MENTAL HEALTH SERVICES WITHOUT BOUNDARIES

Cumberland Mountain Community Services
Leads Southwest Virginia
Into The Telemedicine Frontier

WHAT IS TELEMEDICINE?
Telemedicine is the use of interactive state-of-the-art telecommunications systems to deliver, at a distance, medical services which otherwise would be unavailable, inaccessible or difficult to obtain. The practice of telemedicine actually has a thirty year history, primarily focused on tele-radiology, but including telepsychiatry and specialty medical consultations. Within the past five years, with the rapid advancement of computer technology and improvements in data transmission networks utilizing enhanced telephone lines, an explosion of applications in telemedicine is occurring nation and world-wide. This article reviews these innovative developments within Southwest Virginia, which places us on the national frontier of telemedicine applications.

WITHOUT SEEING AN ACTUAL DEMONSTRATION OF TELEMEDICINE OR TELEPSYCHIATRY, HOW DOES IT WORK? Using high speed enhanced telephone lines, a computer codes and decodes digital video and audio data transmissions in order to maintain almost real-time, two-way interactive communications. These images are displayed on large monitors. The end result is very much like being in the same room together, even though each person may be separated by hundreds of miles. We can see and hear one another with very little noticeable delay in our interactions. In no way is this like "talking to the TV" as there is a phenomena of "presence" which occurs, with a resulting eye to eye contact between the involved parties. It is far superior to talking on the telephone and the next best thing to being physically present with the other party. Those students who have participated in "distance education" programs are familiar with this experience, which in the telepsychiatry application is even more personal, as there is more close up one on one contact.

HISTORY OF APPAL-LINK
On February 14,1995, through a three year federal Office of Rural Health Policy grant, obtained with support of Congressman Rick Boucher, Appal-Link, The Southwestern Virginia Telepsychiatry Project, began to provide clinical and support services between Cumberland Mountain Community Services Board and the Southwestern Virginia Mental Health Institute in Marion. Within a few days, Dickenson County Community Services Board connected to the network. This was the first telepsychiatry project in Virginia and one of only six other projects in the nation testing telecommunications technology to deliver mental health care at a distance. After two years , the Appal-Link Project lead the nation in telepsychiatry service units delivered, with 263 patients involved in 820 total clinic appointments with Institute psychiatrists. Overall, 1,190 patient contacts occurred over the Appal-Link Network during the first two years of the project’s operation. Medication review, case consultation, discharge planning, commitment hearings, family visits and staff training activities occur daily over this network. Cumberland Mountain Community Services Board is the grant administrator for Appal-Link.

APPAL-LINK NETWORK SITES
The Appal-Link network now includes a total of nine sites: New River Valley Community Services Board at Blacksburg, Mt. Rogers Community Services Board at Wytheville, Highlands Community Services Board at Abingdon and Planning District One Community Services Board at Big Stone Gap, as well as the three original sites at the Southwestern Virginia Mental Health Institute at Marion, Dickenson County Community Services Board at Clintwood, and  Cumberland Mountain Community Services Board at Cedar Bluff. Through partial support from the Appal-Link project’s grant, Blue Ridge Community Services Board in Roanoke began in spring 1997 to provide highly specialized services to the deaf and hard of hearing mental health population who need interpreting, counseling, case management and support services. With the ability to immediately connect to any of the other sites where the client or recipient of the services will be located, previously unavailable or very difficult to obtain services can be delivered as easily as making a telephone call. Blue Ridge Community Services Board became the eighth site in the network. This highly innovative application has major implications through replication for service access by the deaf and hard of hearing community nationwide.

In April 1997, The Laurels, an alcohol and drug treatment program, came "on line" as the ninth site. Located in Lebanon, Virginia and administrated by Cumberland Mountain Community Services Board, this program serves a broad region of seven counties. As part of the network, pre-admission reviews, case consultations with the referring Community Services Board, medication follow up, discharge planning and family visits can occur. The resulting benefits are within two essential processes, best described as "continuity and connectivity". Continuity is the principle of care being provided by an ongoing team of the same providers, in this case insuring that the distant community services board staff can provide input to the inpatient plan of care. Previously, before this telemedicine network, community care and inpatient care were disconnected, fragmented and disjointed. By gaining connectivity, previously uninvolved but essential contributors to the health care plan can now be easily included. Most significantly, in order to provide effective mental health and substance abuse treatment, the family must be included. When the facility is located in Marion or Lebanon and the family is in Big Stone Gap or Clintwood, the potential for successful treatment outcomes was reduced when the family could not take the time or incur the expense to travel to these facilities to take part in the treatment process. Now that there is a network connection in each Community Services Board community, family members can easily become an essential part of the treatment team, with little cost of time and travel expense. We are not aware of any other inpatient alcohol and substance abuse treatment program using telemedicine applications in this way. We believe there will be growing national interest in this program.

In February 1999, the Clearview Center, a twenty bed inpatient psychiatric treatment center located in Lebanon, Virginia, became the tenth site. The Clearview Center is located within and owned by Russell County Medical Center. Patients admitted to this facility will have access to their families and community treatment providers. Psychiatrists at Clearview will be able to provide aftercare to discharged patients into their home community. As of January 2000, Blue Ridge Community Services dropped out of the network as a result of changes in the alignment of the public mental health service area.  At the same time, the Southwestern Virginia Training Center at Hillsville joined the network, returning the total number of participating sites to ten.

In September 2000, an agreement was signed with the Salem Veterans Administration Medical Center to establish a telepsychiatry clinic for area veterans.  The psychiatrist at the Salem VAMC provides outpatient services to eligible veterans, who otherwise would have to travel two or three hours one way to that facility.  Veterans travel to a closer site at the main center of Cumberland Mountain Community Services where a nurse facilitates the telepsychiatry link to Salem, Virginia.  The Veterans Administration estimates that there are some four hundred veterans in this region who could participate in this innovative service to extend outpatient mental health care into their home region.

NATIONAL RECOGNITION
A survey conducted by "Telemedicine Today" (Aug. 97) reviewed the fifty most active telemedicine projects in the nation, based on clinician-patient contacts. The Appal-Link Network was ranked tenth in the nation, over many major university and medical center projects. Our project was the only one in the top ten to reach this level on mental health applications alone. Most projects had a combination of internal medicine and mental health applications. The Appal-Link Network was also the only project within the top ten to receive federal grant funding. Therefore, it is reasonable for us to be able to say that the Appal-Link Network leads the nation in telemental health applications.

Tele-health Magazine (December 1999) named the Appal-Link Network one of the "Top Ten Tele-Medicine Programs For 1999".   This award is particularly remarkable in comparison to the majority of other projects recognized, which includes six major universities.

SIX YEARS OF SERVICE
After six years of operation (February 1995 - February 2001), we have come away with these key points about the use of interactive telecommunications technology to deliver mental health at a distance.

• The use of this technology is a tool, not a new way of practicing or a new body of knowledge.
• It's not as good as being together for face-to-face mental health treatment, but it is certainly the next best thing.  In some situations it is better.
• Service consumers readily accept the use of this approach and become comfortable with it quickly.
• These networks carry the secondary advantage of allowing the participants in mental health care, whether consumers, families or professionals, to become connected.
• Continuity of care and more frequent service contacts for the seriously mentally ill are absolutely possible with this system.

A six-year service report reflects 2,873 clinically related network hours, involving 5,173 separate activities.  During these six years 853 consumers received a telemental health service.  Over three-hundred fifty consumers participated in psychotropic medication management clinics.   Psychiatrists at the Southwestern Virginia Mental Health Institute (Marion, Virginia) delivered 1,743 hours of tele-medication management clinic service over these six years.

THE BANDWIDTH QUESTION
As the use of this technology spreads for the delivery of mental health care at a distance, the most frequently asked technical question is what is the acceptable bandwidth for these networks.  Bandwidth refers to the size of the "pipeline" (the number and type of telephone lines) that carries the video and audio signals.  At higher bandwidths, picture and sound are transmitted more quickly and with better quality.  However, there is a direct relationship between bandwidth and transmission expense.

There are two research reports, which address the bandwidth question for mental health applications of interactive telecommunications technology.  A study of video assessment reliability by Zarate addressed the questions whether video assessments of patients with schizophrenia are comparable to live assessments, and whether video quality will effect the ability to assess subtle negative symptoms.  This revealed that at lower bandwidths (128 kilobits per second) negative symptoms were more difficult to assess.

A similar study by the Southeastern Rural Mental Health Research Center addressed the reliability of psychiatric assessments at different bandwidths.  The Abnormal Involuntary Movement Scale (AIMS) was found to be more reliable at higher transmission rates.  If fact, the AIMS assessment was actually most reliable when conducted at a distance at the highest bandwidth (762 kbps).

The Appal-Link Network promotes the use of 336/384 kbps as a minimum bandwidth standard, when clinical service is part of a network.   Although lower bandwidth systems are less costly, adequate clinical assessment cannot be assured.

TELEMENTAL HEALTH REPORTS AVAILABLE
We have learned a great deal about the uses and benefits of integrating this technology within our region.

For more detailed information on the bandwidth issue and more related critical concept of psychological presence, please refer to Telemental Health: Delivering Mental Health Care at a Distance.   There are two versions of this report:  A Summary Report and A Guide for Rural Communities.   These reports are in final draft and waiting publication by the Center for Mental Health Services.  Both reports are available from Cumberland Mountain Community Services, P.O. Box 810, Cedar Bluff, VA  24609.

All of us have been greatly affected by technological advances in our society. Many people have home computers, who five years ago had never used one. Daily items related to the Internet appear on the news. Our children are considered to be receiving a poor quality education if they do not have ready access to computers in their schools. Telecommunications technology is the merging of computers and television. Within five years telecommunications systems will be as commonplace as personal computers are now. Most of us grew up with televisions on most of the time. In the very near future, it will seem very natural to receive education and health care "through the television".