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Final Copy of Case Study LOCATION:

Columbia, SC, US

YEAR:

2010

STATUS:

Nominee

CATEGORY:

Non-Profit

Organizations

Technology Area:

Video Conferencing

Technology /

Mental Health

Consultation

ORGANIZATION:

South Carolina Department of Mental Health

ORGANIZATION URL:

http://www.scdmh.org/telepsychiatry/

PROJECT NAME:

DMH Telepsychiatry Program

Introductory Overview The South Carolina Department of Mental Health (DMH) is

South Carolina's public mental health authority. The

Department operates 17 community-based, outpatient mental

health centers, each with clinics and satellite offices,

which serve all 46 counties in South Carolina. DMH also

operates four licensed psychiatric hospitals, currently

comprising approximately 675 beds, making it the third

largest hospital system in the state. One of the hospitals

is for persons with addictive diseases and one is for

children and adolescents with psychiatric or substance

abuse disorders. DMH also operates three nursing homes,

including two for veterans. DMH provides mental health

services to between 90,000 and 100,000 patients per year,

more than 30,000 of whom are children. The majority of the

persons served by DMH are low-income or indigent.

Like many states, South Carolina faces an 'urban-rural

dilemma,' with much of the population of South Carolina

living in rural areas, while the mental health expertise is

concentrated in the urban centers. Add to that a high

percentage of citizens with limited resources, namely a

lack of health insurance and no transportation to an urban

hospital, and it can be difficult for the DMH to reach the

patients most in need of care.

The DMH Telepsychiatry Consultation Program was the result

of DMH leadership securing a grant for the program from The

Duke Endowment. The grant award allowed the DMH to utilize

telemedicine in a unique way: by offering all South

Carolina hospital emergency departments (EDs), many of

which are located in remote regions of the state, timely

access to a DMH consulting psychiatrist. DMH can make a

positive impact on a serious health care problem in South

Carolina: patients in a behavioral health crisis in some

EDs without access to psychiatric expertise being held for

long periods awaiting transfer to a distant psychiatric

hospital for psychiatric evaluation and/or treatment.

Timely psychiatric assessment and consultation through the

DMH Telepsychiatry Consultation Program, utilizing wireless

and high-definition Polycom telepresence equipment,

including Polycom Practitioner Carts, provides ED

physicians with prompt, expert treatment recommendations.

Expert assessments result in appropriate treatment being

provided to behavioral health patients in participating EDs

in a timely manner. Expert assessment and timely treatment

not only speed the patients' recovery, but also potentially

reduce the patients' length of stay in emergency

departments, thereby allowing the participating hospitals

to direct critical personnel and financial resources to

other needs. The local emergency department doctor and the

remote DMH psychiatrist can identify those patients who can

safely be discharged from the ED and referred to treatment

resources in the community, and those patients who will

need continued psychiatric hospitalization. The program not

only improves patient care, but also saves costs by

decreasing the lengths of stay of patients in emergency

departments and by avoiding unnecessary psychiatric

hospitalizations. For example, at Springs Memorial Hospital

in Lancaster, in the five-month period following the advent

of the DMH Telepsychiatry Consultation Program, the average

length of stay for patients in a behavioral crisis dropped

by more than 55 percent.

The project is currently in 15 hospital emergency

departments in South Carolina and DMH is currently in

contract with 10 others to start the program. The first of

the hospitals being equipped are primarily in rural areas,

where the need for access to mental health expertise is

greatest. A total of 35 hospitals will be rolled out by

completion of the third year of the program with the

ultimate goal of equipping a total of 65 EDs.

The Importance of Technology How did the technology you used contribute to this project and why

was it important? Video conferencing technology is at the core of the South

Carolina DMH telehealth program. In the mental health

treatment setting, non-verbal communication is often as or

more important than what the patient says, making HD-

quality video key to the DMH network. HD video allows the

DMH practitioners to see the smallest details, which are

critical when treating someone with, for example, a

substance abuse problem. The physician can zoom in and

clearly examine the patient's pupils to determine whether

the person may be under the influence of drugs or has had a

true psychotic episode.

The South Carolina DMH has deployed fifteen Polycom high

definition HDX Practitioner Carts to date, with a plan to

roll out 65 in total. The Practitioner Carts, located in

each hospital, consist of a mobile wireless, high

definition screen assembled on a roll cart so that the

system can be moved to the area in the ED where the

patient is waiting, thus not requiring the patient to be

moved for the consultation. This mobile "pole system"

contains a pan/tilt/zoom camera, 26-inch flat screen

monitor, speaker, computer and power supply. The

interactive video and voice transmissions are carried over

dedicated T-1 (or other fiber optic) lines and linked to

the SCDMH consultation sites.

Polycom's CMA 4000/5000 centrally manages and deploys the

organization's visual communication solution. The CMA

4000/5000 solution also offers a desktop video

collaboration software client, which is what the five

psychiatrists employed in the program use to connect from a

variety of remote locations.

To access care, local hospital ED physicians contact the

SCDMH psychiatrist to request the consultation. The SCDMH

psychiatrist uses the telepsychiatry system to interview

the patient and others as needed and will review hospital

ED information, EHR data, and other available information

to provide a written and electronically signed consult

which is immediately available to the ED physician. Each

consult results in an electronic medical record which, at

the conclusion of the consultation, is transmitted to the

hospital, the mental health center where follow up care is

provided and a copy is retained within the agency's

database for future use should the patient return for

additional services. While sixty percent of persons served

have information in the DMH database, the doctors also use

an accompanying electronic health record (EHR) which

contains selected health information drawn from a 20-plus,

multi-agency database currently housed in the Office of

Research and Statistics (ORS). This reliable access to the

EHR information dramatically improves the quality and

appropriateness of critical care treatment in both rural

and urban hospital EDs.

Always cognizant of leveraging to the fullest any

investment it makes, DMH leadership built multipoint

capability into its video conferencing network with

Polycom's RMX 2000 real-time media conference platform to

support multi-site calls. The RMX enables all of the video-

equipped hospitals to connect with each other and is going

to be used to support training moving forward. In addition,

the Polycom RSS 2000, an on-demand recording, streaming,

and archiving solution for multimedia conferences was

implemented for instruction and training.

Benefits Has your project helped those it was designed to help? Yes

Has your project fundamentally changed how tasks are performed? Yes

What new advantage or opportunity does your project provide to

people? Without question, the telepsychiatry solution offered by

the DMH has changed the lives of those in hard-to-reach,

rural areas. The use of high-definition, interactive video

conferencing has greatly added to the number of patients

that can be seen by DMH providers. It also facilitates a

more rapid recovery for patients and helps sustain

recovery. The DMH initially anticipated that it would

provide 1,700 consults per year when it had deployed video

conferencing systems in 45 to 55 of its targeted EDs.

However, with only 15 systems deployed, it has far exceeded

that number, providing 1,579 consults to date.

As a goal, the telepsychiatry network is designed to

provide emergency department physicians with access 24

hours a day, seven days a week to a DMH psychiatrist who

can provide an assessment and recommendations for initial

treatment. In addition, the local doctor and the remote DMH

psychiatrist can begin identifying resources in the

community to help the patient with follow-up care, a

necessity for many patients that reduces the need for re-

hospitalization and improves quality of life for the

patient and his or her family.

The DMH telepsychiatry network is also providing

significant cost savings benefits for the state of South

Carolina. The agency has seen travel and related costs

reduced. The rate of in-patient emergency department

admissions is also decreasing, resulting in significant

savings per patient who receives an early discharge. A

typical mental health emergency department admittance

results in a five-to-six day hospital stay at a cost of

$2,000 per day, or $10,000 to $12,000 over the length of

the stay. Hospitals report a drop in length of stay from an

average of six days to just over three days, cutting the

total cost nearly in half from $12,000 to just over $6,000.

The sooner the DMH can intervene, the shorter the hospital

stay can be.

A critical added benefit, the video network connects the

state's hospitals in an unprecedented way, allowing for the

coordination and sharing of access to specialty medical

care consultation among participating hospitals. In fact,

the telemedicine system was specifically designed to

facilitate not only the DMH telepsychiatry application, but

also a remote stroke care initiative serving the state's

rural residents. In addition, because the on-call DMH

psychiatrists are practicing over video, none of them was

required to relocate to make this program work.

If possible, include an example of how the project has benefited a

specific individual, enterprise or organization. Please include

personal quotes from individuals who have directly benefited from

your work. Palmetto Health Baptist, Easley, SC, was the first hospital

to participate in the program. Hospital leadership reports

that since the inception, the program has offered

consistent, high quality and timely service to their

patients and represents a major step forward in the

delivery of this vital service. Prior to this program,

there were lengthy "hold" times in the emergency

department. Not only was this unsatisfactory for the

patient in need, it created an unnecessary critical lack of

bed availability for patients with medical and surgical

emergencies. The telepsychiatry program has improved

patient care and outcomes for one of their most vulnerable

and underserved populations.

Springs Memorial Hospital in Lancaster, SC, reports that

while more patients are receiving telepsychiatry

consultations, fewer are being committed to hospital beds;

the average length is reduced from three plus days to less

than one day; and that the hospital has saved in excess of

$100,000 in the first six months of telepsychiatry use.

Their staff has been impressed by the quality of the

equipment, the policies and procedures for the service and

the psychiatrists involved with the program.

In a letter to The Duke Endowment, Philip A. Clayton, CEO,

Conway Medical Center, Conway, SC, states that as a pilot

hospital in the program, they have seen positive results.

Since the inception of the telepsychiatry program, Conway

Medical has served 540 psychiatric patients in their

emergency department. Of those, they were able to have a

consult for 106 of the patients and, as a result, were able

to discharge 57 of them from the ED. Without

telepsychiatry, the medical center would not have been able

to discharge any of them directly.

Originality Is it the first, the only, the best or the most effective application of its

kind? Most effective

What are the exceptional aspects of your project? SCDMH, in cooperation with supporting partner agencies and

academic institutions, has designed and implemented the

nation's first statewide behavioral health consultation

service to include mental health and substance abuse

consultation to local hospital EDs. As such, DMH is in a

position to support a shift in culture in that the

department is proposing a system that will offer

interconnectedness and interoperability to all

participating hospitals. The primary method of connection

is either through T-1 or a fiber optic system identified as

the Palmetto State Providers Network (PSPN). The Palmetto

State Network is composed of 135 health care institutions

and agencies. Additionally, the telepsychiatry equipment is

designed to jointly allow REACH Call stroke consultations

on a single cart in the emergency department. Finally, the

telepsychiatry network allows participating hospitals to

directly contact each other for other medical consultations

as desired. These are truly value added characteristics.

In terms of measured outcomes of the telepsychiatry

program, the wait time for mental health consultation in

the emergency department is reduced in many cases from days

to hours, initial treatment is offered earlier, the length

of stay in the ED is reduced from and average of six to

three days and discharge planning to community service

follow up is strengthened. In short, the patient receives a

higher quality of care and the hospitals have reduced

costs.

Difficulty What were the most important obstacles that had to be overcome in

order for your work to be successful? Technical problems?

Resources? Expertise? Organizational problems? In November 2007, the SCDMH was awarded a two-year grant

from The Duke Endowment totaling $3,739,075. The first

round of funding easily launched the program, but the

organization's leadership is challenged with sustaining it.

Many of the patients being served through the DMH

Telepsychiatry Consultation Program are low income or

indigent, which was accounted for in the program's initial

planning phase. However, DMH anticipated that

Medicare/Medicaid would cover the costs for approximately

55 percent of the consults, but in actuality, those

programs are covering only 24 percent, leaving the agency

with a significant shortfall. To counter this deficit, DMH

is working closely with the state legislature, as well as

the Medicare and Medicaid programs to develop a business

plan that clearly defines sustainability for some time to

come.

Another ongoing challenge for the DMH program is that in

three or four hospitals wanting the program, operational

budgets do not allow for immediate purchase of equipment

and software. In these cases, telepsychiatry program

representatives work closely with hospital leadership to

identify potential areas of funding over a period of time

so as not to lose the opportunity to implement the program.

From a technology perspective, the blending of technology

and human service was not a straight-forward task. For

example, high definition video is required, as is full-

duplex sound and a pan/tilt/zoom camera that can be

controlled remotely. And all of that activity hinges on

very good EMRs, without which telepsychiatry isn't feasible

because of significant documentation requirements. Finding

a vendor to support the correct blending of technology with

behavioral health services at the right price and in the

desired timeframe was no small task. In addition to an

exhaustive vendor review, the DMH looked to other states'

telepsychiatry programs for guidance.

In addition, there are 25 different telephone companies in

South Carolina ranging in size from very small to quite

large. There is significant variation across those 25

companies in terms of ability to provide DSL or T-1 line

service. DMH had to work very closely with many of the

companies to assist them in meeting the technology

requirements.

Often the most innovative projects encounter the greatest resistance

when they are originally proposed. If you had to fight for approval or

funding, please provide a summary of the objections you faced and

how you overcame them. The issue of program psychiatrists being approved for

hospital privileges was more complicated and time consuming

than first anticipated. While some states may have a

unified application process designed to process preliminary

information for physicians, South Carolina is one where

hospitals manage their own unique set of requirements. The

result of this is that each physician must apply separately

to each hospital, often providing the same information in a

different order and each on an original form. Yet, this

issue has created an awareness of the need for a more

central process and related recommendations are being put

forward to boards and policy makers.

Another potential issue has to do with hospital

administrative leadership and medical staff agreeing on the

need for telepsychiatry. In a number of cases, additional

information was provided to both groups to allay these

uncertainties around workload or service displacement.

Generally, these matters were resolved amicably and these

hospitals became the most positive program advocates.

Success Has your project achieved or exceeded its goals? Exceeded

Is it fully operational? Yes

How do you see your project's innovation benefiting other

applications, organizations, or global communities? This telepsychiatry program has high transferability to

other agencies within and outside of South Carolina. The

program is seen as a vanguard of systems change. It offers

new and innovative strategies to increase critical access

to expertise in previously un-served locations, reduces the

time allotment associated with service provision, allows

hospitals to provide quality mental health care without the

cost of local personnel, reduces issues like transport and

security and reduces the wait time in the emergency

department. On a limited basis, administrative and training

functions may be performed utilizing the video system.

Similarly, specialized agencies like corrections have

examined this approach to consider developing their own

telemedicine to facilitate affordable and quality medical

care to persons in their prisons. The federally qualified

public health clinic system in South Carolina is examining

this technology to better offer medical services to

individuals in largely rural areas.

How quickly has your targeted audience of users embraced your

innovation? Or, how rapidly do you predict they will? There is a brief learning curve for hospital personnel in

that many of the rural hospitals, while providing excellent

personal care for patients, have not had the advantage of

sophisticated electronic equipment outside of the nursing

station. Therefore, the introduction of a high definition

video cart with an interesting looking pan/tilt/zoom camera

controlled remotely by program psychiatrists, require some

hands-on time. Even so, medical staff among three shifts

learn quickly how to operate this technology.

DMH representatives report that they had no trouble

recruiting physicians to join the Telepsychiatry

Consultation Program. All of the physicians they work with

are fully prepared to embrace this level of technology.

Following is a quote from Brenda Ratliff, MD, the lead

psychiatrist for the program that illuminates the role of

the technology in doctor-patient interactions. "A lot of

people wonder whether the technology is a distraction when

speaking to patients. I can confidently say that the answer

to this is no. The technology fades into the background,

and the interaction is just as effective as if it were in

the same room offering face-to face consultation."

DMH places high value on patients' reaction to the

technology solution and as a part of every consult asks the

patient for their reactions to the video-enabled

consultation and if it was helpful to them. Out of the

1,579 consults to date, only once has a patient reacted

negatively. DMH also performs patient satisfaction surveys

after the fact and all of the data has come back with an

above average rating.

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