Appendix A: Case Studies

Rural and Remote Mental Health Service of South Australia

The telepsychiatry services at the Rural and Remote Mental Health Service of South Australia were initially trialed between Whyalla Hospital and the Royal Adelaide Hospital in 1993, funded by the SA Health Commission. The success of the trial resulted in a Health Communications Grant and the start of the telepsychiatry project formally in January 1994, initially with three remote sites. An additional three sites were added in 1995. In October 1995 the South Australian Mental Health Service Telemedicine Unit was formed and the telepsychiatry services moved from being a project trial to an established medium for service delivery. This has become one of the most experienced telepsychiatry services in the world.

Over 2000 patients have been seen and psychiatrically assessed over videoconferencing. The primary application of the telepsychiatry service has been in the provision of acute psychiatric consultations. Patients are referred to the service by a rural or remote primary care provider. The consultation is to assist the primary carer to most effectively support and treat patients in their own community. The videoconferencing system has also been used to deliver training and professional development to rural and remote mental health practitioners. There is a high level of acceptance of telepsychiatry by clinicians, patients and mental health workers who have used the system.

There are now 65 sites within rural South Australia that can use the service. Units are located in the local hospital or community health centre to facilitate access to all health professionals and to ensure privacy of consultations. The equipment is linked by ISDN at transmission speeds of 128 kbps. Some services use 384 kbps ISDN connections. It is envisaged that all services will be stepped up to this level if and when transmission at this speed becomes economically feasible.

Benefits

The success of the telepsychiatry services has highlighted the benefits of pursuing the enhancement (rather than replacement) of service delivery to rural and remote regions via videoconferencing. An evaluation of the experience with the system show benefits to include:

• A reduction in the professional isolation of, and an increased support to, health professional in rural and remote regions.
• Increased access to consultant assessment and recommendations so that patients are more able to receive the treatment they need when they need it and within their own community.
• A reduced need for the costly, disruptive and distressing process of having to transport patients to Adelaide for psychiatric assessment and admission.
• Better communication between the patient and their home based family and health care providers when they are admitted to the Adelaide service.
• The Adelaide based treating team are better able to communicate with the community health providers to ensure appropriate discharge planning and post discharge follow-up.
• Many of the educational and administrative needs of rural and remote based health services and other community agencies can be largely met with the use of telemedicine, providing resources that otherwise would not be available, or otherwise dramatically reducing the need for people to travel.

Collaborative Training and Education Centre and the Haptic Workbench

CTEC is a unique purpose built, state of the art, medical technology building at the University of Western Australia. It provides a variety of hands-on practical training courses for medical and surgical professionals across all disciplines and at all career levels. This project began with a vision to contribute to better medical and surgical skills training -and ultimately - better health. The CTEC partners have created the most technically advanced medical and surgical skills training centre in the southern hemisphere. Medic Vision has invested $3 million in audio visual and communication components in the CTEC training facility (a $20 million facility).

Medic Vision owns and operates the audiovisual and telecommunications equipment to provide telemedicine and communication services. CTEC currently uses this network for videoconferencing to deliver seminars throughout Australia and internationally using 768 kbps connections. They also use a broadband network within their facility to provide simultaneous transmission of training simulations to multiple sites. They can also use the facilities to record simulations for debriefing and analysis.

Haptic Workbench

In conjunction with CSIRO and private company MedicVision CTEC has been developing an immersive environment for surgical training. This system uses 3D stereo graphics, audio and haptic (force-feedback) displays of data in the user's immediate working space for interactive modelling and interpreting information, so that the user has his or her hands in the data and works directly with the data or objects in the display. The Haptic Workbench was developed in 1997 in the Virtual Environments Laboratory of the Cooperative Research Centre (CRC) for Advanced Computational Systems (ACSys). The VE laboratory is a joint activity of the Australian National University (ANU) and CSIRO. This technology will make it possible for students to practice on 'virtual' patients as it is possible to represent an exact situation and 'experience' it, providing the sense of touching, cutting or manipulating the objects involved.

The CSIRO used the CENTIE network to demonstrate collaborative use of this technology on a gall bladder simulation between two sites, each with a haptic workbench. Through the sharing of the virtual environment by the two workbench users at separate locations they were able to interact cooperatively on a single procedure. With the addition of studio quality videoconferencing and voice, participants could not only see and feel the interaction on the workbench, but could communicate as if they were in the same room. This application was demonstrated using a 10 Gigabit per second Ethernet network. This very high end broadband network was necessary for such a data intensive application to be performed interactively in real time.

This technology is still in development, but offers opportunities for distance training in the future.

South West Alliance of Rural Hospitals (SWARH)

In June 2000 the $9.8 million Internet-based communications system, SWARHnet, was announced. It included a $4 million expansion of AAPT's VicOne network to make broadband available at substantially less cost than was previously available.

This network enabled productivity savings in the running of the single patient management systems that necessitated links between all sites. These were previously ISDN links that had limited capacity to be used for any other applications. Using high speed links (2-4Mbps) which can support Internet, Intranet, voice, video and data applications created an opportunity to save real costs, for example telephony and videoconferencing usage costs.

The Internet-based switched network that was implemented links SWARH's cooperative of 12 hospitals, spanning 33 sites in the south-western region of Victoria. The broadband network has an annual lease cost of $600,000. It was anticipated that this network, enabling the hospitals in the region to shift all of their data, voice and video applications onto the single network, would save an estimated $400,000 annually in telephony and videoconferencing costs. It also replaced the old ISDN system that was only used for the Patient Management System and cost $200,000. This meant that the original premise was cost neutral. The implementation of the network required additional capital to:

establish communications equipment at each participating site;

• to establish the network hub;
• to ensure each site had the correct cabling and switching infrastructure; and
• to ensure the network would be supported, monitored and maintained 24 hours a day 7 days a week.

Early indications from the use of the network are that this level of savings is realistic. The calculation of the savings was based on 40 percent savings on telephone and 90 percent savings on videoconferencing. Current savings are in the order of 30 percent on telephone and 70-80 percent on videoconferencing. This savings figure does not include savings from reduced travel due to the increased use of videoconferencing (which has increased dramatically with the reduction in costs).

Once the network is in place the clear opportunity is the potential to increasingly reduce service delivery costs through the use of video based services. This business re-engineering was seen as the key to not repeating the costs of the past. The uptake of virtual visiting, virtual reception and virtual assessment are critical in the provision of additional clinical services to clients in rural Australia without having the normal increase in costs.

For organisations, the ability to have virtual patient monitoring, virtual staff, peer review, education, quality control where services are delivered through remote agencies creates further opportunities for improving existing services without escalating costs.

The network has allowed new and innovative applications to be developed. SWARH is considering a system using wireless hand-held devices for the input of patient data at the bedside. They are also developing records sharing between General Practitioners' offices and the hospitals for a small number of GPs linked as part of a trial. The benefits of these new innovations cannot yet be measured, but they are designed to save time and money in duplicating records and improve the quality of care through better availability of patient records.