Written public comments may be submitted to Nancy Roberts by December 20, 2002, at the following address: Division of Legislative Services, General Assembly Building, 910 Capitol Street, Richmond, Virginia, 23219 (e-mail nroberts@leg.state.va.us or fax 804-371-0169). If you have questions, please call Nancy Roberts at (804) 786-3591.
Item 312 J, 2002
Appropriation Act
James S. Reinhard, M.D.,
Commissioner
September 30, 2002
The following individuals provided information that assisted with the findings and recommendations contained in this report:
The Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS) has supported the development and expansion of telemedicine and more specifically, telepsychiatry in the delivery of services and supports to mentally disabled citizens of the Commonwealth. Telepsychiatry is being utilized by all aspects of the mental health delivery system when providing care to clients in rural areas. This gained further momentum in recent years in light of the department’s policy initiatives relative to continuity of care between Community Service Board’s (CSB), DMHMRSAS facilities and training centers and other constituencies involved in treatment and care of individuals with mental illness and mental retardation and substance abuse. Current budget considerations, increased workload demands, reduced in-patient lengths of stay and higher patient acuity levels demand coordinated, integrated and timely interventions that are best accommodated thru the use of video teleconferencing. The Department is very committed to providing resources and time to assist the Commonwealth in the expansion of telepsychiatry services.
This report reviews the current status of telepsychiatry practice within the Department, as well as the more general use of telemedicine technology within other state agencies with which the Department needs to link to further expand telepsychiatry in rural areas of the Commonwealth.
The report recommends that the Commonwealth support DMHMRSAS in pursuing several strategies to promote the continued development and expansion of a coordinated telepsychiatry network. Specifically,
§
The Department will
continue to give priority status to Community Service Boards in underserved
areas to install the equipment and educate staff on the uses of this
technology.
§
The Department should
explore the feasibility of expanding DMHMRSAS telepsychiatry linkages with Universities
and hospitals in of Virginia. This
would include conducting a study to determine the cost of converting current ISDN system to an internet/intranet
network to communicate within existing
systems.
§
The Department will need
additional funding to pay for airtime costs to facilitate the use of the
teleconferencing for telepsychiatry initiatives. Rather than travel, all the telepsychiatry activities mentioned
in this report could be achieved via teleconferencing, but money is needed to
pay for bridging and airtime costs. Bridging costs are 80 cents a minute per
site and airtime costs are 5 cents a minute per line and the minimal number of
lines used is 2, the maximum 6.
§
The Department should
designate coordinators in CSB’s and DMHMRSAS facilities, by location or
regionally to better facilitate and implement telepsychiatry.
§
A consortium of
universities and state agencies should be established to develop a strategic
plan to further expand the use telepsychiatry in the State of Virginia and to
identify research funding and grants that could be used statewide.
§
The Consortium should
identify resources within Virginia that can be shared to further expand
telemedicine and telepsychiatry.
The budget language as stated in Item 312 #J of the 2002 Appropriation Act states:
The Department of Health and the Department of Mental Health, Mental Retardation and Substance Services (DMHMRSAS) shall explore the expanded use of telepsychiatry for medical shortage areas and submit their findings and recommendations, including the recommended resources, to the Chairmen of the House Appropriations and Senate Finance Committees by September 30, 2002.
Telemedicine is the use of telecommunications technology to deliver health professional education (tele-education) and health care services to sites that are distant from the host
site of the educator or health care provider. For the delivery of health care services via telemedicine, the host site is known as the consulting site. The remote site, also known as the referring site, is the location at which the patient or physician originates a consult. Health professionals believe that the use of telemedicine will greatly increase by the year 2010. Telepsychiatry is one branch of telemedicine and is defined as the application of telecommunications technology in the practice of medicine. Dr. Jane Preston, president of the American Telemedicine Association and one of the pioneers of telemedicine, has defined telemedicine as “telecommunication that connects a patient and health care provider through live, two way audio/video transmissions across distances and that permits effective diagnosis, treatment and other health care activities” (Preston, Brown, & Harlley, 1992, p. 25). Telepsychiatry has been defined as “psychiatry practiced through two way interactive television” (Dongier, Tempier, Lalinec-Michaud, & Meunier, 1986, p. 32).
Advances in videoconferencing technology and reduction in costs of the equipment is making telemedicine an efficient and effective way of providing healthcare services to those who cannot typically access this care. Most current telemedicine programs connect academic medical centers with rural hospitals or other isolated health care areas. These programs are characterized by the goal of extending access to medical specialty expertise into isolated and underserved areas. Numerous states including Virginia have developed and continue to develop telemedicine projects which include telepsychiatry as part of the project. The most successful of these projects in Virginia is the Southwestern Virginia Telepsychiatry Project. This project was created to provide additional psychiatric services into the most rural sections of the Appalachian southwestern Virginia. The project provides psychiatric aftercare services, psychiatric consultation for emergencies or crisis intervention, psychotherapy, psychiatric evaluations and medication management.
This report will discuss what has happened as a result of the project and what other resources are available in DMHMRSAS and other state agencies within Virginia. It will also explore the expansion of telepsychiatry in DMHMRSAS and what needs to be considered to accomplish this task. Although the language in 312#J asked that the Virginia Department of Health (VDH) and DMHMRSAS explored the use of telepsychiatry, DMHMRSAS took the lead in the study and obtained research and guidance from the VDH. VDH has a very sophisticated telemedicine network, but does not provide psychiatry services to its clients.
Through a series of legislative study reports, the Commonwealth has fostered and monitored the development of telemedicine for the delivery of Health Care Services. These studies include, A Study of Current Telecommunication Resources and Activities in Western Virginia, February 2002, Report to the Governor and General Assembly on Telemedicine Initiatives, Annual Report FY01, Telemedicine Study, To the Governor and the General Assembly of Virginia, Senate Document No.18, 2000 (All of these reports are available upon request and some excerpts will be used throughout this report).
The primary providers of telemedicine in state agencies that provide health care services are: the University of Virginia Health Center (UVA), the Virginia Commonwealth University (VCU) Health System, the Virginia Department of Health (VDH) and the Department of Corrections (DOC). The VDH does not provide telepsychiatry since this is not part of their health care mission. Radford and Eastern Virginia Medical School plan on implementing telemedicine in the near future. The Department of Mental Health, Mental Retardation, and Substance Services (DMHMRSAS) has purchased equipment that would facilitate the expansion of telepsychiatry but has not completed the installation of all of the equipment. This will be discussed in greater detail later in the report.
Currently, the use of telemedicine for care of patients in community settings represents a small portion of telemedicine usage. In one of the most recent reports, Report on Telemedicine Initiatives(2001), VDH concluded that for a comprehensive study of telemedicine activities to be evaluated for cost-effectiveness and medical efficacy of telemedicine services comparable data are required. They also recommended that the following actions be taken:
The VDH has applied for grant funds to work on the third recommendation
.
DMHMRSAS and VDH explored the expansion of telepsychiatry for medical shortage areas in the State of Virginia. Initially, DMHMRSAS needed to determine the medical shortage areas in the State of Virginia related to psychiatry. The Office of Health and Quality Care in DMHMRSAS received this information from the Center for Primary Care and Rural Health in the Office of Health Policy and Planning in the Health Department. The Mental Health Professional Service Areas or MHPSAs areas are attached to this report. The report provides the listing of Community Service Boards (CSB) and the locations served by the CSB. The MHPSAs are designated in the Type column. If there is no designation in this column that area is not considered a shortage area, but telepsychiatry should still be expanded in these areas. These areas can provide resources to the underserved areas via the video-teleconferencing equipment. Several of the CSB’s that are not designated as rural or underserved still may not have enough staff to maintain their services. In a study conducted by DMHMRSAS in July of 2000 it was estimated that the CSB’s required 50 additional psychiatrists to maintain appropriate services.
Based on this information DMHMRSAS explored the current availability of services and actions required to expand the network in these areas.
APPAL-LINK, which is the Southwestern Virginia Telepsychiatry Project has been operational since 1995. Originally, the program served clients of the Cumberland Mountain Community Services Board who were hospitalized at Southwestern Virginia Mental Health Institute in Marion. Within two years, all of the community service boards in the Institute’s service area joined the network. This includes over twenty two cities and counties. Seventeen of these are designated shortage areas. This system uses Integrated Services Digital Network (ISDN) lines which allow for two-way interactive video teleconferencing. The current equipment used to broadcast is the Polycom 512 Viewstation Multipoint. This system allows for point to point transmission and serves as a bridge to connect three other sites at 128 transmission speed. The telepsychiatry services offered thru this project include the following: patient evaluations, case management, medication management, crisis response, pre-admission, and pre-discharge planning, treatment planning, individual and group therapy, family therapy, mental status evaluations, court commitment hearings, case conferences, family visits, family and consumer support groups, staff training and administrative activities. This project continues to serve clients in rural areas of Virginia and provide continuity and quality of care. It has also allowed families to participate in the care of their family members by being able to teleconference from a site close to their homes.
Most recently this project has partnered with the DMHMRSAS Office for the Deaf and Hard of Hearing and Western State Hospital to provide telepsychiatry services to those individuals who are deaf and hard of hearing being served by DMHMRSAS facilities and CSB’s. Included in the project are: Fairfax/Falls Church CSB, Henrico CSB, Valley CSB, Blue Ridge CSB, Hampton-Newport News CSB, Cumberland Mountain CSB, Danville-Pittsylvania CSB, and Northern Virginia Mental Health Institute.
The University of Virginia and Virginia Commonwealth University also provide telepsychiatry services thru their linkages with community health care facilities as part of the telemedicine system. Their systems are connected by internet/intranet. DMHMRSAS’s network is not compatible with this internet system. VDH also has an extensive telemedicine network but its function is related to medical issues and not psychiatry issues. VDH has an extensive teleconferencing network which uses internet/intranet services rather than ISDN lines. This network reduces costs associated with long distance charges for airtime costs and costs related to bridging more than four sites at a time or more than two sites at a time using a higher transmission speed and quality. The initial cost to establish this network is over $300,000 but it reduces cost over time and enhances the quality of the communications.
During the past three years DMHMRSAS has been developing and has expanded its video teleconferencing capacities around the Commonwealth via ISDN lines and the Polycom Viewstation 512 Multipoint. The video teleconferencing network is available at all 15 DMHMRSAS state psychiatric hospitals and training centers. The DMHMRSAS is currently in the process of installing videoconferencing equipment to CSB’s which did not otherwise have the capacity. When this project is completed, all 40 CSB’s will have teleconferencing capacity.
The Departments interest in augmenting the use of telepsychiatry has been largely predicated on assuring the highest possible continuity of care linkages between DMHMRSAS facilities and CSB’s as well as local judiciary and other law enforcement personnel. These linkages are paramount at particular intersections of treatment, most notably during the preadmission screening, hospital liaison, and discharge planning processes. Over the past several years, the technology has been useful in conducting involuntary commitment procedures, in facilitating community and family participation and involvement in treatment planning during the course of hospitalization and in CSB participation in discharge planning. CSB’s are required by law to be the gatekeepers for all admissions to DMHMRSAS state psychiatric hospitals. Communication and coordination of care between the CSB’s and hospitals is critical. Similarly, Department policy requires the CSB’s active participation in all aspects of treatment. In addition, CSB’s are required to provide discharge planning. As a result, recent experience has evidenced that there is increasing use of the technology to facilitate these required linkages between community and hospital providers. Further, CSB’s are playing an active and more central role in treatment and discharge planning process thereby leading to improved outcomes of care. It is anticipated that potential budget reductions and increased workload demands will further support and necessitate expanded use of the technology.
In summary, expanded use of the technology will allow greater ability to do all the things referenced above with the current ApalLink, Deaf Services, facility and CSB linkages.
IV.
Recommendations
1. The Department will continue to give priority status
to Community Service Boards in underserved areas to install teleconferencing
equipment and educate staff on the uses of this technology.
2. The Department should explore the feasibility of
expanding DMHMRSAS telepsychiatry linkages with Universities and hospitals in
the state of Virginia. This would
include conducting a study to determine the cost of converting the current ISDN
system to an internet/intranet network to communicate within existing systems.
3. The Department will need additional funding to pay for
airtime costs to facilitate the use of the teleconferencing equipment for
telepsychiatry initiatives. Rather than
travel, all the telepsychiatry activities mentioned in this report could be
achieved via teleconferencing, but money is needed to pay for bridging and
airtime costs. Bridging costs are 80 cents a minute per site and airtime costs
are 5 cents a minute per line and the minimal number of lines used is 2,
maximum number 6.
4. The Department should designate coordinators in CSB’s
and DMHMRSAS facilities, by location or regionally to better facilitate and
implement telepsychiatry.
5. A consortium of universities and state agencies should
be established to develop a strategic plan to further expand the use
telepsychiatry in the State of Virginia and to identify research funding and
grants that could be used statewide.
6. The Consortium should identify resources within
Virginia that can be shared to further expand telemedicine and telepsychiatry.