studies may have incorporated the LCVC during an interview was missing on into his delusional system. Psychia- the LCVC. He summed up the whole An exploratory study was perfor- trists were reluctant to use the LCVC experience as, ‘trying to propose mar- med on the reliability of the Brief for sensitive interactions such as riage to someone in Australia on the Psychiatric Rating Scale (BPRS), given a diagnosis of HIV and asking ‘phone that you don’t even know’. rated by independent psychiatrists 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 the- rapist. 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 Figure 1 Mc Laren, Charles-Nicolas 121 seeing the patient by LCVC and face- The MCVC of image quality or evidence of pro- to-face, with the order randomised. fessional bias but its importance Four patients and two psychiatrists The ultimate objective for Work- should be elaborated before Telepsy- participated. Significant positive cor- group 5 of Telemed was to establish chiatry services can be more wide- relations were found and for the a videoconferencing link over broad- spread. Telemed started to look at the observational subscale the correlation band. This was done, but only after impact of the medium on the clinical coefficient was 0.84 [1]. The reliabi- considerable delay. A case series was communication but barely scratched lity of cognitive testing over the studied of patients attending an out- the service. Useful exploratory work LCVC was also explored [3]. patient clinic at the Speedwell Mental was performed on the methods which Studies also looked at levels of Health Centre. One MCVC was could be used to tease out these messy turn taking, when the partici- installed there and the other at Guy’s issues. pants spoke simultaneously in con- hospital about 10 km away. Patient Telmed stimulated the research versation, and mutual gaze for the responses were positive and a proto- groups at Guy’s and the Croix Rouge LCVC consultations. Rates of messy col for running such a remote clinic to work further in this field. turn taking were higher for LCVC developed (8). Prescriptions for me- consultations than face-to-face but dication were posted to the patient’s this difference did not reach statistical home. This phase of the study was significance. Episodes of mutual gaze terminated prematurely because no Literature appeared longer in LCVC consulta- further funding was available for the tions than one would predict from broadband link. [1] Ball, CJ & McLaren, PM (1995) “Com- normative data. Numbers were small parability of Face-to-Face and Video- link Administration of the Brief Psychi- and the range was large making firm atric Rating Scale” American Journal conclusions difficult. of Psychiatry 152-6 When interviewing a patient on Discussion [2] Ball, CJ; McLaren, PM; Summerfield, the LCVC a user can only see the AB; Lipsedge, MS & Watson JP (1995.) A Comparison of Communication head and shoulders image of the other The LCVC and MCVC were tech- Modes in Adult Psychiatry. Journal of user. Nonverbal communication from nically obsolete before the end of the Telemedicine and Telecare. 1, 22-26. other body areas is lost. The effects of Telemed project and had no potential [3] Ball, CJ; Scott,N; McLaren, PM & Wat- this loss of non-verbal communica- for commercial exploitation. The son, JP (1993) “Preliminary Evaluation tion on the clinical impression for- main benefits accruing from the of Low Cost Video-conferencing (LCVC) System for Remote Cognitive med by the psychiatrist was studied. inclusion of technical and clinical Testing of Adult Psychiatric Patients” Six areas of potential clinical signifi- academic partners together in the pro- British Journal of Clinical Psychology cance were chosen for investigation: ject were building new relationships 32, 303-307 anxiety, depression, anger, flattening and mutual understanding. The plan- [4] Glikman, J; McLaren, PM; Lipsedge, M; Abraham, A; Marcellot, JG & of affect, incongruity, and involun- ning of Telemed was highly detailed Bagoe, MC La Pratique des Conferen- tary movements. Twenty-three one and this reduced the flexibility for ces Cliniques Telephoniques Entre minute segments taken from five following leads in an area of new Equipes Pshciatriques en Europe Pres- interviews were used for rating. Each research. Workgroup 5 recognised at ented at LXXXX eme Congress de Psy- chiatrie et de Neurologie de Langue interview had been simultaneously an early stage that the technical re- Francaise Saint Etienne, France 15-19 videotaped from two camera angles, sults would be of limited value and June 1992 one of the head as seen over the focussed on studying user responses [5] McLaren, PM; Ball, CJ & Watson, JP LCVC and the other of the body of and research methods for understan- (1993) “Assessment for Psychotherapy the interviewee viewed from the side. ding the impact of the medium on by Interactive Television Suitable for Transmission Through Telephone Incongruity and involuntary move- clinical communication in psychiatry. Links” Psychiatric Bulletin 17, 104-05 ments occurred too infrequently to be The report of the incorporation of [6] McLaren, PM; Ball, CJ; Summerfield, included in the analysis. The results the technology into a psychotic delu- AB; Lipsedge, M & Watson, JP (1992) showed that, in general, a head only sional system is significant and wort- “Preliminary Evaluation Of A Low Cost Video-Conferencing System For Tea- view does not significantly impair hy of further study. Previous authors ching In Clinical Psychiatry” Medical clinical judgements of depression, such as Solow [13] had not obtained Teacher 14, 103-109 anger, and flattening of affect; but this finding. Another interesting fin- [7] McLaren, PM; Ball, CJ; Summerfield, that it does impair the assessment of ding was the tendency of psychia- AB; Watson, JP & Lipsedge, M (1995) anxiety. trists to over-estimate the degree to “An Evaluation of the Use of Interacti- ve Television in an Acute Psychiatric which the LCVC upset patient users. Service” Journal of Telemedicine and This may be a novelty effect, an effect Telecare 1, 79-85 The Telemed Project (RACE-Project R 1086) 122

[8] McLaren, PM; Blunden, J; Lipsedge, & Dr Paul McLaren MB BS MRCPsych M; Summerfield, AB (1996) “Telepsy- Honorary Consultant Psychiatrist chiatry in an Inner-City Community South London & Maudsley NHS Trust Psychiatric Service” Journal of Tele- medicine and Telecare 2, 57-59 Speedwell Mental Health Centre [9] McLaren, PM; Glikman, G; Abraham, 62, Speedwell Street A; Ball, CJ; Lipsedge, M & Watson, JP London SE 8 4 AT Comparison of User Responses to a Digitised Interactive Videoconferen- Email: [email protected] cing System for Remote Diagnosis and and Medical Directo Treatment in Psychiatric Services in The Priory Ticehurst House France and the UK Presented at World Ticehurst, Wadhurst Congress on Telemedicine Toulouse November 30 - December 1 1995 East Sussex TN5 7HU [10] Morley I.E. & Stephenson G.M. (1969) United Kingdom Interpersonal and inter-party exchange; A laboratory simulation of an industrial negotiation at the plant level. British Professeur Aime Charles-Nicolas MD, Journal of Psychology, 60. 453-545 PhD [11] Mulhall , D.J. (1976). Systematic Self- Professor of Psychiatry and Psychologi- Assessment by PQRST ( Personal Que- cal Medecine stionnaire Rapid Scaling Technique). University Hospital of Fort-de-France Psychological Medicine,6. 594-97. PO Box 632 [12] Short J.A., Williams E., Christie B. (1976). The Social Psychology of Tele- 97261 Fort de France (Martinique) communications. London. Wiley Inter- France national Email: aime.charles-nicolas@martini- [13] Solow C.& Weiss R.J. (1971) 24 hour que. univ-ag.fr Psychiatric Consultation via TV. Ameri- can 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 Neuropsychiatrie, Volume 18, S 2, 2004, page 123-126

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

1Athens University Medical School, Dept. of Psychiatry, Eginition Hospital, Athens 2Institute of Communication and Computer Systems, Athens

Key words absence of disease or infirmity, is a lopment of an organizational structu- telepsychiatry, information technology, fundamental human right and that the re suitable for system or network telematics, Islands Project attainment of the highest possible development and implementation, (e) level of health is a most important normative standards in terms of phy- world-wide social goal whose reali- sician and user regarding quality of zation requires the action of many care, confidentiality, and acceptance. Perspectives of Communication other social and economic sectors in The development of new communi- Technology in Psychiatry: The addition to the health sector”. Even if cation technologies promises to ISLANDS Project in Greece these criteria are not fully met by the enhance access to healthcare for Abstract: The genesis and appli- medical services provided worldwi- remote disadvantaged communities, cation of new communication techno- de, the main objective is to provide to since all citizens have equal rights to logy in delivering psychiatric servi- the entire community high quality benefits pertaining to the healthcare ces in Greece is presented. More medical and welfare services, especi- system. Successfully functioning in specifically in Greece the application ally to those most in need. This may Greece are the low cost telemedicine of communication technology in deli- be the case of the mental health needs systems, that includes telecardiology vering mental health services inclu- in the remote areas (rural and insular). and teleradiology. There is a growing des the low cost telephone lines. Telemedicine is a term applied for need for mental health services, in the Recently new communication tech- specific clinical appellations, such as national health care system, in order nologies has been introduced in men- teleoncology, teledermatology, or to cover gaps, between urban areas tal health in order to provide informa- telepsychiatry. Furthermore, diagno- and insular areas in Greece. tion and educational material on men- stic medical services such as radiolo- The application of communica- tal health issues. Moreover this articel gy and pathology use this technology tion technology and essentials of focuses on conceptual issues of the to capture, transmit, store, and retrie- telemedicine in the delivery of psy- Islands Project in Greece such as: the ve information and also are provided chiatric services, is telepsychiatry. aim and methodological issues in the by specific designations which, in Telepsychiatry therefore includes all development of this project and this instance are teleradiology, tele- forms of contemporary communica- underlying the lack of other projects cardiology and telepathology, respec- tion technologies applied to mental and the lack of a comprehensive rese- tively. Bird [1], provided the first for- health services: synchronous real arch strategy that specifies the objec- mal and published definition of tele- time audio data (telephone), synchro- tives of telepsychiatry in remote are- medicine as “the practice of medicine nous real time audio and video data as in Greece. without the usual physician-patient (videoconference), store and forward confrontation”. Another definition (e-mental health services). The later, was proposed by Bashshur [2]. This could be define as new communica- definition viewed telemedicine as a tion technologies and includes both Introduction system of care composed of six the internet dissemination of psychia- essential elements: (a) geographic tric information and educational Contemporary trends concerning separation between provider and reci- material through web sites and the health and welfare, as described by pient of information, (b) use of infor- use of the e-mail in providing direct the World Health Organization sug- mation technology as a substitute for services by professionals. Aims of the gested that “… health, which is a sta- personal or face-to-face interaction, present article are to describe the cur- te of complete physical, mental and (c) staff including physicians, assi- rent communication technology in social well being, and not merely the stants, and technicians, (d ) the deve- delivering psychiatric services and to Perspectives of Communication Technology in Psychiatry: The ISLANDS Project in Greece 124 present a conceptual framework for tance of communication technology the net anonymously in order to ob- the development of Islands Project in in providing mental health services. tain medical information. The net is Greece. Despite the fact that EPHL has been linked directly to the mental health receiving phone calls from all over services already provided by the Greece, its potential and purpose are Department of Psychiatry and to the limited and cannot provide full psy- Counseling Center for Students. Communication technology chiatric coverage to all (mainly insu- Among the questionnaires the websi- and psychiatric services in lar) under serviced communities. te host are and several assessing the Greece Finally, considering that there is a internet use and the extent to which it growing need for mental health servi- has affected every-day lives of users. a. Emergency Psychiatric Help Line ces a significant question to be asked The main target of the “Glau- is whether the development of full copis-net” are mostly specific groups Over the years the development of scale telepsychiatric services with the of the urban and remote under-servi- telephone counseling and listening application of new communication ced areas that have access to internet services has become widespread technology (NCT) (both telephone, e- providing both information regar- throughout the world [3]. In Greece mental health units and videoconfe- ding the EPHL and educational mate- alternative mental health services rence units) can cover the existing rial. The use of new communication with the use of communication tech- gaps and the needs in the national technology (NCT) through the “Glau- nology begun in 1987 with the use of mental healthcare system [8]. copis-net” may be appropriate in Help Telephone Line located in order (a) to help people who avoid to Athens Mental Health Center [4]. Ten visit classical psychiatric services to years later 1999 a new Telephone b. E-mental health get in contact by telephone with a Help Line, the Emergency Psychia- mental health specialist (b) to unco- tric Help Line (EPHL), was created at The department of Psychiatry at ver new types of possible problems Eginition Hospital under the support Athens University, Eginition Hospital such as the internet abuse and (c) to of the Department of Psychiatry of has commenced the operation of the provide information on mental health Athens University. EPHL as a special “Glaucopis-net”, (http://glaucopis. services [9]. interest line provides services in situ- eginitio.uoa.gr) a network aiming to ations related to mental health pro- provide e-mental health services blems [5]. EPHL acts as a bridge bet- through the internet. Glaucopis-net is ween psychiatric services and being deployed with the help and The Islands Project patients in the community and offers know-how of the laboratory of Medi- Objectives information concerning mental disor- cal Physics at Athens, Greece, Uni- ders to the families of mentally ill and versity. The net is directly linked to The objectives of the Islands Pro- consultation to medical practitioners the Athens ‘Asclepieion Park’, deve- ject has been formulated and includes in remote rural and insular areas. loped by the above mentioned labora- “…. the development of services in During the first year of function tory. The 'Asclepieion Park of Athens' order to provide modular, non-con- EPHL (from May 1999 to May 2000) is the first pilot application of the ventional, remote psychiatric and accepted a total number of 2055 pho- 'Modern Asclepieions' concept in psychotherapeutic assistance for ne calls [6]. During the period May which Health and Culture are promo- remote areas. By these means quality 2002 to May 2003 , more than 3900 ted in parallel for the benefit of the of life of the users, quality of mental phone calls and during the period citizens, the patients, the people who health care and the economic 2001 to 2004, 9000 phone calls. The look after them and the healthcare strength of the region should improve major domains of reasons for seeking and welfare workers. The 'Modern and overweight the costs of imple- telephone-help was: loneliness, coun- Asclepieions' concept is based on the mentation and service support. The seling of mentally ill parents and Ancient Asclepieions, as they were project will reduce inequalities in patients (delusional or not), psycho- conceived, developed, functioned mental health services and status logical crisis and management of and evolved in the Ancient Greek among European regions …” anxious user, psychiatric counseling World (http://asclepieion.mpl.uoa.gr/ in health care practitioners. EPHL Parko/enchoose.htm). The “Glauco- also, has provided services in the pis-net” website aims to provide e- community by facilitating psycholo- mental health services and informa- gical interventions in the context of tion to the general population. During major disasters [7]. This role may be the three years of functioning 2001- reflective of the community accep- 2004 more than 3000 visitors joined Politis, Pehlivanidis, Amditis, Lentziou, † Markidis, Trikkas, Rabavilas 125

The Islands Project in psychiatric disorders in the island. of rural and urban areas in the same Greece: Our department therefore decided to island may lead to a different pattern study the potential benefits of the in delivering mental health services (a) The Islands application of communication tech- with NCT. Insular remote areas are nology in the delivery of special psy- sparsely populated and often trans- The Greek pilot will take place in chiatric services to Andros as a pilot portation is needed to visit specialist the Cyclades islands for the period plan for the rest of the islands or low cost telephone lines are in use August 2004 to February 2005 (for through three different communica- in order to get counseling in these intervention) and June 2005 to Sep- tional channels: remote insular areas. Patients evalua- tember 2005 (for post-evaluation). a. desktop videoconference ted by NCT must still travel to the site Data concerning the prefecture of b. low cost telephone line (EPHL) where the equipment is located. The- Cyclades is available. Nineteen is- c. ISLANDS system se facts lead us to believe that a gap lands with a population of 110.000 may exists also in delivering mental people are serviced by 3 psychiatri- health services in the geographical stis, all occupied at the general hospi- (b) conceptual observations on the dimension of the island with different tal, on the island of Syros. A classical pilot study in Greece implications for the NCT applica- example is the island of Andros tions. Considering that economic which is the second largest island of New Communication technology subsidies will always be necessary, the Cyclades. It is situated in the (NCT) is intend to be used in order to except the cost of equipment, trans- Aegean sea, 37 n.m. from the east provide affordable high-quality men- mission lines, other infra-structure; cost of the peninsula of Attika. The tal health services including diagno- technical personnel; requirements; island had a population of 10.000 sis and continuity of care to patients space and training staff. Thus evalua- peoplte census of 2002. The number in areas that are deprived from psy- ting the accessibility, feasibility, increases significantly to 3 or 4 times chiatric services. The planning and effectiveness and costs-efficiency of during the summer months owing to application of NCT in such remote the new communication mental the influx of the tourist. There are no insular areas must take in considera- health services between urban insular primary or secondary mental health tion all possible methodological limi- and remote insular areas may lead to services. Tertiary services are con- tations [10]. There are no studies indi- an improvement of the quality of care tracted to mental health hospitals on cating the frequency of NCT use in provided by the local Health Center, the city of Athens, that distances 4 mental health from the population in decreasing both the access to tertiary hours, and psychiatric services provi- Greece. However, it seems that use of services and the citizen anxiety du- ded by the General Hospital of the low cost telephone lines and the ring an emergency situation. Could island of Syros that distances 3 hours, access in the internet in order to get other types of services, such as visits but without the possibility to provide information or educational material by psychiatrists or trained primary hospitalization. Users of mental or counseling is more frequent in care physicians supplemented by health services have to travel mostly urban areas than in remote rural and telephone contacts with a psychia- to Athens for psychiatric assessment, insular underserved areas. This gap trist, provide more personal service at treatment and follow up. The health between urban and remote areas in the same or a lower cost? Can a struc- center of the island provides basic the use of communication technology tured interview with the patients and psychiatric follow up to about 60 out- may be the result of various factors. the relatives conducted by another patients every month. The medical Among them social factors (such as clinician, followed by a telephone staff of the health center deal with stigma, acceptance of a new commu- call, accomplish objectives similar to acute or chronic psychopathological nication relationship with a specia- those of a modular, distributed tele- manifestations every month (psycho- list), financial, age related, educatio- psychiatry platform, which will allow sis, depression and others problems nal factors and lack of information on transfer of critical parameters in a related to substance abuse, acute the existing services may affect the secure medical telecare network bet- stress manifestations and dementia) accessibility to mental health services ween patients, their family members and merely number of patients are trough the NCT. Access refers to an and/or stationary centres, equipped admitted in psychiatric hospitals in individual ability to obtain needed with medical staff, enabling virtual Athens for specialized psychiatric services. Access has various dimen- telepresence, remote monitoring and help. However, there are no data sion such as geographical, financial, teleconsultation with medical experts. regarding the delivery of psychiatric social, cultural and psychological. Parameters such as the quality of services from the population and the- Often in the geographical dimension human interaction and the importance re are no epidemiological data regar- of the island we can identify urban of personal contact may influence the ding the prevalence and incidence of and rural, remote areas. The presence acceptance of the NCT. It is one thing Perspectives of Communication Technology in Psychiatry: The ISLANDS Project in Greece 126

to conduct an emergency assessment 9. Lambousis E, Politis A, Markidis M, via NCT to decide whether a person is Christodoulou GN. Development and delirious or suicidal and quite another use of on line mental health services in Greece. J Tele Telecare 2002; 8: 51-52 to have a sustained relationship via 10. Frueh BC, Deitsch SE, Santos AB. Pro- NCT with a chronically ill indivi- cedural and methodological issues in dual? Thus, a satisfaction analysis for telepsychiatry research and program specialists, service users relatives and development. Psychiatric Services health care professionals has to be 2000; 51: 1522–1527 tested. At all events the implementation of NCT is not solely bound either to Prof. Dr. Antonios Politis therapy or teleconsultation. It equally Lecturer in Psychiatry applies to a major parameter of a Athens University Medical School national psychiatric healthcare sys- Eginition Hospital tem, the continuous tele-education of 72-74 Vas. Sophias Ave healthcare providers. However, the 11528 Athens successful application of this new Greece method in healthcare is greatly de- E-mail: [email protected] pending on a careful structural plan- ning, so that its functional cost would not exceed the cost of the problem it is supposed to solve.

References:

1. Bird KT. Teleconsultation: anew health information exchange system. Third Annu. Rep. Veterans Admin. 1971 Was- hington DC. 2. Bashshur RL, Reardon TG, Shannon GW. Telemedicine : A new health care delivery system. Ann Rev. Public Health 2000; 21: 613-637. 3. Seeley MF. Hot lines-we believe. Crisis 1992; 13: 63-64 4. Kontaxakis VP, Stylianou M, Panopou- lou-Maratou O, Chrisogonou S, Poly- chronopoulou K, Christodoulou GN. Seeking emergency help by phone: sex differences. In Preventive Psychiatry (1994) eds GN. Christodoulou, VP. Kontaxakis. Athens, Mental Health Center 5. Seeley MF. What are hot lines? Crisis 1994; 15: 108-109 6. Politis A, Lambousis E, Markidis M, Ber- giannaki I, Christodoulou GN. Athens Emergency Psychiatric help line: report from the first year of service. Technology and health care 2001; 9: 356-357 7. Politis A, Markidis M, Lambousis E, Ber- giannaki I, Christodoulou GN. Effects of a Major earthquake on phone calls to a psychiatric emergency help line. Techno- logy and health care 2001; 9: 354-355 8. Markidis M, Politis A. Telepsychiatry: prospects for the use of new technologies in every day practice. Psychiatriki, 1999 ; 10 :.263. Neuropsychiatrie, Volume 18, S 2, 2004, page 127-130

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 increasingly being applied, relates to reds of telephone calls and he had to telepsychiatry, help-lines, crisis interven- mental health services provided engage his relatives and friends. And tion, counselling through any form of electronic so the first European help-line origi- medium, most commonly via the nated. Inspired by the London model History of Telepsychiatry in the Internet or telephony. many help-lines all over the world Czech Republic The expansion of telephone lines emerged. The development of telemedicine was the first step towards telepsychi- From the very beginning Varah’s and hence of telepsychiatry has atry. Nonetheless at that time terms conception of the telephone help was always been connected to the deve- like telepsychiatry or telemedicine an apolitical, irreligious, independent lopment of communicational techno- were not commonly used. and on volunteer-ship based organi- logies. First telepsychiatric services The cornerstone of telepsychiatry sation. It was named The Samaritans. in the world were the telephone help- in Central and Eastern Europe was This organization trained and psycho- lines, the very first coming from Lon- the foundation of the first Czech help- therapeutically educated various spe- don. This article concerns about the line in 1964. cialists like psychologists and psychi- history of telephone help-lines in atrists to provide help to people in a Czech Republic and former Czechos- crisis and especially to those endan- lovakia, describes the types of help- gered with suicide till nowadays. lines available and gives future possi- Help-lines in Europe According to the results of a study bilities for telepsychiatry in this published in Great Britain in 1982 a region as a pattern for Eastern Euro- We may consider help-lines to be statistically significant reduction in pean countries. the first real-time telepsychiatric ser- suicidal rates could be observed in vices. For already 50 years help-lines those places where help-lines were have its unique place in the system of established. urgent medical aid providing crisis Nowadays help-lines are working Introduction intervention via telephone. not only in Europe but also in Ameri- The first telephone help-line has ca, Australia and Asia. The development of telemedicine been working in London since In Europe the densest network of and hence of telepsychiatry has November 1953. An Anglican vicar help-lines can be found right in Great always been tightly connected to the Chad Varah founded it in the cata- Britain. There are as many as three development of communicational combs of a church. It was working 24 thousand help lines that fulfil the and audio-visual technologies. Its hours a day. The main purpose of this definition of Telephone Helplines present-day expansion is made possi- help-line was the prevention of high Association (THA) that a help-line is ble because of the wide-ranging suicide rates in London. Its origin was an non-profit organization offering introduction of digital data transfer very simple. Vicar Chad Varah was all or at least a part of its services via technologies. inspired by the fact that in London telephone. These services include Telepsychiatry has generally been there were three suicides a day. It is support, counselling, and information thought of as being the delivery of said that a suicide of a fourteen years access as well as links to specialists. health care and the exchange of old girl made him place an advertise- In the vast majority the employees of health care information for purposes ment “Call me before you commit the help-lines working in Great Bri- of providing psychiatric services suicide” in a newspaper. The respon- tain are unpaid volunteers. across distances. The relatively recent se to the advertisement was unimagi- THA is the only help-lines associ- term „e-mental health“, however, is nable. Varah couldn’t manage hund- ating organization. Nevertheless the- History of Telepsychiatry in the Czech Republic 128 re are not more than 650 help-lines nization works in close relation to The term “linka du˚veˇry”is used that work in a standardised way. WHO and many other international as a unifying characteristic of diffe- In 1986 Esther Rantzen, a famous heath and social institutions and orga- rent telephone help-lines with very TV moderator, has founded a Child nizations. similar goal: Urgent and emergency Line in London. From the beginning At an IFOTES congress in Gene- telephone contact with people in it was working 24 hours a day and it va in 1973 international standards of need. covered all the area of Great Britain. telephone help were postulated. The- Some of the help lines have speci- The first help-line in continental se standards are generally accepted alised on a specific part of population Europe has been founded in Western by all help-lines whether or not they (children, teenagers, seniors); other Berlin in 1956. In 1957 in Zurich are members of the IFOTES. help-lines have oriented in particular another help-line named “Given problems of specific population Hand” appeared. Between 1957-1975 (alcohol, drugs, AIDS, homosexuali- other 13 help-lines were set up. After ty, home violence, etc.) a short period of scepticism they were Help lines in Czech Number of telephone calls at the generally accepted. Since 1975 these Republic end of the ninetieths was approxima- services are accessible from all over tely 50 thousand per year. the Switzerland with as many as 50 In the Czech Republic (former The rising number of help-lines thousand contacts per year in 1975 Czechoslovakia) there is a forty years had brought several changes in the and twice as many in 1981. tradition of telephone help-lines. Doc- conception of their practice: The help-lines can be contacted tor Miroslav Plzák founded the first 1. Not only specialists but as well using a three digit emergency calls Central and Eastern European telepho- trained laymen work for the help- telephone numbers since 1976 in ne help-line named „Linka du˚veˇry” lines. They are not licenced psycho- Switzerland. in 1964 in Prague at the Psychiatric therapists. They accomplish acute The help-line founded in Cze- Department of the 1st Medical School intervention only. choslovakia in 1964 became a model of the Charles University. Because of 2. The need to protect and support for founding similar facilities in Cen- his personal initiative this help-line the professionals as well as the need tral and Eastern Europe. In many of was included in the official health care of professional growth and informa- these countries help lines are named system. The founding intentions of tion exchange led to the establish- by the Czech specific term “Linka this help-line were similar to those ment of Czech association of help- du˚veˇry” (=Line of confidence). already mentioned. It had to prevent line workers in 1995. In Poland professor Bukowczyk people from committing suicide, help 3. Specialised software is used by founded telephone help-lines since them with their depressions and other many organizations to store and eva- 1967, named “Telefon zaufania”. mental problems and disorders. The luate data coming from the help lines. In Hungary they have their help- foundation of this help line is still an 4. Specialized educational pro- line since 1971, the first being called unappreciated success of the Czech grammes for help-line workers were “Leki Elsögy Telefonszolgát”. health system. In the following year in created. They should be prepared for In former Soviet Union the first Brno (the second biggest city in Czech various calls of different degree of help-line was founded in Moscow in Republic) a help-line called “Linka emergency or abuse. They should be 1971 to prevent suicides. There are nadeˇje” (= Hope line) was founded able to react quickly but circumspect- other help-lines working in many of by professor Hádlik. In 1967 “Linka ly. They should be well informed the bigger cities in Russia now. du˚veˇry mládezˇe” (= help line for about the community situation, they Help-lines were founded in Bul- youth) has been opened also in Prague should be able to provide psychosoci- garia and former Yugoslavia. at the Psychiatric Department of the al information or give links to proper In most of these countries, as well 1st Medical School of the Charles Uni- specialists or workplace. But as well as in the Czech Republic, help-lines versity. they should remain authentic human are a part of the official health care Fruitful though by political situa- beings. This can be achieved by diffe- system. Towns, cities, regions or tion limited international contacts rent ways. The first one is a speciali- church usually fund help-lines in were from the very beginning used to zed training in telephone crisis inter- Western Europe. share experiences from different coun- vention that includes practice in In Geneva in 1960 International tries. general help-line work as well as in committee and International secreta- The process of establishing help specialized themes (dependence, sex, riat of help-lines was established and lines was very quick and so in 1996 legal aspects, abuse and violence, sui- in 1967 International Federation of there were 37 registered help-lines in cide, reaction to traumatic experien- Telephonic Emergency Services the Czech Republic and around 60 in ce, etc.) The second one is a self- (IFOTES) was constituted. This orga- 2000. experience psychotherapeutic trai- Doubek, Kott, Raboch 129 ning that has its value especially in 2. Help-line with outpatient clinic Personal specific problems are personal growth and development. where the calling person can be invi- solved in online counselling. If the Casuistic seminars where different ted to come if necessary. query is somehow general and if the approaches are presented and discus- 3. Help-line being a part of a inpa- asking person agrees the query will sed are the third way. And the other tient clinic appear in the Archives of online possibilities include Balint supervi- counselling. sion seminars, individual supervision, Types mentioned above differ not Both chat and online counselling self-experience, or literature study. only in help flexibility and prompt- complement each other and give the ness in urgent cases but as well in lekarna.cz visitor a unique possibility overextension of the workers and in to obtain relevant information not the degree of dependence on subse- otherwise found on the web. Working at a help-line quent services.

The work at help-lines is very eventful. People may call because of Conclusion themselves or because of somebody The development of tele- else. They may be in great tension but psychiatry and e-mental The development of modern tele- as well they may be worried about health in Czech Republic communication technologies made somebody or something. The help- other than only help-lines telepsychi- line worker must be well prepared for With the introduction and deve- atry tools possible. Nowadays we are all of these situations. Easy ones or lopment of the Internet in the Czech witnesses of a huge boom of internet even abusive calls (invectives, sense- Republic specialized counselling and mediated help and education possibi- less requests) may follow urgent later on-line chats have emerged on lities that give a person in need but as emotionally filled difficult calls. This medical servers. E-mail counselling well professionals and informal all contributes to enormous psychic running since November 1999 on the carers opportunities to access to help burden of the help-line workers. Fol- web pages lekarna.cz was a forerun- or counselling from the best specia- lowing the principles of mental health ner to an on-line chat. Any web visi- lists all over the world. hygiene may be the easiest way to tor could address his or her query The Psychiatric Department of the prevent the burn-out syndrome. about medical problems using an e- 1st Medical School of the Charles Uni- mail box. The query was quickly redi- versity in Czech Republic is one of the rected to a specialized doctor and the ISLANDS project partners and parti- answer was sent back to the person cipates in the development of integra- The aims of telephone cri- via e-mail. Repetitions of some que- ted system for long distance psychia- sis intervention ries as well as 10-15 queries per day tric assistance and non-conventional made the web page provider to start distributed health services. This pro- The first aim is to calm down the an on-line chat and on-line counsel- ject extends the possibilities and tools calling person to stabilize his or hers ling. Both services have been introdu- of present-day telepsychiatry. situation, to reduce the risk of crisis ced three years ago. progression or to prevent suicidal Chat offered to the visitors many behaviour. interesting topics that could be The perspective aim is to work out discussed in general public. This pro- References the closest future with the calling per- ject was supported by General Uni- son and if possible to find possible versity Hospital in Prague. [1] Eis Z. Volejte linku du˚veˇry! H&H ways of solution. Nowadays live discussion takes Jinocˇany, 1993 [2] Knopová D, Bahbouh R, Basˇtecká B, Help-lines have wide indications part every week at lekarna.cz. A week Bouchal M, Eis Z, Havránková O, but their main purpose is not to make before the discussion is advertised at Kucˇera Z, Lucká Y, Nováková Z, a diagnosis but to solve a problem. the lekarna.cz homepage as well as Tichy´ V, Zajíc R, Zemanová E. Telefo- the specialist profile and a simple CV. nická krizová intervence – Linka du˚veˇry. Remedium Praha , 1997 Those who cannot join the live chat [3] Kopecˇek M.: Internet v lékasˇské praxi. may ask their questions in advance. Psychiatrie, 2002, 6 (2), 92-96 Help-lines types These questions will be answered [4] Plzák M, Br`ezinová B, Zvolsky´ P: during the discussion. All these Depresivní stavy v dospeˇlém veˇku. 1. Help-line as an independent discussions are saved in the Archives SZdN, Praha, 1967 [5] Sekot M.: Vyhodnocení vy´sledky organisation. Other services are not files and are accessible with a full text Vánocˇní linky proti depresi. Cµes. a provided. search engine. slov. Psychiat., 2000, 96(8), 434-436 History of Telepsychiatry in the Czech Republic 130

[6] Wootton R, Craig J. Introduction to Telemedicine. London: Royal Society of Medicine Press, 1999 [7] 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@ceskapsychia- trie.cz Neuropsychiatrie, Volume 18, S 2, 2004, page 131-136

Report Telemedecine in French Guyana

Thierry Le Guen1, Nicolas Poirot2, Olivier Tournebize2 and Antonio Guell3

1Hospital Complex Andrée Rosemon of Cayenne 2French Space Medicine and Physiology Institute, Toulouse Cedex 3French Space Agency, Kourou, Cayenne

Key words (MEDES) an experimentation of tele The means of communication, put French Guyana, Satellite, Telemedicine consultation per satellite took place in aside on the littoral, are the water and portable workstation French Guyana, at the issue of which air ways, what complicates the work it was decided to make profitable and of the health professionals at the inte- to extend the installation of telemedi- rior for the management of the emer- Telemedecine in French Guyana cine portable workstation to the who- gencies and the pathologies requiring From December 2001 to May le guyanese territory. The goal of this a particular expertise. Rounds of spe- 2002 a Telemedicine survey was done article is to explain the methodologi- cialists are organised on the rivers in in French Guyana within the frame- cal steps, to present the results and to order to try to mitigate the difficulty work of an agreement between Cay- envisage the prospects of this project, of access for the isolated populations enne Hospital (CHAR) and the in particular in the field of psychiatry. to specialized care and to limit the French Space Agency (CNES), with delay in the diagnosis and therapeutic technical support of the French Space treatment In spite of these efforts, the Medicine & Physiology Institute inequality of medical treatment com- (MEDES). The context pared to the urban populations Expertise were done by specia- remains real. lists of the CHAR in tree specialities French Guyana is a vast overseas This geographical configuration (Dermatology, Parasitology and Car- department of the size of Portugal, was perfectly appropriate for the diology). Medical reports elaborated covered by 80% by the equatorial experimentation of telemedicine in with Telemedicine portable worksta- forest. The 200 000 inhabitants are order to facilitate the access for the tion, from 4 remotes sites of the Ama- divided to 80% in 3 cities of the litto- isolated populations to the specialist’s zonian forest, were sent by satellite ral: Cayenne, Kourou and St-Laurent expertise of the CHAR of Cayenne. phone to the Cayenne Hospital. of Maroni. These cities have the 3 Three specialities were selected for The survey was assessed on medi- hospitals, the private clinics and the the experimentation: dermatology, cal, technical and economical ways. majority of the health devices of the parasitology and cardiology. The results shown that objectives territory. 21 centres and isolated initially defined were reached, and health dispansaries depend on the decision of extension up to all remote CHAR of Cayenne. medical dispensaries was taken by The centres and health stations are health authorities. held either by general practitioners and paramedical personnel in the important communes, or by the para- medicals, nurses or agents of health Introduction for the small communes. They are the only access of the rural populations From December 2001 to May [1], approximately 20% of the Guya- 2002, within the framework of a col- nese to the cares. These professionals laboration between the Hospital of health thus face technical plates Complex Andrée Rosemon of Cayen- and means of telecommunications ne (CHAR), the French Space Agen- limited to any type of request for care, Map of French Guyana (According to : cy (CNES) as well as the French Spa- tropical pathologies, gynaecology- «Géographie de la Guyane». Jacqueline ZON- ce Medicine and Physiology Institute obstetrics, traumatology, urgencies. ZON; Gérard PROST – Edition: SERVEDIT) Telemedicine in French Guyana 132

The choice of the specialities was out a remote diagnosis, starting from made by the doctors of the CHC after a centre of expertise (CHAR) and for a demonstration of sending macro the benefit of patients located in iso- and microscopic images and ECG lated sites which normally would not numerical recording via satellite from have access to this type of diagnosis real situation in two isolated commu- or have it in times incompatible with nes, carried out in October 2000. The a correct treatment of the pathology. choice was dictated by the important effect of parasitic pathologies (Palu- At the same time the objective of dism, leishmaniosis, intestinal parasi- the experiment, always in medical tosis …) and dermatological ones terms, was to not only validate relia- Telemedicine suitcase (leishmaniosis, various dermatosis ble medical protocols making it pos- the territory in particular the isolated …). The interest of these specialities sible to establish a diagnosis and a sites. being that the principal attacks could therapy but, as guarantee as this dia- effectively remotely be diagnosed gnosis and this therapy, to make sure and the objective evaluation of the the use of average technique like the telemedicine system was possible to tele transmission by satellite of the Results estimate the efficiency and limits of data, are medically (depending on the the use (systematic second reading of parameters of the profession and the 196 files were sent during the 6 the blades for parasitology, negatives state of the art) correct. months of experimentation (51 in after treatment for control for the der- dermatology, 108 in parasitology and matology). 37 in cardiology). The analysis by 4 sites were selected: Maripasou- Technical Objectives speciality allows to refine the use and la, Staint-Georges, Antecume Pata the usefulness of the telemedicine and Trois-Sauts. Each one of these • Validation of the availability and network. sites was equipped with a telemedici- the reliability for the system in time 1. Parasitology ne portable workstation including a and a “difficult” environment ( tropi- 2. Dermatology laptop, a digital camera, a digital cal rain forest, important water con- 51 files sent during 6 months, 32 electrocardiogram, a microscope and tent, random quality of the power from Trois-Sauts, 12 from Mari- a satellite telephone INMERSAT M4. supply, cloud cover, etc). pasoula, 6 from Antecume Pata A specific software was developed in • Ergonomics of the system com- and 1 from Saint-Georges. order to respond to the study’s proto- pared to the level of the users, as well 3. Cardiology cols defines by the guyanese doctors. in emission, in reception and hand- In 6 months 37 files were sent, 2 ling of the data. from Saint-Georges and 35 from Tro- • Quality and reliability of the is-Sauts. 4 files were related to thora- data compared to the requirements of cic pains, 2 were referred for routine Methodology the users and the need for the medical inspections among patients having practice. cardiac antecedent and 31 files corre- The principal objective of this sponded to systematic electrocardio- project was the qualification of an grams before the prescription of application of telemedicine likely to Economical Objectives [2, 3, 4, 5] Halofantrine for falciparum Paludism bring an improvement in the treat- treatment. ment of certain medical pathologies • Validation of the estimated costs in isolated sites. In particular the defi- as well in term of investments as in nes objectives were stated in three term of exploitation and maintenance headings: medical, technical and eco- cost. Discussion nomical • Comparison of the costs inferred from the use of the system of tele medicine and the costs of “traditio- 1. Parasitology Medical Objectives nal” medical interventions (evacua- The requests for expertise was tion by helicopter in particular) related primarily to confirmation’s In the field of parasitology, der- In general, to allow the authorities request for paludism diagnosis matology and cardiology (electrocar- (health and medical authorities) to (99/108 which means 92% of the diogram) we excepted the validation make reasoned decisions in term of expertise requests) on blood smears of a methodology allowing to carry choice of equipment and fitting out and/or thick drops. Le Guen, Poirot, Tournebize, Guell 133

Images of cutaneous lesions Technical complementary measu- In a context of a well trained field and/or cutaneous smears were sent res (new blades of smear blood (10), worker the diagnostic remain relati- within the framework of a diagnostic thick drop (36), strips ICT (15)) were vely easy but a formal diagnosis confirmation of leishmaniosis for 8 required to optimize returned result remain to be establish by a biologist. patients (7,4% of the expertise for 61 files. It was possible for us to validated requests), 6 of them presenting cutan- In the same way, technical advices the system on the qualitative level by eous ulcerations. (12 files) were made on the use of the comparing for the same patient the A diagnosis of intestinal parasito- microscope coupled with the digital result returned by telemedicine and the sis (0,6%) was required based on camera (in term of luminosity, of the result after reading and checking the stool analysis perform in saline water enlargement done, of the quality of blades transmitted to the laboratory of for a patient who was suspected of the pictures). Parasitology-Mycology of CHAR. amoeba dysenteriae (fever and bloo- The technical methods according dy-stools Diarrhoea) to protocols drawn up (time of colou- At total, for the same period, 85 Base on 108 responses sent to us , ring, type of colouring, conservation files could be compared: 12% of the latter had none formulated of the blades, contamination of the - 78 concerning the search for diagnosis, we did not find any parasi- blades by mushrooms) paludism ( on 509 requests for blades tologic contamination for 7 subject To improve the treatment of the from health centres sent to the labora- (6,6%) with 95 of certainty. relapses which have occurred among tory for the same period) For a great part of the files ( 73 certain patients, recommendations - 7 concerning the search for cut- which means 67,6% of the files) the were provided to the health care per- aneous leishmaniosis response was transmitted with 95% of sonnel concerning the possible com- There is no discordance for the diagnostic certainty. Only 7 responses plements of examinations to forward search of leishmaniosis between the were given without any certainty to CHAR and to the Institute Pasteur. tele medicine reading and the reading which means 5% of the files. One notes for 71 patients only one recourse to the expertise without % de P.fal P.viv P.fal+ P.mal P.sp Non for- Leish Amib Total accuracy P.viv mula-ted needing additional information to diag. conclude the files. 95% 24 28 3 1 2 7 8 73 In the same way, there was for 25 75% 8 9 2 0 1 1 0 1 22 patients one resort to the expertise 50% 1 1 0 0 2 2 0 0 6 with 1 to 2 complements of informa- 0% 0 2 0 0 2 3 0 0 7 tion (achievements of new blades of Total 33 40 5 1 7 13 8 1 108 smears or drops thick or strips ICT, clinical and parasitologic follow up at Table I: parasitology results D3 even D7 of the paludal initial access, information on the therapeu- SITES Eczema Infectious Various tic treatment carried out). Trois-Sauts 12 17 1 Folliculitis Six patients presented new palu- • Parasitology 11 1 tumefaction under dal episodes (between 2 to 4). - Leishmaniosis 9 cutaneous Therapeutic prescriptions were - Scabies 2 1 oral ulceration • Bacteriology 1 carried out for 60 files with the mole- • Viral 2 cule indication, the way of admini- • Mycology 3 stration, the posology. Maripasoula 4 2 1 ulcerate leg Concerning the prescription of the • leishmaniosis 1 1 mal perforant plantar Halofantrine (22), it way almost • mycology 1 1 sweat dermatite always recommended to realize a 1 melasma pre-therapeutic ECG (Cf. Cardiology 1 cheloid synthesis). 1 Sutton’s disease Therapeutic advice (18 files) Antécume Pata 2 2 mycology 1 ulcerate leg (molecules choice, reference and 1 pustulosis referral to founded protocols) and Saint-Georges* 0 0 0 prophylactic advice ( 4 files) ( use of Total 18 21 11 mosquito nets, of insecticides) were recommended. We find a clinical fol- Table II: dermatology results low up advice twice. ¥ The file from Saint Georges did not allow a diagnosis Telemedicine in French Guyana 134 carried out on blades within the routi- lost of sight. On 46 patients, 28 are days. This time limit in the event of ne framework at the laboratory. completely cured, 10 have improved, an acute cardiovascular problem is There is 3 cases of discordance 6 are stabilized, and 2 have worsened too long. It is advisable to adapt the (3.5%) for the diagnosis of paludism: (1 related to the pathology and 1 rela- cardiology protocol. - one is due to a writing error at ted to the misuse of the tele medici- Routine inspection among patients the time of the returned result. ne). Finally our estimate is that we having cardiac antecedents. 3 files for - For the second, it was answered were able to prevent an transfer from routine inspection further to known P.vivax at 95% of certainty; on the six Trois-Sauts: a child with an important cardiac antecedent (complete arrhyth- photographs controlled in tele medi- rash impetigo of the face potentially mia by FA, systolic breath from a cine, one confirms the P. falciparum leading to serious infectious compli- trisomic child). The layouts are nor- diagnosis, the other fives are more in cations was diagnosed and treated mal in both cases. favour of P.vivax . effectively with antibiotherapy, via Systematic electrocardiograms - The last file responded P. falci- distant telemedicine communication. before treatment by Halofantrine. parum in telemedicine was controlled A control using the same telemedici- 31 records were systematically trans- P.vivax on blades; only one image ne device showed a very drastic fered in order to diagnoses potential made it possible to establish the dia- improvement of the conditions. eqg conduction anomalies before any gnosis, the second being fuzzy there- On the whole, one can retain only prescription of Halofantrine for falci- fore non-interpretable. one failure related to the use of tele parum Plasmodium treatment. The request for control in tele medicine, by a bad diagnosis posed medicine and the request of blades initially, and a bad secondary orienta- 4. Out of Protocol returns towards the laboratory are tion. In the large majority of cases, The users were confronted with thus very important. Indeed, the the quality of the images is excellent. pathologies not included in the fra- reading of the blades makes it possi- In 4 cases out of 51, the images were meworks defined for the pre-opera- ble to have an overall picture. fuzzy and did not allowed diagnosis tional phase, so they used the electro- with certainty. The richness of the nic messaging as support of informa- 2. Dermatology [6, 7] comments and exchanges between tion transmission and request of On the 51 files, one finds the fol- the hospital specialists and the actors expertise, by joining images as lowing diagnostic index: of health in the communes allowed to attachments, or in certain cases the • Accurate diagnosis: 44 files out help at the continuous training of the- dermatology files. of 51 se latter. Pathologies: • Dubious diagnosis: 2 files out of • Tenosynovitis of the hand, initial- 51, 1 suspicion of clinically atypical 3. Cardiology [8] ly labelled as the carpal ternal leishmaniosis and 1 incomplete obser- 4 files having for reason of con- syndrome vation for lack of clinical information. sultation “thoracic pain” • Phlegmon of the thumb • Absence of diagnosis: 5 out of - Only one of these patients had a • Exocervicitis on ectropion 51: 3 by deficiency of initial observa- pathological recording having requi- • Stomatitis tion (fuzzy photographs, non-inter- red an EVASAN (Sanitary Evacua- • Talipes of a new-born baby pretable, and/or misses clinical infor- tion) on CHAR at a first place, then • Snake bite mation) and complementary absence after 2 days of hospitalization, an of return to the dermatologist’s EVASAN on Martinique for corona- Analysis: request of explanations, 1 by need to rography. A first transmission appro- • Snake bite: an EVASAN was make a cutaneous biopsy (diagnosis ach of a layout paper by fax, sent by prevented since the reptile was for- posed in a second time) and 1 by the doctor of Saint-Georges and mally identified on the attached interpretation error from the recei- checked by the cardiologist allowed photograph ( Bothrops atrox) and the ving doctor. the medical evacuation of the patient. patient did not show any clinical In Summary, the dermatology tele The electronic file was established signs of serious poisoning. consultation is reliable and as effica- secondarily to test the functionality of • Phlegmon of the thumb: an cious as (28 cases out of 31) a tradi- the tele medicine system. There is a EVASAN was carried out in emer- tional consultation. lapse of time of 4h10 between the gency after surgeon’s advice, the ima- An improvement can still be sending of the request and the dia- ge attached highlighting a functional introduce by a more detailed initial gnostic return. urgency. The vocal communication observation and a better quality of the - The three other files had normal by itself would not made it possible to exchanges. layouts. appreciate the gravity of the situation. 46 files out of 51 could be evalua- The delay of the response are too • Talipes: the physiotherapist of ted, the other 5 patients having been important: several hours to several CHC transmitted to the nurse of Tro- Le Guen, Poirot, Tournebize, Guell 135 is-Sauts protocols of massages and final results, in particular for the con- The average cost of a file is 78 physiotherapy preparatory to the sur- firmation or the invalidation, of the Euro of which 53 Euro goes for the gical treatment, preventing at the tele-diagnosis. cost of satellite communication same time an EVASAN of the new- • 16 “functioning of the telemedi- (INMERSAT). born and the mother for a specialized cine” items in two headings, treat- On a total of almost 200 files, 3 consultation. ment of the case without telemedici- EVASAN were prevented thanks to ne, to try to have comparative data the tele medicine per satellite system, 5. Economical Assessment between the normal practice and the both from “out of protocols”, coming As shown by the recent economi- use of the network of tele medicine from Trois-Sauts, located at three cal studies of telemedicine [9, 10], per satellite, and appreciation of the hours from Cayenne (roundtrip medi- there is an absence of methodological tele medicine in term of contribution cal helicopter): consensus on this particular subject. to the medical practice. • A snake bite All users are unanimous to say that, in • 17 “economical” items, in three • Talipes of a new-born baby addition, the traditional methods of headings • an important impetigo of a child economical evaluation in health do • The time passed, by the various face being able to involve serious not take into consideration the overall health professionals concerned, for infectious complications specificities of the medical practice the specific use of the system. These three prevented EVASAN supported by a telemedicine network. This specific time for the users of represent a cost directly avoided by Within the framework of the pre- the health centre does not include the the tele medicine per satellite system operational setting of the telemedici- time of examination (for example this of 14 250 Euro HT (before taxes); ne network per satellite in French heading, in the case of a parasitology Guyana, it was not possible for us to request includes the time to constitute 6. Technical Assessment set up a scientific methodology for the electronic file, of taking digital pic- French Guyana shows logistic economical evaluation by comparing tures and verify them, but does not take (transport of the material by air or the activity of the centres using tele into account the time of taking samples, river) and extreme climatic characte- medicine with the centres not equip- of preparation, and for blade’s reading, ristics for electronic material (heat, ped but having a comparable activity. time normally passed by the professio- very important hygroscope suppor- Nevertheless a particular effort was nal out of the use of the system). ting the moulds and premature wear). carried out to define and allow the For the doctor-coordinator and the A standard, equipment was selected exploitation of economic indicators, specialists it is the time of data analy- with specific humidity and dust pro- of efficiency and of the use of the set sis and of writing responses. The of as well as shock-proof . To hold up system. time to constitute the synthesis card is account of the constraints of moistu- A specific synthesis card was defi- also taking into account. re, we had absorbers containers of ned with the support of a professor • Medical extra costs, allowing an moisture and microwave ovens to and researcher of health economy at evaluation of the impact of the net- dehydrate the absorbers of moisture the ENST of Brest (Myriam LeGoff- work in term of treatments carried out in a regular basis. Pronost) [11]. locally, which would not have been The constraints concerning the This card is complete by the doc- prescribed without the exchanges electric provisioning of the sites tor-coordinator at the end of each tele permitted by the network of tele (power generating unit, sector) of medicine file. medicine. variable quality and being able to This card includes 56 items: • The economies achieved in term undergo abrupt variations, led us to • 11 “administrative” items allo- of EVASAN but also in term of protect the material by a catch light- wing to locate the cases (name of impact on the whole medical chain. ning protector out of frontal connec- health professionals, of the patient, Besides the functional approach ted to an inverter, itself connected to date …) of the analysis reserved for the syn- the electronic material. • 12 “medical” items in three hea- thesis card, more classical evaluation dings (final diagnosis, clinical evolu- data were collected: investment cost, INMARSAT RNIS Service tion, hospitalization) to specify the functioning cost, EVASAN. However The 64 Kbytes/s terrestrial RNIS case of the patient during the whole we have dissociated the fixed costs service from INMERSAT M4 was medical treatment process, tele con- from the variable costs depending on selected as being the only alternative sultation, treatment and local evolu- the functioning of the network, as of telecommunication in the Amazo- tion, or the become of the patient after well in term of personal time, as of nian zone allowing a deployment his hospitalization in order to be able costs of telecommunications which without pre-existent infrastructures to to correlate the initial medical data are the two principal factors. equip the centres and health stations exchange on the network with the of the capacity and especially suffi- Telemedicine in French Guyana 136 cient data to support the exchange of Conclusion References information. A certain number of breakdowns The pre-operational phase of the [1] Edlin M. Success in rural telemedicine. were noted concerning the antennas network of telemetry per satellite in Healthplan. 2003 Jul-Aug;44(4):60-2 [2] Gardeur P. [1996]: “ L’évaluation en of the terminals: French Guyana brought a certain num- santé”, Actualité et dossiers en santé • 2 intrinsic breakdowns: “HP ber of knowledge. publique, 17, pp.I-XLIV. LNA roasted” on a terminal, break- First of all, that it is possible, in [3] Contandriopoulos A.P. [1991]: “ L’éva- down related to a technical problem spite of the extreme operational diffi- luation dans le domaine de la santé : con cept et méthodes ”, in T. Le brun, J.C. on the antennas, defect of series of the culties of French Guyana, to deploy a Sailly, M. Amouretti L’évaluation en manufacturer on a new model of ter- telemedicine network in truly isolated matière de santé. Des concepts à l prati- minals. sites and to follow pre-established pro- que, Sofestec/Cresge Editeur, pp.15-32. • 2 extrinsic breakdowns: bad tocols. The dermatology forms part of [4] Dechant H.K. et al. [1996]: “ Health Systems Evaluation of Telemedicine : A handling of the cable of the antenna the medical specialities with the ima- Staged Approach ”, Telemedicine Jour- by the health professionals. gery which were evaluated the most in nal, 2, pp.303-312. telemedicine. Paradoxically if very [5] Giraud A. [1992]: L’évaluation médi- many works and a good number of ca-le des soins hospitaliers, Economie, Paris. operational networks of telemedicine [6] Al-Qirim NA. « Teledermatology: the Assessments and use the microscopic teletransmission case of adoption and diffusion of tele- Outlines of images with diagnostic aiming, they medicine health Waikato in New Zea- almost exclusively relate to the anato- land ». Telemed J E Health. 2003 Sum- mer;9(2):167-77. The very encouraging results of mopathology and the cytology. Very [7] Weinstock MA, Kempton SA. « Case the experimental phase led to the per- little examples of the use of tele micro- report: teledermatology and epilumine- petuation of the installations on the scopy for the diagnosis in parasitology scence microscopy for the diagnosis of initial 4 sites and to a development on was found in the bibliography which scabies. Cutis. 2000 Jul;66(1):61-2. » [8] Saxena SC, Kumar V, Giri VK. « Tele- 8 other isolated sites in 2003 and reinforces the interest of the choice cardiology for effective healthcare ser- 2004. carried out in French Guyana. vices. » J Med Eng Technol. 2003 Jul- Others specialities will be the Then , that it is essential to take Aug;27(4): 149-59. object of specific protocols: ophthal- care to integrate to the maximum the [9] Lobley, D. [1996]: “ The Economics of Telemedicine ”, Journal of Telemedici- mology, gynaecology-obstetrics, pae- applications of telemedicine to the ne and Telecare, 3, pp.117-125. diatrics, diabetology, traumatology. pre-existent system of care, to limit the [10] Luce, B. R., and Elixhauser, A. [1990]: A connection with the CHU of impact in the work organization and to “Estimating Costs in the Economic Fort de France will also make it pos- facilitate the appropriation of the tools Evaluation of Medical Technologies ”, International Journal of Technology sible to transfer files of neurosurgery by the professionals. Assessment in Health Care, 6 pp.57-75. and carcinology. Finally, that the quality of the care [11] Le Goff – Pronost M. [2000]: “ Evalua- Concerning telepsychiatry, it remains the final objective. It is impe- tion économique de la télémédecine ”, appears reasonable to use the existing rative to implement the methods and Congrès mondial de télémédecine, Tou- louse, mars. infrastructures. The network of vide- tools allowing an initial evaluation of oconference joining the three hospital the system. These methods must be of the littoral allows to contemplate, integrated into the protocols of specia- on the occasion of a phase of pre-ope- lities in order to allow a monitoring of Dr. Thierry Le-Guen rational study, the feasibility of the the network activity, and to cross- Char Cayenne telepsychiatric consultations within check the information if necessary. Rue de Flamboyants the framework of the ISLANDS pro- The efficiency of a system 97300 Cayenne ject (Integrated System for Long obviously goes through the relevance French Guyana distance psychiatric Assistance and of the technical choices, the elabora- [email protected] Non-conventional Distributed health tion of scientifically validated proce- Services). dures, but especially by the implica- Each telemedicine portable work- tion of the health professionals and the station having at its disposal a web acceptance by the patients of this new cam, an extension of telepsychiatry form of medical practice. Acknowledgement towards the equipped villages, accor- In conclusion, the tele consultation ding to protocols elaborated at the is a reliable and useful medical practi- Special thanks to Stéphanie time of the first phase, is completely ce in isolated sites, reasonable in term Gaston for her hard work translating possible. of cost and technically well controlled. 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, elder- ly drivers tend to be overly involved in specific types of accidents in specific situations, such as intersections, or, when changing lanes, mer- ging 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” develo- ped 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 distrac- ting 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: [email protected] • www.psytest.net Charles University Prague

MMU UHFF

www.islands-project.etsit.upm.es

Co-funded by http://www.springer.com/journal/40211