INTRODUCTION:

Telepsychiatry is one of the oldest applications of telemedicine. Although the first experiences date back to the 1950s, telepsychiatry really began to develop in the 1990s with the implementation of a number of projects. Since these were almost exclusively initiatives in clinical settings, the first concern was to assess this application's feasibility before considering providing a framework with guidelines and technical standards. With care delivery being reorganized across Québec, telepsychiatry is being called on to play a greater role, since it provides a means of improving continuity and complementarity in psychiatric care throughout the province. However, in order for well-structured programs to be put in place, standardization is necessary. This involves two areas of equal importance, one dealing with the contents, the other with the container telepsychiatric clinical practice and the technical conditions for transmitting voice and images over distances. The objective of this report is therefore twofold to propose clinical guidelines and technical standards that would foster the optimal telepsychiatry use. Although it does not examine them in great detail, this report also looks at the economic, legal and ethical aspects, as well as the human and organizational factors, in order to highlight their importance in implementing programs successfully. CLINICAL GUIDELINES This report posits that the quality of telepsychiatric care delivery should be relatively the same as that expected in a conventional face-to-face psychiatric setting. "Relatively the same" is not to be understood as second-class care, but rather that a realistic view must be taken of the technological medium denoted by the prefix "tele-." This overall objective served as a basis for the proposed clinical guidelines and led to the exclusion of certain clinical conditions and therapeutic interventions from the area of application of telepsychiatry. CONCLUSION AND

RECOMMENDATIONS:

Defining clinical guidelines and technical standards aimed at standardizing telepsychiatric practice will foster its broad implementation. Québec will thus be better able to avail itself of the large-scale projects funded by the Health Infoway. When seen from the standpoint of the restructuring of primary care and the reorganization of highly specialized medicine overseen by Québec's four integrated university health networks (RUIS French acronym for réseaux universitaires intégrés de santé), this technology could prove to be a valuable asset in ensuring a more equitable distribution of psychiatric expertise throughout the province. This would promote the smooth development of telepsychiatry in Québec. Given the foregoing considerations, AETMIS recommends that the Ministère de la Santé et des Services sociaux (MSSS) adopt the main guidelines and technical standards proposed in this report, in cooperation with the authorities concerned. AETMIS is firmly convinced that telepsychiatry can help improve the offer of quality health care and proposes procedures that could support clinical activities in this regard. Specifically, a central reservation system and a generic consultation tool should be instituted, as should fee-for-service remuneration for physicians, for the absence of these elements is a significant disincentive to physician involvement in telepsychiatry. In addition, plans should be made to include a certain number of key players to support the implementation and use of telepsychiatric services. All the players should have the appropriate training. From this standpoint, to permit a quality practice environment, the technical infrastructure should be upgraded to a minimum standard of 384 Kbps of bandwidth together with an H.263 data-compression protocol, then gradually be brought up to an optimal standard of 384 Kbps of bandwidth with an H.264 data-compression protocol. Data-packet loss should not exceed 0.5%. Minimally, latency should be less than 500 ms, optimally, less than 300 ms. These standards should be applied to the entire data capture, transmission and reception chain. Telepsychiatric consultation rooms containing the appropriate equipment and accessories should be set up in the appropriate clinical settings and where the needs are the greatest. Taking the human and organizational aspects into account helps ensure the success of this type of activity. The legal and ethical aspects should also be considered. As well, a more detailed economic analysis should be carried out prior to any massive investment in telepsychiatry. Lastly, the implementation of telepsychiatry should be subjected to a rigorous downstream assessment in order to improve its management and performance.