Abstract
The health-care environment in the twentieth century has been primarily focused on hospitals and other health-care institutions, which consume the majority of the 8.5% of Australia's Gross Domestic Product (GDP) presently spent on health. In 1996/1997, 21 billion dollars was allocated by the various health-care sectors in Australia for the provision of institutional care in hospitals and nursing homes [1]. It is clear that this model of care, with the increasing associated costs and ageing population, is simply unsustainable in the twenty-first century. Moreover, the rise of consumerism, with more importance being placed on patients being informed about their disorders, means that there will have to be much more collaboration with patients in the future, and a much greater focus within our health-care systems on patients' needs, as encapsulated in the Second National Mental Health Strategy [2].
The general standard of mental heath care in Australia is world class. The level of training of Australian psychiatrists is admired internationally and psychiatric research in Australia has a strong, proven track record with publication and discovery outcomes accepted as being two to three times higher than in other Western countries per dollar of research spending [3]. Australia is also known for its uptake and effective use of information technology. There are more mobile telephones and video recorders per head of population than anywhere in the world, and Internet usage levels in the Australian adult population are already about 40% with an even gender distribution. Australasian psychiatrists need to become highly Internet literate in order to provide the type of high quality mental heath care that will be required in the 21st century.
In April 1999 the Internet had 160 million users world wide, with 2.7 trillion email messages sent annually. By the year 2002 it is anticipated that there will be 300 million Internet users [4]. The number of websites is presently doubling every 53 days. At present there are over 100 000 health-related websites, and in the US 25% of the population over the age of 16, about 54 million adults, makes use of the Internet and, of this population, about two-thirds retrieve health and medical information [5]. It is becoming self-evident that the presence of the Internet will dramatically change the way our mental health care is delivered [6] and that, to quote Rick Satava, the eminent USA surgeon who has worked for NASA for many years, ‘The future isn't the way it used to be' [7]. The purpose of this article is to look broadly at the delivery of electronic mental health care, noting that this is an area where Australia already has a strong international reputation [8–11], and arguing that the move of health care to the Internet will be the second stage of the information technology revolution which will lead to dramatic changes in our health-care system. As psychiatrists, we have to take a leading role in ensuring that these changes are in the best interests of our patients.
The technologies
Online health involves the use of any electronic technology to allow people in different locations to meet for the purpose of improving health care without travelling either in real time or in an asynchronous manner. Telephones, facsimile machines, video recorders, televisions and tape recorders are all examples of such technologies that are well known, accepted and used. Importantly, it is crucial to remember that patients still derive the majority of their health information from books, magazines and newspapers, although all of these are rapidly going online. More recently introduced technologies include computing and multimedia incorporating the use of the Internet, email and video streaming. Videoconferencing, which is commonly called telemedicine, and call centres, are also widely used for the provision of mental health services [12,13]. More futuristic technologies include the development of integrated, shared electronic medical records; the use of smart cards; the upcoming introduction of the Internet2, a faster broad band version of the present Internet and the development of virtual hospitals and global health-care systems [1,14]. None of these technologies will ever replace the traditional face-to-face consultation, nor will they be as good as it, but they will increasingly be used as an adjunct to such consultations, or in place of a proportion of them, with patients being able to choose whether they see their doctors face-to-face or use some form of online technology, depending on mutual convenience.
Australia has an international reputation for excellence in the use of the more recent health communications technologies, such as telemedicine [9,10], which is generally defined as the use of videoconferencing for health service delivery. Psychiatry has been the discipline that has led the way in the introduction of telemedicine throughout most Australian States and Territories. The Queensland Telemedicine Network is now the single most heavily used multi-application telemedicine network in the world [8] where 1800 h of clinical time are used each month across about a dozen different specialties, with 25% of the overall use still remaining within mental heath. The South Australian Telepsychiatry System [10] has seen more patients for psychiatric reasons than any other system in Australasia and has, interestingly, developed in a rather different way from the Queensland network. South Australia focuses much more on clinical consultations, whereas in Queensland only about one-third of the mental health time is spent on consultations, with one-third being used for teaching and another third for administrative purposes and meetings. Mental health usage in Victoria has been less consistent, as has been the case in New South Wales and Western Australia. The Northern Territory, the Australian Capital Territory and Tasmania are all equipped with systems, but generally receive most of their online services from other States [15].
The introduction of telemedicine, mainly in the public mental health sector, has been an important learning curve for those psychiatrists involved. Pleasingly, it looks likely that the Health Insurance Commission will create Medical Benefit Schedules item numbers for telepsychiatry within the next year (2000/2001), which will mean that more extensive use of these technologies to provide rural and remote mental heath care will become available within the private sector.
What have we learnt? First, there is no doubt that patients accept the use of assessment and treatment on video systems quite easily [16]. No-one argues that such communication is as good as face-to-face care, but it is a great deal better than no care at all, or the cost and disruption of very significant travel and social dislocation that is otherwise inevitable. It is evident that it is possible to make good emotional contact with patients over the wires [17], that clinical assessments are just as accurate across the range of diagnoses [12,18–20], that most of the legal and administrative barriers within Australia have been overcome and that these technologies are covered under Mental Health Act provisions [21]. There have been documented examples of patients being certified across State lines [22] and the process of mutual recognition of medical registration allows doctors to be fairly easily registered in several States. This is an important contrast to America where lawyers have had a field day, and the whole development of telemedicine systems is being slowed by cross-State boundary issues that are unresolved [23]. The legal barriers and related restricted jurisdictions and practices in the United States have meant that telemedicine has had the opportunity of flourishing much more rapidly in Australia and we are now the world leaders in this area. Telemedicine programs have recently been supported by specific clinical protocols, such as those developed in Queensland and endorsed by Queensland Health [24]. A variety of sophisticated training approaches and packages are available and the importance of using user-friendly, low-cost technology has been demonstrated [25]. We are now in a position where we have a substantial number of psychiatrists around Australia who have experience in telemedicine and who are no longer afraid of using these systems. Indeed, the college training program in some States is now delivered to trainees using telemedicine, notably in Queensland and South Australia. There are also exciting plans being developed to commence a national child psychiatry training program facilitated by telemedicine. What we have to do in the next few years is to convert our clinical skills learnt using videoconferencing to the Internet, and to the health-care environment of the future.
Therapy online: a recent update
A wide number of alternative approaches to electronically mediated mental health care are presently being used around the world. Apart from the large number of clinicians presently using the Internet to provide a variety of information and counselling services, there are a number of sites where patients can undergo structured diagnostic tests [26]. There have been several examples of highly effective treatment programs for the anxiety disorders, in particular panic disorders, which integrate the use of palmtop or laptop computers into the treatment process [27]. Here, patients carry a palmtop with preloaded instructions about what they should do if they have a panic attack. When they are afflicted by panic, they follow the instructions on their palmtop, and also document what has worked and what has not. When they next see their therapist, all of this information is downloaded to the therapist's computer. The evidence so far is that the outcomes for patients are just as effective as with conventional cognitive-behavioural therapy, but that patients need to be seen a lot less frequently using this approach. Virtual reality scenarios are also occurring in the treatment of phobias, particularly fears of heights and of spiders, where patients are asked to put on a virtual reality helmet and then literally ‘walk the plank’ in their virtual space, while at the same time receiving assistance in managing their anxiety. The outcomes from these treatments looks good so far [28,29]. Wireless telemetry, using global positioning satellite systems, is likely to be used in the not-too-distant future to allow monitoring of community-based staff for their safety, as well as possibly patients with dementia, or those with forensic constraints placed upon them. Call centres and triage systems are already here, and provide rapid and effective screening for mental health problems, particularly for after-hours services. Further into the future, the advent of affective computing will occur, computing relating to the use of monitored physiological parameters to measure moods [30].
The health-care environment of the future
Health care in Australia, and in most developed countries, has been undergoing very major changes over the past two decades. We are moving away from providing episodic care to concentrating on the importance of continuity of care, particularly for patients with chronic illnesses that we know will cause the greatest disease burden in the future [31]. Psychiatric disorders are among the most significant illnesses that will affect global disease burden. We are moving from a focus on the service provider to that of the informed patient and from an individual approach to treatment, to a team approach. We are also focusing less on the treatment of illness and more on wellness promotion and illness prevention, and are shifting away from institutional care to community care [1]. This is particularly evident in mental health with the development of integrated mental health services throughout the country, and the continuing closure of long-term psychiatric beds. The health system is also moving away from paper medical records held by the health provider to the development of shared, distributed electronic patient records incorporating evidence based decision support systems. A working party has been set up under the auspices of the National Health Information Management Advisory Council to the Commonwealth Government [32] to recommend how to implement this change nationally. Several States are introducing electronic records into their public mental health services and it is obvious that these will eventually be available through the Internet, and accessible to patients in their homes. Indeed, this is now the expectation of the Federal Government [32]. Trials of such systems are under way internationally, and the Centre for Online Health [11] at the University of Queensland is developing just such a model of care. All of these changes mean that we are moving away from the traditional focus on departments, hospitals, providers or small practices, and away from the cottage industry approach to health care of the past, to a more business- and enterprise-focused approach whereby we will work with groups of partners and collaborators to provide best-practice, multidisciplinary health care in an environment that is much more flexible. It will be interesting to see whether traditional one-on-one psychiatric private practice can survive these changes and persist in its present form. In my opinion this seems highly unlikely.
The logical consequences of these changes are that we will gradually develop flexible distributed health systems that do not have boundaries and which can exist, if patients wish to use them, in virtual space. There will obviously be fewer hospitals, and increasing numbers of services will be provided directly to the home, or in a primary care environment [1]. Patients should certainly have increased choice and accessibility, and the doctor-patient relationship itself will alter dramatically. Increasingly, doctors will be required to have their own websites, not only for marketing purposes, but also to provide evidence of the effectiveness of their treatment outcomes. Psychiatrists will need to indicate the numbers of patients they have seen in particular diagnostic categories, the specific outcomes of those patients [33] and clearly identify the types of processes that they use for treatment and assessment. Surgeons, similarly, will be required to give details of their infection and complication rates. Increasingly, patients will select doctors for specific expertise, and will not depend on our present system of relatively random referral selection that depends mainly on who you know, or who your general practitioner has heard of, and which specialists are available and when.
Patients are increasingly presenting to doctors with large amounts of information derived from the Internet, as well as from other sources, and while there are still major problems with the reliability, quality and validity of this information, such issues will gradually be resolved [34,35]. The roles of doctors will probably change and we will become more advisory and analytic. We will be the providers of specific interventions, while home-care providers, perhaps based on an upgraded version of our present-day mental health case managers with prescribing rights, specific skills in cognitive-behavioural therapies, and a much more extensive commitment to continuing education, will treat the majority of patients using evidence-based guidelines and pathways, supervised by general practitioners and psychiatrists.
All of these changes will occur gradually over the next 5–10 years and will be driven by technological changes, in particular the presence of the Internet with its rapidly improving information sharing ability, as well as by financial necessity and by the continuing rise of consumerism.
Australia will have tremendous opportunities in this new world as we will be able to provide clinical services right across our time zone to about 45% of the world's population that resides ± 2 hours away from Central Australian time. The world of the future will clearly be different, and will be divided into three time zones, especially for the purposes of providing real-time services, such as occur in health. Australian psychiatrists have the opportunity to take a real lead within the Asia–Pacific time zone [1], as long as we learn more about our neighbours, their languages and cultures. For those who wish to work across time zones, there is no technical reason why, particularly with the relatively weak Australian dollar, Australasian psychiatrists should not provide clinical services to the United States.
There are obviously multiple barriers to the introduction of these scenarios and visions of the future. The most important barrier is clearly our own inherent cultural conservatism, and the lack of understanding by our political leaders of the likely global changes that will occur as a consequence of the Internet, in particular. At the same time, this is a very complicated area to work in, as there are so many stakeholders. As traditional clinicians, we tend to deal mainly with patients, other clinicians and third-party funders. Now we must get used to dealing with all of these people as well as learning new skills of a technological and clinical nature to use these systems. We will have to learn how to perform within a broader, more flexible enterprise-focused environment where we no longer have a stranglehold on health content, and where in fact patients may well frequently know more specific content than us, but where our skills are in analysis and advice. So what should psychiatrists do to prepare for all of this?
Our future
Clearly the first thing we have to do is to prove that we are the clinical leaders within mental health. We have to embrace these new technologies, because they are here to stay, whether we like them or not, and we have to learn to use them excellently, and to the benefit of our patients. If we do not do this, then others will certainly force us into using them in ways that are not necessarily the most clinically effective or sensible. We have to learn to communicate between ourselves and our patients using a variety of electronic technologies, and we have to learn how best to use these technologies to supplement our present best-practice models of face-to-face care. We have to perform basic research on human and electronic communications and environments. It is inevitable that in the relatively near future patients will be able to access their electronic records, their doctors, their pharmacies and other mental healthcare professionals, via the Internet from their homes, perhaps using browser-enabled televisions on a pay television connection. Such systems are already being driven and designed at the Centre for Online Health [11]. It is absolutely crucial that the solutions for the next millennium of information technology-enabled health care are provided by clinicians, and not by technologists or financiers. I have selected the Internet sites in the appendix as a good start for any psychiatrists who wish to explore the Internet [29]. They also serve as a good basic list of sites to give to patients who are interested in accessing reliable information on the Internet. After all, patients are already using the Internet to a quite extraordinary degree. There are multiple discussion lists, mental health newsletters and self-help sites available, and if we do not actively join our patients online, the only alternative for us all is to stay out of touch.
Footnotes
Acknowledgements
This article has gradually evolved from the many conference presentations and public lectures given on the topic over the past 18 months by the author. Many of the ideas and opinions have arisen as a result of discussion at such conferences, and the assistance of these audiences is greatly acknowledged. I would also like to acknowledge Sheila Cleary who has continuously reworked various conditions and versions of this paper.