New Technologies in Forensic Mental HealthFionnbar Lenihan & Alex Quinnfionnbar.lenihan@nhs.net

Who Am We?(and why are we taking up your time?)

• Fionnbar Lenihan– Consultant Forensic Psychiatrist in the Orchard Clinic in

Edinburgh– Longstanding Health Informatics interest - local and

national involvement• Alex Quinn– Consultant Forensic Psychiatrist in the Orchard Clinic in

Edinburgh– Prison psychiatry – Saughton and Addiewell

Scope of Talk

• Not comprehensive• Not a manual• Overview• Breadth not depth

Aims & Objectives

• To provoke discussion and debate• To encourage exchange of ideas

Cautions

• Services differ - what works one place may not in another

• Consult your own IT experts before implementing anything ambitious

• No conflicts of interest

Acknowledgements & Thanks

• Stella Clarke• Cathy Dorrian• Alex Quinn• Other colleagues in the Orchard Clinic

Information Technology Increases Efficiency

• IT has revolutionised other industries?

• Or has it?• Solow's Paradox -

“computers are visible everywhere except in productivity statistics”

Some Industry Sectors

• Clearly increases efficiency within sectors– Airlines– Banks– Publishing

But …• Efficiency gains can be a

while coming but outlay is upfront

• Not without pain• Costs = people• Fewer people / Cheaper

people or not …• Systems have complex

responses ...• Increased use to

compensate• Services become different• Expectations will change

Features of Forensic Mental Health

• Forensic psychiatry is paper / document heavy

• Multiple information sources

• Multiple health boards• National / Regional

services => Distances• Secure locations => time

wasted in transit• High expectations

Grounds for Caution• History of well-publicized

failures in public sector IT procurement (NPFIT etc)

• Complex, poorly-understood business processes

• Waterfall model of software development

• Resistance to change• Genuine need for tight

governance - safety critical• High public exposure

Specific Technologies

1. MS Exchange/NHSnet2. Smartphones3. Telepsychiatry4. Paper/document management5. Remote access6. Thin clients7. Voice recognition

Microsoft Exchange

Exchange/NHSnet

• Server rather than client product• Provides email, calendar, tasks• Most of you will have used Exchange• NHSnet/NHSmail largest Exchange install• Many (not all) Scottish health boards - the

only email/groupware system• Secure, encrypted, endorsed by various

authoritative bodies (BMA, RCN)

Exchange/NHSnet - II• Probably underused & under appreciated• Secure patient email a godsend. Permitted to other

secured government domains eg. .gsx.• Shared calendars incredibly useful.– Delegated powers– Supervision– Appraisal– Team working

• Can be used to send text messages and faxes too (and share files too large for email)

• Can be accessed via web or email clients in a variety of locations

Smartphones• Various types

– iPhone (3gs onwards)– Android– Blackberry– Some Nokia/Symbian models (with encryption)

• All can be securely linked to NHSnet and store data in encrypted form

• Security enforced centrally (e.g. PIN and remote wipe)• Provided by organization or BYOD• Usual voice & SMS but also calendar, tasks, shared address

book, GPS, stored documents, access to network resources (e.g. remote access to EHCR for mobile staff)

• iPhones expensive but some very economical Android models (<£60 retail)

Telepsychiatry• Telemedicine is “the remote diagnosis and treatment of patients by

means of telecommunications technology”• Telepsychiatry is “the application of Telemedicine to the field of

Psychiatry”• Excellent recent review Phil Crockett, Harry Millar and others• Around a long time• Limited uptake despite generally favorable evidence base• Use in exotic locales

– Australia– Antarctica– Peterhead

• But distance not the only barrier to access …

Telepsychiatry Basics

• Simple telepsychiatry can be done with a speakerphone

• Moving to video requires a SECURE video connection– Skype and a webcam will not suffice!

• NHS has a secure IP-based network (IP means like the Internet)

• Gateways exist to allow older ISDN (like telephone) systems to interoperate

Our First Equipment

Starting Out

• Our first kit was a hand me down from management suite

• Gathered dust for a year before we begged funding to connect it to an ISDN line

• Situated in our seminar room on ground floor => patient accessible => can be used for family “visits” and CPA meetings for OC patients

• Initial suspicion gave way to enthusiasm– “sneaky use”

Newer Developments

• 2nd, modern set thanks to good offices of Cathy Dorrian, Stella Clarke and NHS 24

• Installed upstairs in staff-only area => can be used for seeing patients at OTHER end

• Can be moved between rooms upstairs• Overall kit has been used for a variety of purposes –

mostly CPA meetings and prison MDMHT meetings• Has been used to give evidence in a court in Inverness• Formal evaluation delayed by ethics process but just

now starting direct patient assessments in prison

Future Plans

• Review clinics in prison• Emergency cover for

prison• Initial assessments

police cells

Paper & Document Management

• We (OC) have too many places for information to hide …– Paragon (basic electronic

patient record)– Discipline-specific notes– Ward notes– Paper notes– SCI store– PIMS– Shared network drives

Consolidation

– Paragon (basic electronic patient record)

– Discipline-specific paper notes

– Ward notes– Paper notes– SCI store– PIMS– Shared network drives

• New EHCR (TRAK or whatever)

• Genisys/PIMS• SCIStore– All above contained

within a local clinical portal

Electronic Health Care Record Systems

• Proceeding regionally• Avoiding the centralized model that failed in

England• This poses challenges for cross-regional

services like forensic psychiatry– Best addressed with some kind of portal

functionality at a national level

Printers• Small inkjet printers are cheap to buy but have high

running costs• Color printers are particularly wasteful• Administrative time wasted managing a dozen different

printer cartridge refills• => consolidate on single large economical laser printer

which is shared out on network• We had an existing large multifunction Ricoh machine for

which we had inclusive prints we were not using!• There are features to protect sensitive documents etc• Short breaks to retrieve print jobs are healthy and sociable

Scanners

• Flatbeds only good for fiddly photographs etc• You want Automatic Document Feeder (ADF)

models• Our big MFD already had an ADF– Feed paper into the hopper and it will email a PDF

to an email address you select from a menu

• Reduced need to manage paper• We also use 2 Fujitsu ScanSnap S500s

Remote Access Tools• Let you access a remote

computer• Remote computer appears as

a window on local machine• Allows most normal activities• Various products for home

users• Security vital. Unapproved

remote access tool = hacking!!• Firepass product used in

Lothian

Use Cases Remote Access

• Part time/home working• Multiagency working• Multi-site working• Resiliency e.g. flu pandemic or adverse

weather• Support and training• Reduction in travelling

Thin Clients

SunRay

Voice Recognition

Voice/Speech Recognition

• Was a high profile “official” project in the acute side of NHS Lothian

• We looked at it and had some concerns– Designed for medical/surgical outpatients– Didn’t match our workflows– Inflexible

• Now seems to have been discontinued• Now our own limited use “in-house”

Dragon Dictate• Purchased a few copies• Price reasonable if not going for profession-specific

versions• Generous licensing• Very useful for text-orientated workers• Helpful if reduced dexterity or if hands in use• No substitute for either dictation skills or computer

skills• We plan to get more licenses• Hard to deal with commercial vendors from inside the

NHS

To Sum Up

• IT can contribute to efficiency and quality• However, it’s not always a simple process and

expectations need to be realistic• Simple, locally driven, initiatives more likely to

succeed• We are interested in sharing ideas and

experiences