New Technologies in Forensic Mental Health Fionnbar Lenihan

New Technologies in Forensic Mental Health Fionnbar Lenihan & Alex Quinn fionnbar. 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, poorlyunderstood business processes • Waterfall model of software development • Resistance to change • Genuine need for tight governance - safety critical • High public exposure

Specific Technologies 1. 2. 3. 4. 5. 6. 7. MS Exchange/NHSnet Smartphones Telepsychiatry Paper/document management Remote access Thin clients 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 – – i. Phone (3 gs 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) • i. Phones 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 • 2 nd, 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 Scan. Snap S 500 s

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

Sun. Ray

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