Health Canada
Symbol of the Government of Canada
Skip to content | Skip to institutional links

Common menu bar links

Home > First Nations, Inuit & Aboriginal Health > Reports & Publications > Health Care Services

Institutional links

First Nations, Inuit and Aboriginal Health

HTF 402 National First Nations Telehealth Research Project

Final Report 1998 - 2001
Cat. N° H35-4/14-2001E
ISBN 0-662-31053-5

Help on accessing alternative formats, such as Portable Document Format (PDF), Microsoft Word and PowerPoint (PPT) files, can be obtained in the alternate format help section.

Portable Document Format(PDF Version - 238 K)

Table of Contents

Appendix A: Final Evaluation Report

Acknowledgements

First Nations and Inuit Health Branch - Health Canada - wish to thank the following communities and individuals for their participation and contribution to this research project.

Communities

Anahim Lake, BC - Ulkatcho Band
Fort Chipewyan, AB - Mikisew & Athabasca Cree First Nation
Southend, SK - Peter Ballantyne Cree Nation
Berens River, MB - Berens River First Nation
La Romaine, QC - Montagnais de Unamen Shipu

Site Participants

  • Brian Ballantyne - Peter Ballantyne Band - Southend
  • Josephine Berens - Berens River First Nation
  • Rod Bird - Health Director - Southend Health Centre - Southend
  • Elsie Bouchie - Councillor - Berens River First Nation
  • Barbara Boutin - Nurse Responsible - Montagnais de Unamen Shipu - La Romaine
  • Tammy Buchanan - Rehabilitation Officer - Nunee Health Authority - Fort Chipewyan
  • Jackie Evert - Health Director - Berens River First Nation
  • Jeanne George - Nurse - Southend
  • Maureen Hanson - Director of Finance - Nunee Health Authority - Fort Chipewyan
  • Lynda Kushnir-Pekrul - Director - Health Canada - FNIHB - SK Region
  • Edmond Mark - Director of Community Services- Montagnais de Unamen
  • Shipu - La Romaine
  • Yvette Mark - Montagnais de Unamen Shipu - La Romaine
  • Trish Merrithew-Mercredi - Executive Director - Nunee Health Authority - Fort Chipewyan
  • Stan Myran - Berens River
  • Donna Norman - Nurse in Charge - Anahim Lake Nursing Station
  • Frieda Olson - Nurse - Southend
  • Claude Pedneault - Director - Montagnais de Unamen Shipu - La Romaine
  • Connie Piochion - Nursing Supervisor - Peter Ballantyne Band - Southend
  • Margaret Pynenburg - Zone Nursing Officer - Health Canada - FNIHB - N. Pacific Region
  • Will Sandoval - Ulkatcho Band Administrator - Anahim Lake
  • Judy Sandford - Zone Nursing Officer - Health Canada - FNIHB - PAC Region
  • Mary Cookie Simpson - Nunee Health Authority - Fort Chipewyan
  • Dr. David Strong - Telehealth Coordinator - Health Canada - FNIHB - AB Region
  • Nancy Szilbereisz - Telehealth Manager - Montagnais de Unamen Shipu - La Romaine
  • Charlotte Thompson - Regional Nursing Officer - Health Canada - FNIHB - PAC Region
  • Dr. Sara Whitehead - Medical Health Officer - Community Health - Southend
  • Mary Williams - Ulkatcho Band - Anahim Lake

Project Officers

  • Wayne Boyce - Telehealth Consultant - Winnipeg Regional Health Authority
  • Genevieve Cimon - Telehealth Evaluator - McGill University
  • Joseph Connor - Consultant - Winnipeg Regional Health Authority
  • Valerie Gideon - Telehealth Consultant
  • Natalie Kishchuk - Telehealth Evaluator
  • Josee Lavoie - Telehealth Consultant
  • Stephen Maislin - President - Tagge Medical Solutions Inc. - Technical Consultant
  • Jocelyne Picot - President - Infotelmed Communications Ltd., Telehealth Evaluator

Peer Review Team

  • Dr. Alain Cloutier - Centre Hospitalier de l'Universite Laval
  • Lisa Dutcher - Aboriginal Nurses Association
  • Dr. James Irvine - Associate Member in Community Health and Epidemiology, University of Saskatchewan
  • Dr. Penny Jennett - Professor - University of Calgary
  • Dr. Joe Kaufert - Professor - University of Manitoba
  • Maria MacNaughton - Senior Nursing Consultant - Health Canada - FNIHB - HQ
  • Margaret Neylan - Health Specialist - British Columbia Institute of Technology

Steering Committee

  • Brenda Baptiste - Health Director - Nk'Mip Health Services
  • Al Garman - Regional Director - Health Canada - FNIHB - Atlantic Region
  • Paul Glover - Director General - Health Canada - FNIHB - HQ
  • Donald Horne - Executive Director - Kahnawake Shakotiia'takennahas 102
  • Lesley Larson - St. Elizabeth Health Care
  • Mary Lynch-Taylor - First Nations Representative - Anishinabek Health Commission
  • Faye North-Peigan - First Nations Representative - Peigan Nation
  • Ian Sutherland - Manager - Saskatchewan Health
  • Dr. Mamoru Watanabe - President - Canadian Telehealth Society

Overall Project Management

  • Alexa Brewer - Director, Health Programs Analysis Division, First Nations & Inuit Health Branch, Health Canada
  • Ernie Dal Grande - Telehealth Program Manager - Health Programs Analysis Division, First Nations & Inuit Health Branch, Health Canada
Top of Page

Executive Summary

In the February 18, 1997 Budget, the Government of Canada announced the creation of the Health Transition Fund (HTF). This Fund, responding to a recommendation of the National Forum on Health, supports large-scale pilot projects in key areas of health system modernization. These projects are the basis for evaluating what should be added to, or refined in, the public health care system of the future. The Fund was a three-year federal investment of $150 million to support national, provincial and territorial projects contributing to Medicare modernization. Decisions on projects and priorities were made by Canada's Ministers of Health.

This Final Results Report is an amalgamation of experiences and lessons learned by participants in the 2 million dollar National First Nations Telehealth Research Project (HTF402 - September 1998 - March 2001), mainly of five, isolated First Nations communities. It also contains evaluation outcomes collected and analyzed by an independent evaluation team. The Report has been reviewed by each community project team, as well as by the project Steering Committee and Peer Review Team.

Telehealth is most commonly defined in Canada as "the use of communications and information technology to deliver health and health care services and information over large and small distances". [ Jocelyne Picot, Telehealth Industry: Part I - Overview and Prospects (Ottawa: Industry Canada, 1998) 1. ]

Although the potential of telehealth has been explored in Canada for over four decades, the boom in telehealth activity began four to five years ago, prompted by important federal initiatives and the convergence of key drivers (e.g. health care reform, increased capacity of information and communication technology etc.). Many provincial and territorial projects and networks emerged during this time. While the visions of these initiatives are very diverse, they all emphasize access to better health regardless of location through the use of information and communications technologies as enablers to enhance health service delivery and share health information and expertise.

It would seem that, since the impetus for telehealth diffusion in Canada is the need for improved access to health services, First Nations and Inuit communities are a natural environment for telehealth implementation if the the following conditions are taken into account:

  1. over 1/3 of First Nations and Inuit communities are located in isolated locations;
  2. significant inequities in health outcomes among the Canadian and Aboriginal populations have been documented;
  3. telehealth has the potential to address many priorities in First Nations health identified by Health Canada and the Assembly of First Nations.

Considering the above, the National First Nations Telehealth Research (hereinafter "National Project") was proposed to the Health Transition Fund in order to achieve the following overall goal:

To test whether telehealth improves access to high quality health care and improves the delivery of health services in a cost-effective manner in five isolated First Nations communities across Canada.

The National Project involved the planning, implementation, operation and evaluation of telehealth in five First Nations communities: Anahim Lake (British Columbia), Fort Chipewyan (Alberta), Southend (Saskatchewan), Berens River (Manitoba) and La Romaine (Quebec). These communities were selected by the First Nations and Inuit Health Branch's (FNIHB) regional offices because they satisfied the following criteria:

  • remote, isolated or semi-isolated community;
  • Chief and Band Council support of the project;
  • Community Nurse and Health Director support of the project;
  • support from FNIHB's Regional Nurse/Physician;
  • support from Regional Director.

While the design of each community telehealth research sub-project was adapted to the needs and culture of the community at hand, the National Project was implemented in eight main phases: (1) drafting of the Accountability Framework; (2) needs assessment; (3) applications selection; (4) sending out Requests for Proposals and selecting the vendor; (5) negotiating agreements with provincial health and educational facilities; (6) securing access to the required telecommunications infrastructure; (7) installation/testing of the equipment and training of personnel; (8) evaluation and ethics review.

The National Project is a pioneer in the implementation of telehealth in First Nations communities. Its design and process are unprecedented and, for this reason, it encountered many issues and obstacles that had never before been tackled. Some issues/obstacles compelled the project to deviate from its initial methodology in the following ways.

  • Two project extensions were granted.
  • Implementation of the Anahim Lake telehealth project was delayed until April 2001 due to the difficulties experienced in obtaining the required telecommunications infrastructure.
  • The La Romaine telehealth project had to switch from a real-time videoconferencing system to a store-and-forward system to deliver its selected telehealth applications due to the high cost of securing high bandwidth;
  • Some selected telehealth applications could not be implemented due to limits in financial resources and human resources (i.e. limited scope of practice, temporary staffing and time management).
  • Staff turnover created disturbances in all five community telehealth projects, ranging from low usage of the equipment to the need for additional training.

These deviations did not hinder the success of the project. Rather, they contributed many lessons learned, valuable outcomes of the National Project.

With respect to experiences of the National Project, four main types of project outcomes are highlighted:

  1. Lessons Learned;
  2. Critical Success Factors for any new telehealth implementation in isolated First Nations and Inuit communities, derived from the lessons learned;
  3. Evaluation Results, compiled from analysis of the data collected during the operational phase of four community telehealth projects;
  4. Recommendations, based on a review of outcomes identified above.
  1. Lessons Learned

    The main lesson learned during the National Project is the realization that a variety of elements can potentially guarantee or hinder success in adopting, implementing and sustaining a telehealth project. Lesson learned were categorized according to three elements, critical to achieving success if they are concurrently taken into account:

    Telehealth Element A: Human Resources

    Telehealth is not a panacea, it cannot do all things for all people. It is for the purpose of conquering the "panacea" vision that community expectations regarding the potential of telehealth should be managed. A detailed communication plan is an important step in the implementation process. The success of any telehealth project will largely depend on human interaction and stable/sound relationships rather than on interaction with the technology.

    "Getting your people to buy into the IDEA of Telehealth."

    Telehealth Element B: Financial Resources

    There are many anticipated and unanticipated cost items. Start-up and operating costs should be distinguished. Sources of sustained funding need to be identified to ensure the long-term viability of telehealth services.

    "Finding the money to do it."

    Telehealth Element C: Technical Resources

    If technology companies come knocking on the door, it is important to be informed of all the steps and considerations involved in telehealth implementation, many of which are not technology related. Although important, technology is often the last piece of the implementation puzzle.

    "Putting the tools in the hands of those who need them."

  2. Critical Success Factors

    From the many lessons learned, it is possible to extract a list of Critical Success Factors for potential future telehealth implementation in First Nations and Inuit communities. These relate to key elements in the implementation process, namely community, funding, management, health care/educational practice, technology and policy.

  3. Evaluation Results

    The National Project hired independent project evaluators to create a framework and tools, in consultation with community project teams and provincial health care and educational facilities. The evaluation addressed three main questions pertaining to the implementation and impacts of telehealth in the communities, specifically to (1) the impacts of telehealth on patient and community access to needed, quality care; (2) the role of telehealth in health services delivery, including cost-effectiveness; and, (3) the linkages created through telehealth with existing health resources. Several data collection methods were used:

    • ongoing monitoring of frequency, nature and implications of telehealth usage through forms completed by staff in both the community and referral sites;(Over the evaluation period, information was received about 927 telehealth sessions involving 176 patients. The number of sessions per community varied from 40 to 755, and the number of patients seen from 17 to 59.)

    • patient satisfaction assessment, through a total of 110 questionnaires completed by patients using telehealth in each community;

    • 43 qualitative interviews with 65 key informants including telehealth coordinators, Band and nursing station managers, nursing staff, health centre board member, elders, patients (in one community only), tertiary care providers and management, provincial telehealth representatives, and Health Canada representatives.

    A case study of each community was produced based on the above data. A cross-case analysis summarized below examined the findings in light of the evaluation questions, the consequences of telehealth in relation to costs, and the main lessons learned.

Top of Page

Access to needed, quality care

To what extent do the telehealth applications respond to community needs, as defined by the needs assessments?

In general, telehealth applications responded to community needs, although this was clearer in some communities than others. At issue are not only the definition of needs, but also how the technology and organizational arrangements can respond to needs. For instance, telehealth can be used to address the issue of diabetes within a community in a number of ways, with some ways being more easily integrated than others.

To what extent do patients and families find each telehealth application acceptable?

It seems overwhelmingly clear that, once initial concerns are overcome with a positive experience, telehealth is acceptable to the vast majority of patients and families who use it. Consistent with the findings in the research literature review, satisfaction levels are high, and almost all patients would use the system again. In addition, although the evaluation design did not permit assessment of the views of those patients who did not use the system, refusals to use the system were infrequent. It should be noted, however, that the quality of many patients' experience with telehealth is due to the quality of the care provided by nursing station staff and the relationships they have with them; when telehealth provides a new service, what is most salient to many patients is not the new technology but the new relationship and the new care received.

To what extent has telehealth improved access to needed, quality care?

The extent to which telehealth has improved access to needed care in the community depends on the extent to which it was used and integrated into ongoing health service delivery. When usage and integration were higher, telehealth certainly improved access to care within the community. Moreover, the quality of care provided was, insofar as can be estimated by this study, of quality equivalent or better to standard care. These findings are consistent with the research literature examined.

To what extent are services provided through telehealth consistent with established means of improving patient health outcomes?

Insofar as can be assessed in this study, services provided through telehealth are consistent with established means of improving patients' outcomes. In the views of the health professionals consulted, in no case was telehealth seen as inconsistent with established professional practice guidelines. Moreover, data obtained from the encounter forms suggest that educational interventions delivered through telehealth to patients were generally consistent with established patient education guidelines, although some aspects were addressed more frequently than others.

Health services delivery

To what extent has telehealth use been organized successfully?

The successful organization of telehealth usage in this project varied among the communities, according to a number of factors. Key among these were the stability of staff during the implementation period and the quality of the relationships established with the remote referral centres. Stable, committed staff in the nursing station was a key success factor for effective implementation of telehealth in these communities. This is an issue that was not identified in the research literature, and may be unique to isolated
communities.

To what extent have the professional skills and competencies required for telehealth been identified and successfully addressed through training?

The main issue with respect to the development of professional competencies for telehealth through training was the constant need to provide training to new staff members due to turnover. The adequacy of training received was also a result of the user-friendliness of the technologies involved. Training received for the interactive video-based systems was generally felt to be adequate partly because the systems were very easy to use; this was not the case for the store-and-forward system.

To what extent are telehealth applications used by eligible patients in the community?

It is not really possible for this evaluation to answer this question adequately, as little information was made available on the numbers of eligible patients (those with the health conditions which would make them candidates for using the available applications) who did or did not use telehealth during the study period. In some cases, it is clear that only a small fraction of eligible patients used the systems; while in others, the identification of new patents with health needs that had never before been addressed as a result of the implementation of telehealth suggests a high level of penetration.

To what extent does telehealth improve competencies and confidence of local health personnel?

In all communities, the implementation of telehealth brought new competencies to local health personnel, and in all cases, these were widely welcomed. Telehealth was seen as greatly improving access to outside expertise, reducing feelings of professional isolation, increasing confidence in judgments and improving the quality of patient care decisions made about cases in conjunction with remote experts. These results confirm those of existing studies in the area of tele-education for professionals.

How does telehealth affect staff workload, task allocation and professional practices?

When telehealth coordination responsibilities were assigned to a nurse in the nursing station who also had patient care duties, workload demand slowed full implementation. There were, therefore, advantages to assigning these to a separate individual, although it seems preferred that this person have some medical qualifications in order to facilitate communication with remote providers. Other impacts on task allocation seemed limited, perhaps due to the only partial integration of telehealth into some of the community's practices. To the extent that nursing station staff participate in continuing professional education using telehealth, their scope and quality of practice may be improved.

In terms of workload and practice shifts for remote providers, the overall pattern of responses would suggest that telehealth decreases efficiency. The appointments themselves are longer because of set-up time and perhaps increased attention to patients. The rate of patient no-shows also reduces efficiency and productivity for tertiary care providers. While, in many case,s this has not been an issue so far because of the pilot nature of the project, there are several indications in our data that institutionalization of telehealth will require attention to ensuring adequate compensation to remote partners for the loss of productivity - a critical issue compounded by the general scarcity of resources.

To what extent does telehealth result in cost increases, decreases or shifts for health service delivery at the community level?

Overall, the evaluation suggests that the net effect of telehealth is to generate greater access to care, thereby, increasing costs. Cost increases result both from increases in the numbers of patients receiving services -- services are now available where none were before - as well as in the intensity of services delivered - patients, especially in some applications, are seen more frequently (regularly using telehealth) than they had been before. The increases in care provided are accompanied by increased indirect costs, over and above provider remuneration and telecommunications cost, in terms of auxiliary equipment supplies and maintenance, patient supplies and within-community patient transportation costs. In addition, some of the data suggest that telehealth sessions take longer than equivalent in-person sessions, thus reducing efficiency.

In terms of avoidance of patient transfers and their associated costs, the results suggest that telehealth will result in avoided transfers in about 30 to 40% of patient care utilizations. This is somewhat less than the rates that can be estimated from the few studies available in the literature, but not a striking difference. As a proportion of total telehealth utilization within a community, this rate will depend on the balance between patient care and other types of applications that the system is used for, notably continuing professional or community education. That is, the more a community uses its telehealth system for non-patient-care applications, the less its telehealth utilization will result in patient transfers. In addition, avoiding transfers seems to be more appealing to patients whose lives or health are most disrupted by leaving the community - elders and families with young children -- and least appealing to those patients who are less inconvenienced by transfers and are, in fact, convenienced by them. When a community chooses applications that are concentrated on these two extreme age groups, the proportion of transfers avoided out of all utilizations may be expected to be higher than when a community chooses applications for health problems that affect its population throughout the lifespan.

What is the level of technical success of the platforms, applications and suppliers?

All communities experienced, at minimum, occasional technical problems, but these were resolved with adequate technical assistance in all but one community. In general, the interactive video platforms were found to be reliable and easy to use, although with occasional visual and sound quality limitations, depending on the application. Support provided by the three suppliers involved ranged from excellent to less than satisfactory and was a critical success factor in telehealth deployment.

Linkages among health resources

To what extent is telehealth appropriated, integrated and sustained as a part of the community's self-governed health care system?

The extent to which telehealth was appropriated, integrated and will be sustained varied greatly from community to community. In one community, appropriation and integration have exceeded both the community's and its partners' expectations, and sustainability and expansion of the initiative are almost certain. In the others, varying degrees of integration were associated with varying levels of community mobilization and support, stability within the community's health resources during the study period, technical success, and support provided by both existing telehealth initiatives and by the vendor. In addition, the capacity of the initiative to develop the committed, trusting relationships necessary to ensure good communication and problem-solving was critical to appropriation and integration. Relating to this issue, real-time technologies and applications are advantaged over store-and forward systems.

To what extent have the telehealth applications become linked to and integrated with provincial initiatives?

In those provinces where provincial initiatives exist, the communities became linked with them in accordance with the extent of their resources. Interoperability was not a barrier in any of these sites. These links provided access to a larger community of telehealth users, broader support and development from which these communities benefited. The existence of such provincial networks and their capacity to bring the pilot communities into their fold was a critical success factor in the project.

To what extent does telehealth improve access of secondary/tertiary care and education providers to local health service providers?

Access of education providers to the communities was improved when there was an existing provincial network coordinating educational opportunities for network members, publicizing its activities, and in some cases, covering the costs of the telecommunications link.

To what extent does telehealth improve health service providers' awareness and knowledge of local conditions and resources?

In several cases, remote providers did maintain that the relationship created through the telehealth initiative had improved their awareness and knowledge of local conditions and resources, as well as challenges faced by the communities. This has led to increased sensitivity on the part of remote health service providers to the special situations of First Nations communities, as well as to relationships based on mutual trust and respect.

Overall, the results of this evaluation showed that telehealth can be successfully implemented in isolated First Nations communities, bringing with it access to needed, quality care, stronger relationships with external health providers, and greater community capacity to undertake major health initiatives. In the long term, telehealth can, therefore, potentially improve health of community members and health service infrastructure within communities. However, successful implementation is contingent on several important factors at the community level: nursing station staff stability, community mobilization, strong relationships with remote providers and provincial telehealth systems, and effective technology and supports.

Top of Page

Recommendations

Taking into account lessons learned, critical success factors and evaluation results, FNIHB - in consultation with the community project teams and Peer Review Team - recommends the following next steps to build on achievements of the National Project:

  1. A concerted approach to the lack of connectivity in rural and remote communities, and especially Aboriginal communities, is required. This issue is one that cannot be resolved by FNIHB, nor by Health Canada, in isolation. The National Broadband Task Force and the Connecting Aboriginal Canadians strategy will no doubt raise the profile of this issue. However, their effectiveness in increasing infrastructure deployment will depend on the allocation of dedicated funding to this end.

    A concerted approach to connectivity would not be designed to solely benefit the community health care system. Rather, it would adopt the Smart Community model that enables the uptake of technology for community and economic development, education, health, social services, law enforcement, band management etc.
  2. It is recommended that new research be undertaken to further explore issues raised in the context of this project and to build a unique body of knowledge needed for the implementation of successful telehealth initiatives in First Nations and Inuit communities. New research could be used to: develop implementation strategies based on type, needs and capacity of a community; to develop funding models for sustainable telehealth initiatives once again based on the unique community situation; to conduct enhanced cost-benefit analyses; to develop models of F/P/T cooperation guiding telehealth implementation, particularly in rural and remote communities. New research should be undertaken over a longer amortization period to substantially increase its value.
  3. Opportunities to undertake telehealth (including research) should be offered in a manner that is equitable and sustainable across all First Nations and Inuit communities. Many First Nations communities do not have the structure nor resources to undertake major proposal writing. As well, a clear commitment to provide sustainable funding should be made at the outset. New project timeframes should be adapted to the implementation process required in First Nations communities (a minimum of 3-5 years).
  4. New research should study the system-wide impact of telehealth on various funding envelopes and on human resource infrastructures of communities, provinces and FNIHB. Research data will contribute to the building of a Business Case for telehealth in First Nations and Inuit communities. [ The Business Case is a comprehensive analysis of the full potential of what can be achieved by telehealth thanks to identified strategic investments. It is a means of addressing the main concerns of decision-makers and funders and encouraging them to ultimately support an ideal scenario for telehealth implementation. The main components of the Business Case are the Environmental Scan, a list of tangible and intangible benefits, a Tactical Plan and a Costing Model (cost assumptions and estimates). The Tactical Plan determines who, when, where and how telehealth will potentially be implemented in First Nations and Inuit communities. This is critical to determining a costing model for potential future telehealth communities (i.e. how many sites). The Tactical Plan anticipates what would occur if funding is granted for large-scale implementation. The scope of this possible funding is not known and, therefore, the Tactical Plan explores, and remains flexible to deal with, various funding options. ] Sustaining telehealth activity in the long term will have significant impact on current funding levels in the following ways: it will decrease, and in some cases, increase the costs of patient travel; it will increase the costs of certain allied health services; it will introduce new health services (and, thereby, new costs) to the community; it will increase the pressures on human resources at the community level, at the provincial level and at the FNIHB regional office level.
  5. It is recommended that strategies be elaborated to ensure that telehealth effectively contributes to capacity-building, service integration and sustainability in First Nations and Inuit communities. These are shared priorities in First Nations health of FNIHB and of the Assembly of First Nations.
  6. Increased awareness/understanding of, and communication to, First Nations and Inuit stakeholder in matters relating to telehealth will enable them to take advantage of new and existing initiatives and funding opportunities. A rising interest among these stakeholders in the deployment of information and communications technology to benefit health has been demonstrated. However, beyond interest, it is important to gather the knowledge of First Nations and Inuit on why and how this deployment should take place within specific communities, regionally as well as nationally. A primary vehicle for information-sharing and feedback is the creation of a Standing Working Group composed of First Nations and Inuit representatives appointed by national and regional associations, in addition to FNIHB representatives. The primary mandate of this Working Group will be to design a Blueprint and Tactical Plan for potential telehealth implementation.
  7. Linkages between telehealth and other initiatives of the Aboriginal Health Infostructure (such as FNIHIS, EHRs and health research initiatives), as well as with Canadian Health Infostructure initiatives, are critical in order to leverage investments to benefit Aboriginal peoples.
    [ A preliminary vision of the AHI was elaborated by the Advisory Council on Health Infostructure in 1999. It is intended as a distinct component of the Canadian Health Infostructure. Main principles of the AHI were suggested by the Council: self-determination, knowledge as power, and building human resource capacity and autonomous institutional development. Currently, development of the AHI is being undertaken by a Planning Committee composed of representatives of Aboriginal organizations and of FNIHB. ]A concerted approach to health infostructure development - emphasizing harmonization, linkages and leveraging of investments - will ensure that policy and other issues are addressed concurrently, and that economies of scale are created wherever possible. For instance, a comprehensive information management/technology framework - for health information systems, automated records, telehealth systems etc. - could be made available that is culturally adapted and coordinated with community capacity-building strategies. It is important to ensure that Aboriginal interests are represented in F/P/T discussions and partnerships involved in the development of the Canada Health Infoway. More specifically, awareness should be raised concerning unique federal/provincial/Aboriginal jurisdictional issues.

Project Purpose

1. Project's Overall Goal

Telehealth is most commonly defined in Canada as "the use of communications and information technology to deliver health and health care services and information over large and small distances". [ Ibid. ] Telehealth can encompass the delivery of a broad range of health and social services. In the United States of America, the term "telemedicine" is used to designate these services and, in Europe, the phrase "health telematics" is common. Telehealth traffic - that is, what travels on telehealth networks - includes: health information (clinical information such as patient records, administrative information such as costs or service utilization data, research information such as analyses and findings), images (still or moving), signals (vital signs, ECGs), audio (heart beat, voice) and multimedia (audio, image, text).

Some broad types of telehealth are:

  • telemedicine: all forms of medicine-at-a-distance;
  • inter-institutional and health information networks: the exchange of patient and clinical records and databases;
  • tele-education: for professional education (e.g. Continuing Medical or Nursing Education) and for public education (e.g. self-care)
  • tele-monitoring and telecare: for triage, remote home care and emergency networks.

Telehealth mainly serves to:

  • collect, share/access and disseminate data (images, audio, text);
  • advise, support, triage, consult, monitor and overall manage patient care;
  • educate, train, coach, support and mentor health care practitioners.

Although the potential of telehealth has been explored in Canada for over four decades, the boom in telehealth activity began four to five years ago. It was prompted by important federal initiatives, seeking to support this new technology in its next phase of development: the integration of telehealth into mainstream health care delivery. Such initiatives include the Government of Canada's Science and Technology Strategy and Information Highway Action Plan, Health Canada's National Task Force on Health Information and National Forum on Health, Industry Canada's support of key, high export, knowledge-based Canadian businesses. More recent federal initiatives have built on achievements of previous strategies by focusing on F/P/T partnerships and by contributing more considerable investments: the Connecting Canadians strategy and National Broadband Task Force, the Office of Health and the Information Highway, the F/P/T Advisory Committee on Health Infostructure and the Canadian Health Infostructure Partnerships Program (CHIPP).

During the last decade, the convergence of key drivers in the telehealth industry has been witnessed on a worldwide scale: cost containment and health care reform (service integration, accountability mechanisms), an aging population, high technology investments in the health care market (portable medical devices, biotechnology, genetics research and engineering, health informatics), increasing consumer demand for health information, decreasing cost, increased capacity of information and communications technologies, and global partnerships to advance health (e.g. G7). Key drivers and strategic federal investments have given rise to provincial/territorial telehealth networks across Canada.

Telehealth initiatives vary in their purpose and direction. The Provincial Vision Statement of Telehealth, elaborated by the British Columbia Government, is: "A health system in which telehealth technology is used effectively as a tool to improve the health of the people of the province, by enabling the delivery of accessible, affordable and efficient quality health services." [ British Columbia Ministry of Health, Telehealth in British Columbia: A Vision for the 21st Century, August 1999 (http://www.moh.hnet.bc.ca/him/moh/img/paper.html#intro). ] The Technology in Government Week 2000 Conference outlined a vision for telehealth as follows: "The vision for Telehealth is to offer fully integrated citizen-centred health services over short or long distances, and in urban as well as remote areas." [ Technology in Government Week 2000, "Telehealth: Delivering Primary Health Care Services On-Line", Abstract (http://www.webeventregistration.com/registration/ session_home?v_session_id=8336). ] During the First International Congress on Telehealth and Multimedia Technologies, hosted by the Telehealth Technology Research Institute of the University of Alberta, a draft Alberta Declaration on Telehealth was formulated. This Declaration begins with the vision: "Health Everywhere from Anywhere." [ First International Congress on Telehealth and Multimedia Technologies, Draft Alberta Declaration on Telehealth, Edmonton, Shaw Conference Centre, August 1999 (http://www.ttri.ualberta.ca/ttri.html). ] Although these visions are very diverse, they all emphasize access to better health regardless of location through the use of information and communications technologies. These technologies act as enablers to enhance health service delivery and share health information and expertise.

As demonstrated in this fused Canadian Telehealth Vision, the impetus for telehealth diffusion in Canada is the need for improved access to health services. Ergo, First Nations and Inuit communities would seem to be a natural environment for telehealth implementation if the the following conditions are taken into account:

  • Significant human hardships and financial costs result from transporting patients from remote locations to medical facilities.
  • Roughly one third of First Nations and Inuit communities are located over 90 kilometers from physician services.
  • Geographic isolation restricts access of these communities to specialist health services, health information and professional education for community health providers.
  • Geographic and professional isolation of primary care service providers working in First Nations and Inuit communities hinders recruitment and retention of these providers.

In consideration of all of the above, the National First Nations Telehealth Research Project (hereinafter "National Project") was proposed to the Health Transition Fund in order to achieve the following overall goal:

To test whether telehealth improves access to high quality health care and improves the delivery of health services in a cost-effective manner in five isolated First Nations communities across Canada.

2. Project's Objectives

Relating to Health Care:

  • To improve linkages between the community health facility and provincial primary/secondary/tertiary care centers and/or educational facilities;
  • To reduce unnecessary travel and hospital stays of community members by delivering new services from the community health facility;
  • To provide training opportunities locally for community health providers;
  • To improve access of community members to health information/education;
  • To improve access of community members to specialist health care.

Relating to Knowledge:

  • To conduct an evidence-based assessment of the benefits to the community of telehealth;
  • To learn the most effective and appropriate ways to introduce telehealth in First Nations communities and how to provide opportunities for First Nations to contribute to telehealth implementation;
  • To learn ways to increase the involvement of community members in health-related activities by adapting the project to the community's needs and culture;
  • To elaborate partnership-building strategies based on negotiations with provincial health organizations and equipment suppliers;
  • To share lessons learned with other telehealth projects in Canada, obtaining an extensive understanding of Canadian telehealth.
Top of Page

3. Strategic Importance

First Nations and Inuit telehealth is a distinct component of Canadian telehealth. While telehealth in Canada is not a new phenomenon, its implementation in First Nations communities is a recent initiative that has received much attention by people active in the field. For many telehealth enthusiasts, the implementation of telehealth in First Nations and Inuit communities seems like a natural fit for these main reasons: 1) over 1/3 of First Nations communities are located in isolated locations; 2) significant inequities in health outcomes among the Canadian and Aboriginal populations have been documented; 3) telehealth has the potential to address many priorities in First Nations health identified by Health Canada and the Assembly of First Nations; 4) telehealth has the potential to reduce the high costs of patient travel.

Geographical Isolation

Health Canada is mandated to provide for the delivery of health care services to over 600 First Nations and Inuit communities by funding 565 health care facilities and by offering a range of community-based programs such as home care, diabetes prevention, prevention of Fetal Alcohol Syndrome, pre-natal nutrition etc. 252 of these facilities are located over 90 km from physician services. For this reason, they are classified as Remote-Isolated, Isolated or Semi-Isolated.

Geographic isolation hinders a community's access to health care and community health providers' access to professional support. It has many dire consequences for communities, including: hardships resulting from travel experienced by patients and health providers, and difficulties in recruitment and retention of community health providers. In eliminating some patient and provider travel by offering services remotely, telehealth alleviates some of these hardships.

Inequities in Health Services and Outcomes

According to the First Nations and Inuit Regional Health Survey, approximately 60% of respondents believed that health services available to First Nations and Inuit are unequal to those available to the general Canadian population. Respondents also identified those services in greatest need of improvement: pediatric services, disease prevention, medication awareness, diabetes education, homes for the elderly, home care and mental health services. [ Fred Wien and Lynn McIntyre, "Health and Dental Services for Aboriginal People," First Nations and Inuit Regional Health Survey National Report 1999 (Ottawa: First Nations and Inuit Regional Health Survey National Steering Committee, 1999) 241. ] Inequities in health outcomes were also revealed in the survey, such as:

  • Infant death rates are twice as high among First Nations and Inuit than among Canadians.
  • Chronic conditions are more prevalent among First Nations and Inuit elders than among those of the Canadian population.
  • Type 2 diabetes is 2-5 times higher in the Aboriginal population.
  • Disability rates among Aboriginal peoples are more than double the Canadian rate.

Service inequality is reflected dramatically in nursing and physician shortages in First Nations and Inuit communities. Depending on the region, from 15% to 53% of nursing positions in these communities are either vacant or staffed on a temporary basis. [ Health Canada, FNIHP, Action on Nursing: Nursing Retention and Recruitment Strategy (Ottawa: Health Canada, 1999) 2. ] Communities can experience a delay of 8 to 10 months before staffing a vacant position. Filling a vacant position can cost upwards of $35,000. The situation is only expected to worsen. Canada faces a projected shortfall of 59,000 to 113,000 nurses by 2011. [ Ibid. ] This is due in part to the aging of the nursing workforce, whose current average age is 44 years.
[ Ibid. 3. ]

The number of generalist physicians in rural Canada fell by 15% from 1994-1998. In 1996, only 14.3% of generalist physicians and 2.9% of specialists served 9 million people living in rural Canada. In the North, nearly two thirds of the population is 100 or more kilometers from the nearest physician. In 1993, areas that did not consist of large or small urban centres had 23% of the Canadian population, but had access to only 9% of physicians (including 3% of specialists).
[ Edward Ng, Russell Wilkins, Jason Pole and Owen B. Adams, "How Far to the Nearest Physician?," Health Reports 8.4 (Spring 1997): 19-31. ] The physician shortage in rural Canada is no doubt experienced in First Nations and Inuit communities. For instance, Manitoba's Burntwood Health Region - 60% of whose residents are First Nations - has the highest population to physician ratio (3,817) in the province.

In response to nursing and physician shortages:

  • Telehealth increases access of First Nations and Inuit communities to health expertise.
  • Telehealth offers remote professional support (including education), facilitating the recruitment and retention of nurses and physicians.
  • Telehealth improves nursing care by enabling access to remote physician consultations, health information and continuing education.
  • Telehealth assists the community in building its capacity to deliver health services and to produce health information by offering learning opportunities.

Telehealth can also contributes to improving the delivery of community health programs funded by FNIHB such as mental health, child health, FAS/FAE, home care, diabetes, HIV/AIDS etc.

Priorities in First Nations Health

The table below demonstrates how telehealth can respond to strategic priorities in matters of First Nations health identified by Health Canada and the Assembly of First Nations (AFN).

Health Canada, Plans and Priorities in Aboriginal Health, 2000-2001 [ Health Canada, 2000-2001 Estimates: Part III - Reports on Plans and Priorities (http://www.tbs-sct.gc.ca/tb/estimate/20002001/rH_____e.pdf) 78-86. ]

Overall Objective: To assist Aboriginal communities and people in addressing health inequalities and disease threats and in attaining a level of health comparable to that of other Canadians, and to ensure the availability of, or access to, health services for registered First Nations people and Inuit.

Priority 1

  • Strategic Priorities
    • Sustainable health services and programs: reduced health inequalities and disease threats; First Nations and Inuit autonomy and control.
    • Planned Results:
      • Better health and reduced health inequalities among non-Aboriginal and Aboriginal populations.
      • Informed First Nations and Inuit population and raised awareness of health factors and behaviors.
  • Possible Response by Telehealth
    • By improving access to high quality health care and existing federal programs (e.g. Aboriginal Head Start, addictions programs, Home and Community Care, Community Health Nursing Practice, Aboriginal Diabetes Initiative, dental health, Canada Prenatal Nutrition Program, environmental health and nutrition), reduces health disparities.
    • Promotes a comprehensive, holistic approach to health service delivery with applications in mental health, traditional medicine, spiritual healing, community and economic development, education, prevention.
    • Builds community capacity (training, community and economic development, research).

Priority 2

  • Strategic Priorities
    • Effective health care services available and accessible to First Nations and Inuit people.
    • Planned Results:
      • Service and health systems integration.
  • Possible Response by Telehealth
    • Linkages with other information and communications technology initiatives (FNIHIS, electronic health records).
    • By reinforcing linkages amongst providers and facilities, improves regionalized health service delivery.
    • Promotes cost-effectiveness, especially in the area of non-insured health benefits.
    • Builds on partnerships with organizations such as the AFN, Inuit Tapirisat of Canada, P/T telehealth initiatives, provider associations etc.

Priority 3

  • Strategic Priorities
    • Increased First Nations and Inuit management of, and accountability for, health care services and the non-insured health benefits program.
    • Planned Results:
      • Transfer of health programs to First Nations and Inuit.
  • Possible Response by Telehealth
    • Supports community-driven projects and health systems.
    • To be implemented in accordance with standards and accountability frameworks developed in consultation with First Nations and Inuit (e.g. flexible accountability mechanisms and joint accountability to government, community & partner).

Assembly of First Nations, Health Priorities, 2001-2002 [ AFN Health Secretariat, AFN National First Nations Health Technicians Network and the AFN Chiefs Committee on Health, First Nations Health Priorities, 2001-2002 (Http://www.afn.ca/Programs/Health%2...irst_nations_health_priorities.htm). ]

Priority 1

  • Strategic Priorities:
    Sustainability
    Building and sustaining First Nations Health
    and Health Care Systems
    • Possible Response by Telehealth
      • By improving access to high quality health care, reduces health disparities.
      • Provides for needs-based and flexible implementation strategies to accommodate diverse community approaches.
      • By reinforcing linkages amongst providers and facilities, improves regionalized health service delivery.
      • Promotes cost-effectiveness, especially in the area of non-insured health benefits.
      • Improves community capital infrastructure and provides sustained resources to meet infrastructure needs
  • Strategic Priorities:
    Sustainability
    Human Resources Development, Capacity
    Building and Training
    • Possible Response by Telehealth
      • Increases training opportunities for First Nations and other community health care workers and administrators.
      • Delivers Aboriginal health careers programs.
      • Establishment of a training fund and program for telehealth coordinators.
      • Development of standards of practice/protocols for telehealth training, implementation and operation.
  • Strategic Priorities:
    Sustainability
    Enhancement of Under Funded Programs (i.e.
    diabetes surveillance)
    • Possible Response by Telehealth
      • Provides remote diabetes surveillance, screening, diagnosis, treatment and education services.
Top of Page

Priority 2

  • Strategic Priorities:
    Health Research and Infostructure
    • Possible Response by Telehealth
      • Partnerships among telehealth users/integrators and health researchers such as the the National Aboriginal Health Organization, the Aboriginal Peoples' Health Research Institute, the First Nations and Inuit Regional Longitudinal Health Survey, the First Nations Statistical Institute and others, can be established.
      • Enables community members to be trained remotely in evaluation.

Priority 3

  • Strategic Priorities:
    Jurisdictional Issues
    • Possible Response by Telehealth
      • Jurisdictional issues pertaining to telehealth implementation and use to be outlined.
      • Strategies for ensuring that these issues are addressed in First Nations/F/P/T leadership forums are targeted.
      • A formal policy for dealing with these issues is developed.

Priority 4

  • Strategic Priorities:
    Mental Health
    • Possible Response by Telehealth
      • Delivers remote mental health services to First Nations communities, including suicide prevention programs targeting youth.
      • Delivers remote training programs for community health workers relating to mental health services, including community crisis response strategies for suicide, family
        violence and other crises.

Priority 5

  • Strategic Priorities:
    Children's Health/Gender Health
    • Possible Response by Telehealth
      • Delivers remote early childhood development programming and training.
      • Delivers remote screening and diagnostic tests for cancers (e.g. tele-mammography).
      • Delivers remote support programs for cancer victims/survivors.

Priority 6

  • Strategic Priorities:
    Smoking
    • Possible Response by Telehealth
      • Delivers remote smoking prevention, cessation, treatment and training programs.

Priority 7

  • Strategic Priorities:
    Environmental Health & Infrastructure
    • Possible Response by Telehealth
      • Delivers remote environmental health awareness and emergency measures training programs.
Top of Page

Project Activities

1. Methodology

The HTF National project (2 million dollars) HTF, was managed by Health Canada's First Nations and Inuit Health Branch (FNIHB). It involved the planning, implementation, operation and evaluation of telehealth in five First Nations communities: Anahim Lake (British Columbia), Fort Chipewyan (Alberta), Southend (Saskatchewan), Berens River (Manitoba) and La Romaine (Quebec). These communities were selected by FNIHB regional offices because they satisfied the following criteria:

  • remote, isolated or semi-isolated community;
  • Chief and Band Council support of the project;
  • Community Nurse and Health Director support of the project;
  • support from FNIHB's Regional Nurse/Physician;
  • support from Regional Director.

While the design of each community telehealth research sub-project was adapted to the needs and culture of the community at hand, the National Project was implemented in eight main phases.

Accountability Framework

The Accountability Framework was finalized with all project participants during a meeting in Winnipeg in October 1998.(The Minister of Health announced the launch of the National Project on September 8, 1998.) It outlined the National Project's organizational chart, objectives, expected outcomes, principles and assumptions, roles and responsibilities, workplan (including a checklist of tasks/activities), budget, risks, categories of potential telehealth applications, main communication messages, management structure and preliminary evaluation plan. The Accountability Framework was instrumental to identifying key members of the national and community project teams, i.e. the National Project Manager, Community Project Officers, Regional Project Coordinators, Community Site Leaders, Community Health Authorities/Managers/Providers, Community Political Leadership, Telehealth Technical Consultant, Technical Vendors, Telehealth Evaluator Specialists, Peer Review Team and Project Steering Committee.

Needs Assessment

In September 1998, community health providers were asked to complete a Pre-Site Visit: Data Gathering Instrument. The evaluation team then provided Community Project Officers with Community Needs Assessment Guidelines and Tools. Needs assessments were undertaken during the Winter of 1999. Key informant interviews were conducted with health and social services personnel, service providers outside health, community leaders (including elders) and provincial secondary and tertiary care resources. Health records and data collected by Health Canada concerning patient transportation, life expectancy etc. were also studied. Information was compiled and analyzed according to a grid intended to match identified needs to potential telehealth applications. The grid's three main categories of evaluation criteria were: response to needs; community readiness; and, feasibility.

Application Selection

To limit the scope of the project and increase its feasibility, communities were asked to select up to three telehealth applications based on identified needs. Applications selected by each of the communities are outlined below.

Community

  • Anahim Lake
    • Applications
      • Urgent/Emergent Telehealth: real-time, on demand teleconsultations between the Anahim Lake Nursing Station and Cariboo Memorial Hospital in Williams Lake for emergency assessment/triage and support.
  • Fort Chipewyan
    • Applications
      • Telerehabilitation: remote supervision of a Rehabilitation Assistant in the Fort Chipewyan Nursing Station by senior professionals at the Northern Lights Regional Health Centre (Fort McMurray) to conduct occupational, speech and physical therapy sessions;
      • Televisitation of family members with patients hospitalized in Fort McMurray.
  • Southend
    • Applications
      • Teleconsultations in the areas of General Practitioner (GP) and specialist services with a main focus on dermatology;
      • Remote educational sessions on diabetes management;
      • Remote mental health services provided from Saskatoon.
  • Berens River
    • Applications
      • Remote diabetes prevention and intervention: foot care program (education and video examination of feet), community-based screening activities with training and referrals conducted over the audio-video link to health educators and specialists;
      • Remote mental health services: patient assessment and counseling, specialist consult and group therapy;
      • Continuing education programs for health staff, administrators and para-professionals.
  • La Romaine
    • Applications
      • Remote diabetes monitoring from the patient's home: use of electronic glucose monitor connected by telephone line to La Romaine Nursing Station and tele-ECG;
      • Teledermatology: store-and-forward system (i.e. an asynchronous communication where voice, video and/or data is "stored" in a computer and than "forwarded" to a computer in another location);
      • Tele-Ear/Nose/Throat (ENT): store-and-forward system.

Request for Proposals and Vendor Selection

A Request for Proposals (RFPs) template, was developed for purchase of the telehealth equipment (i.e. videoconferencing, peripherals, network technologies). Community Project Officers sent RFPs to a maximum of ten potential equipment suppliers. Submitted proposals were then evaluated by the officers according to a Bid Review Package. The main groups of criteria pinpointed in the package were: Group 1 - Compliance with Submission Requirements; Group 2 - Vendor Profile; Group 3 - Vendor Commitment; Group 4 - Costs; Group 5 - Equipment and Software. In some cases, equipment suppliers were invited to present their proposed solution to the community project team. The Peer Review Team and Steering Committee were also asked to evaluate the proposal selected by the community project teams according to a list of assessment criteria.

In the majority of cases, partnerships were struck to share provincial resources with pilot communities. The Mental Health Services Program of BC Health and Ministry Responsible for Seniors contributed $30,000 to the cost of purchasing the videoconferencing system installed at Cariboo Memorial Hospital. Southend was linked into the Northern Telehealth Network created by SaskHealth. The Winnipeg Health Sciences Centre contributed the use of its pre-existing videoconferencing equipment to conduct teleconsultations with Berens River. Thanks to the technical simplicity of the store-and-forward system, no additional equipment was required at the secondary and tertiary care centres delivering telehealth services to La Romaine except for the secure software required to open transmitted images.

Memoranda of Understanding (MOU)

Successful partnerships were negotiated with provincial secondary care centres, tertiary care centres and educational centres to ensure delivery of remote services to the five participating First Nations communities. Community Project Officers guided discussions between community leadership and provincial facilities/authorities (i.e. hospitals, regional health authorities, colleges etc.). Often, officers were asked to draft an MOU that was then reviewed by legal advisers of both parties. MOU included, in some cases, agreements to transfer funds from the community to the provincial facility to refund costs related to professional fees and administration. In British Columbia, Alberta and Quebec, teleconsultations conducted in the context of the National Project were not recognized by the provincial government as an insured service. For this reason, provincial fee-for-service health care providers delivering services using the telehealth link were compensated with funds originating from the Project's budget. In the table below is the list of provincial partners involved in the National Project.

Community Partners

  • Anahim Lake Nursing Station, Ulkatcho Band (Anahim Lake)
    • Provincial Partners
      • Cariboo Memorial Hospital, Central Cariboo Chilcotin Health Council (Williams Lake).
  • Nunee Health Authority, Athabasca and Misikew Cree First Nations (Fort Chipewyan)
    • Provincial Partners
      • Northern Lights Regional Health Centre, Northern Lights Regional Health Council (Fort McMurray)
  • Southend Health Centre, Peter Ballantyne Cree Nation Health Services Inc. (Southend)
    • Provincial Partners
      • Northern Telehealth Network (more specifically, La Ronge Hospital, Victoria Hospital in Prince Albert, Royal University Hospital and Saskatoon City Hospital in Saskatoon, SaskHealth )
  • Berens River Nursing Station, Berens River First Nation (Berens River)
    • Provincial Partners
      • J.A. Hildes Northern Medical Unit, University of Manitoba
      • Winnipeg Health Sciences Centre (Winnipeg)
  • Centre de santé Unamen Shipu, Conseil des Montagnais Unamen Shipu (La Romaine)
    • Provincial Partners
      • Centre hospitalier régional de Sept-Iles (Sept-Iles), Centre hospitalier des universités de Québec Quebec City)
Top of Page

Telecommunications Access

The level of access to the required telecommunications infrastructure varied from one community to the other. Since the type of telehealth application determines the level of telecommunications bandwidth required, initial research aimed at identifying the extent of available telecommunications infrastructure was conducted during the needs assessment to ensure that unfeasible applications would not be selected. A summary of the telecommunications made available to each community in the context of the National Project is provided below.

Community

  • Anahim Lake
    • Telecommunications Access
      • Prior to the project, telecommunications access was restricted to bad quality Plain Old Telephone Service (POTS). A satellite C-Band 3.7M to C-Band 2.4M (384 kbps raw link) communication link between the Anahim Lake Nursing Station and Cariboo Memorial Hospital had to be established. Telesat was contracted to provide this service under its R&D program, allowing the community to purchase space segment at 15-minute increments. As well, the installation and testing were conducted free-of-charge by Industry Canada's Communications Research Centre. Notwithstanding, the high cost of the satellite communication link required the negotiation of a cost-sharing partnership with the BC office of Indian and Northern Affairs Canada (INAC). INAC agreed to contribute $75,000 to the satellite link if Internet access could be provided to the Band Administration Office.
  • Fort Chipewyan
    • Telecommunications Access
      • At the outset, the community had high line speed availability thanks to 6 sets of switched-56 lines converted to ISDN using Telesync adapters (high point is 336 kbps).
  • Southend
    • Telecommunications Access
      • At the outset, the community had high line speed availability thanks to switched-56 lines. Its connectivity to the Northern Telehealth Network was feasible.
  • Berens River
    • Telecommunications Access
      • Prior to the project, telecommunications access was restricted to low speed (33.6) POTS. A satellite C-Band 3.7M satellite communication link between the Berens River Nursing Station and the Winnipeg Health Sciences Centre had to be established. Telesat was contracted to provide this service under its R&D program, allowing the community to purchase space segment at 15-minute increments. As well, the installation and testing were conducted free-of-charge by Industry Canada's Communications Research Centre. A cost-sharing arrangement was made with the tertiary care center to cover the civil works costs related to the installation of the satellite earth station at the Winnipeg site.
  • La Romaine
    • Telecommunications Access
      • The community has access to ISDN but requires a new cross-connect digital switch to access a dedicated T1. This capacity was required for the community to connect to the private telemedicine network of the Quebec Health and Social Services Ministry. Called the Réseau de télécommunication socio-sanitaire (RTSS), the network links all provincial health care facilities, including the secondary and tertiary care centres that deliver health care to La Romaine community members. The network is established and maintained by a partnership between Bell Canada, Telebec and QuebecTel. La Romaine's access to the RTSS was evaluated at $10,000 per month by the provincial government. This high cost prevented the community from linking into the network and, therefore, set up any videoconferencing link with its referral centres. It instead chose to build a store-and-forward system using a dial-up Internet account.

Installation/Testing/Training

Installation/Testing/Training took place during the Spring of 2000, except in Anahim Lake. Additional training sessions were held during the Fall 2000 and Winter 2001 in La Romaine, Berens River and Southend. These sessions were needed mainly due to staff turnover.

Evaluation and Ethics Review

There is no standardized evaluation framework for telehealth. Some researchers, such as Marilyn Field [ Marilyn J. Field, Telemedicine: A Guide to Assessing Telecommunications in Health Care (Washington, D.C.: National Academy P, 1996). ], are known for their development of telehealth-specific evaluation methodologies. There are two general approaches used to evaluate telehealth: program evaluation and health technology assessment. Program evaluation assesses the effectiveness of a service delivery program. It can include several sub-components such as a needs analysis, an economic analysis (cost-benefit, cost-effectiveness or cost-consequence analyses), formative (process-oriented) or summative (outcomes-oriented) evaluations. Health technology assessment relates to the safety and performance of the technology, as well as to the costs of the technology.

The National Project hired independent project evaluators to create a framework and tools, in consultation with community project teams and provincial health care and educational facilities. The National Project hired independent project evaluators to create a framework and tools, in consultation with community project teams and provincial health care and educational facilities. The evaluation addressed three main questions pertaining to the implementation and impacts of telehealth in the communities, specifically to (1) the impacts of telehealth on patient and community access to needed, quality care; (2) the role of telehealth in health services delivery, including cost-effectiveness; and, (3) the linkages created through telehealth with existing health resources. Several data collection methods were used:

  • ongoing monitoring of frequency, nature and implications of telehealth usage through forms completed by staff in both the community and referral sites; [ Over the evaluation period, information was received about 927 telehealth sessions involving 176 patients. The number of sessions per community varied from 40 to 755, and the number of patients seen from 17 to 59. ]
  • patient satisfaction assessment, through a total of 110 questionnaires completed by patients using telehealth in each community;
  • 43 qualitative interviews with 65 key informants including telehealth coordinators, Band and nursing station managers, nursing staff, health centre board member, elders, patients (in one community only), tertiary care providers and management, provincial telehealth representatives, and Health Canada representatives.

A case study of each community was produced based on the above data. A cross-case analysis summarized below examined the findings in light of the evaluation questions, the consequences of telehealth in relation to costs, and the main lessons learned. It is important to note that the constrained project timeframe of 2.5 years did not allow an evaluation period of more than an average of 8 months. As background information for their Final Report, the evaluation team completed a literature review of evaluations of selected telehealth applications in rural settings [ Applications consisted of cardiology, continuing medical education, dermatology, diabetes management, ENT, mental health/counselling, ophthalmology, neo/post-natal and pediatric assessment, rehabilitation, respiratory problems, trauma and emergency medicine. ], also attached in Appendix A.

Since the National Project was, first and foremost, a research project and since it involved human subjects, an ethics review process was undertaken by each community project team. That is, during their first visit to the pilot communities, the evaluation team appealed to community members and leadership to approve the research procedures to be utilized in the data gathering and analysis. Upon request, some communities made available formal letters of approval of the research ethics involved in the project. In November 2000, consolidated ethics review submissions were then prepared for ethics review committees of tertiary care centres/universities participating in the project, mainly the University of Manitoba, the Centre hospitalier des universités de Québec, the Northern Lights Regional Health Centre and Royal University Hospital. This submission compiled all the ethical rules of these centres, as well as the Code of Research Ethics developed by the National Steering Committee of the First Nations and Inuit Regional Health Survey in 1997. Each centre was contacted in order to extract their protocols, questionnaires etc. No requests to appear before an ethics review committee has yet to be received from these centres by the main project investigator (FNIHB).

2. Deviations in Project Methodology

The National Project is a pioneer in the implementation of telehealth in First Nations communities. Its design and process are unprecedented and, for this reason, it encountered many issues and obstacles that had never before been tackled. Some issues/obstacles compelled the project to deviate from its initial methodology. However, such deviations did not hinder the success of the project. Rather, they contributed many lessons learned, valuable outcomes of the National Project. Below is a description of the principal project deviations experienced.

Project Extensions

Two project extensions were granted by the Health Transition Fund Secretariat (from March 2000 to September 2000; from September 2000 to March 2001). These allowed the National Project to adapt its methodology to community needs and processes. Furthermore, extensions allowed project team members to familiarize themselves with the technical and human components of telehealth implementation (i.e. negotiating agreements with provincial health care providers, securing satellite communication links, negotiating agreements with Band and Tribal Councils to guarantee protection of their inherent treaty rights and funding envelopes).

Delays in Anahim Lake Project Implementation

Despite project extensions, telehealth applications were not operational in Anahim Lake before the end of the National Project. This inability to collect usage data is due primarily to the lack of telecommunications infrastructure. Various solutions were sought. Negotiations were undertaken with Telus and Telesat. While satellite communication was selected as the only available option early in 2000, obstacles were faced relating to the feasibility of using Telesat equipment: the high cost, the issue of potential inadequacy of the roof of Cariboo Memorial Hospital to carry a satellite earth station, and the switch from KU-Band to C-Band equipment due to lack of space segment. As previously indicated, a contribution of $75,000 made by INAC was successfully negotiated to partly subsidize the high cost of the satellite equipment. As the situation now stands, the satellite equipment will be installed in Anahim and Williams Lake in April 2001. The project will begin its testing and training phase at that time. It is expected that data will be collected in Anahim Lake until March 2002. This data will be analyzed according to the evaluation framework outlined in the context of the National Project. The analysis will contribute further to the continued effort of building a Business Case for telehealth implementation in First Nations and Inuit communities.

Top of Page

Switch from Real-Time to Store-and-Forward in La Romaine

Once again, the lack of telecommunications access impeded the implementation of telehealth in a second community, La Romaine. However, in this case, the applications selected (tele-ENT, teledermatology and remote monitoring) did not, in and of themselves, require real-time videoconferencing. It was, therefore, possible to implement a store-and-forward system using dial-up e-mail accounts (whose infrastructure is POTS). Notwithstanding, the community's expectations were no doubt disappointed by this switch in the system design. It is possible that this switch partially contributed to the low level of usage of the tele-ENT and teledermatology applications (see Final Evaluation Report in Appendix A).

The Will to Do More in the Face of Limited Resources

In some communities, applications selected according to the needs assessment process were not implemented due to a lack of financial resources. [ These applications were mainly: the use of a defibrillator to expand the tele-ECG application in La Romaine, a link to Medicine Hat College to train a community member as a rehabilitation assistant in Fort Chipewyan, tele-mental health and addictions counselling as well as tele-ultrasound in Anahim Lake. ] These applications required additional equipment that could not be purchased within the limits of the allocated funds. The expansion of existing community telehealth projects is an important issue that has been raised during recent negotiations for sustained funding.

Secondly, community expectations relating to the potential of telehealth are, at times, not achievable due to limited scope of practice, competencies and time of nurses. In Anahim Lake, specialists at Cariboo Memorial Hospital suggested that the use of ultrasound to remotely diagnose internal injuries would greatly increase the effectiveness of the urgent/emergent telehealth application. In addition to the exorbitant cost, the lack of qualified personnel to capture ultrasounds available at the community level made this application unfeasible. Clear protocols relating to the use of telehealth in urgent/emergent cases had to be developed by the FNIHB zone nursing officer, the community nurse, a project consultant with a nursing background contracted by Cariboo Memorial Hospital, and a clinical advisor employed by the equipment supplier to ensure compliance with nurses' scope of practice.

Confronting Challenges Precipitated by Staff Turnover

Staff turnover at the community level impacted all five community telehealth projects as demonstrated in the table below.

Community

  • Anahim Lake
    • Instance(s) and Impact of Staff Turnover
      • During project planning, the community lost its Nurse-in-Charge in two separate instances. Notwithstanding, the project was able to advance. The current Nurse-in-Charge has been actively involved in protocols development.
  • Fort Chipewyan
    • Instance(s) and Impact of Staff Turnover
      • The inability to train a community member as a rehabilitation assistant by establishing a link to Medicine Hat College due to limited financial resources jeopardized the feasibility of the telerehabilitation application. Thankfully, the community was able to recruit a Rehabilitation Assistant to participate in the project. The community member initially targeted for training was able to participate in the project as the telehealth coordinator.
  • Southend
    • Instance(s) and Impact of Staff Turnover
      • The loss of a nurse temporarily disrupted the project's progress. However, the community was quickly able to recruit a new telehealth coordinator, a community member, who then partnered with a new nurse to form the telehealth team.
  • Berens River
    • Instance(s) and Impact of Staff Turnover
      • The loss of three nurses each of whom had over ten years experience in the community was an unfortunate consequence of the transfer of health services management from FNIHB to the Band Council. Innovatively, a community health representative (CHR) was able to take over the telehealth project by acting as its coordinator. With additional training, the new coordinator allowed the project to move forward and promote community involvement.
  • La Romaine
    • Instance(s) and Impact of Staff Turnover
      • The loss of the nurse coordinator and health director impacted progression of the project during the Summer of 2000. Temporary staffing during this time prevented any resources from being dedicated to telehealth coordination. However, a new telehealth coordinator was appointed and a new training session scheduled in September 2000.

Project Outcomes

There are four main types of project outcomes:

  1. Lessons Learned, identified during each phase of the methodology;
  2. Critical Success Factors for any new telehealth implementation in isolated First Nations and Inuit communities, derived from the lessons learned;
  3. Evaluation Results, compiled from analysis of the data collected during the operational phase of four community telehealth projects;
  4. Recommendations, based on a review of outcomes.

1. Lessons Learned

The main lesson learned during the National Project is the realization that a variety of elements can potentially guarantee or hinder success in adopting, implementing and sustaining a telehealth project. The following three elements are critical to achieving success if they are concurrently taken into account; otherwise there is a high risk of project failure:

Telehealth Element A: Human Resources

Telehealth is not a panacea, it cannot do all things for all people. It is not designed to replace clinical practitioners and other health staff, but instead is designed to provide easier, more timely access to health services to everyone, especially to those in remote locations or to those whose access is limited by culture, language, or available clinical resources. It is for the purpose of conquering the "panacea" vision that community expectations regarding the potential of telehealth should be managed. A detailed communication plan is an important step in the implementation process. The success of any telehealth project will largely depend on human interaction and stable/sound relationships rather than on interaction with the technology.

"Getting your people to buy into the IDEA of Telehealth."

Telehealth Element B: Financial Resources

There are many anticipated and unanticipated cost items. Start-up and operating costs should be distinguished. Sources of sustained funding need to be identified to ensure the long-term viability of telehealth services. If a health organization is weary about receiving continued funding for telehealth, it will view telehealth as an experimental activity and will not integrate it fully into its existing service delivery patterns.

"Finding the money to do it."

Telehealth Element C: Technical Resources

If technology companies come knocking on the door, it is important to be informed of all the steps and considerations involved in telehealth implementation, many of which are not technology related. Although important, technology is often the last piece of the implementation puzzle.

"Putting the tools in the hands of those who need them."

A more detailed account of lessons learned pertaining to each of these critical elements, in addition to a brief discussion on policy issues raised by the project, are provided.

Human Resources

More and better information on communities (on available resources within those communities and within regional referral centres) is needed to improve the process of selection of communities in which telehealth is to be implemented. Time invested in community needs assessment and feasibility studies prior to selection can increase the chances of success and greatly facilitate the implementation process. It is important to determine if telehealth fits into the strategic plans of the community and connecting health/educational organization(s). Find out what human resources are already available at the main and referral site(s). Ask the question: "What is the impact of telehealth on community and referral/educational centre human resources?" The human infrastructure that supports telehealth must be developed. This development, however, is hindered by the lack and instability of human resources available in remote First Nations and Inuit communities.

It is important to manage high community expectations by communicating that telehealth is not a panacea or an easy fix to all community health problems. Generally, some community members will believe that telehealth can deliver locally complicated diagnostics (e.g. ultrasound). Community members often cite cases where "if only telehealth had been there" a better outcome would have resulted, but this is not always likely. However, while community members are showing an interest in telehealth, the majority are also waiting to see if any significant changes to health care delivery will result before endorsing the technology. The communication strategy adopted by project managers will be more complex and time-consuming the larger the community. More elaborate communication strategies enable broader-based decision-making which later contributes to more consistent support for the project's direction. Public education materials on telehealth should be developed for and with users of telehealth in remote and rural areas (and ideally, with users in First Nations communities).

It is important for communities to be ready for the ways in which telehealth can change health care delivery. A change management strategy is necessary; this strategy must take into account the organizational impact of telehealth, that is, its impact on existing community health care resources. Management of a telehealth project that is new to an organization, and/or its users, requires extra investment of time and effort, as well as education and training. Adequate initial and periodical training of health staff is critical to ensure rapid adaptation and high continued usage of the telehealth equipment. A sufficient testing and demonstration period is required to familiarize staff with the equipment at the inception of the system and as new staff come on board. Clinical protocols for the use of telehealth are required and should be developed by the project team. Be alerted to the fact that a project bringing about change will create uncertainty. This is often accompanied by considerable resistance to the changes in question. However, providing community members and health care providers with educational materials and demonstrations of telehealth applications will help them understand what telehealth is about and the impact it may have on their community. It will also increase the likelihood of project success. For instance, such an orientation may alleviate the concerns specialists may express with liability, especially as it relates to the technical quality of transmitted medical images. Other concerns expressed by health care professionals, in the context of the National Project, were: insurance, interprovincial licenses (needed to deliver telehealth from one province to another), scheduling (determining how much time is required for teleconsultations), patient confidentiality (particularly the presence of community translators and other family members in teleconsultations). Lastly, patients should be kept informed of the various options available to them, from the use of telehealth to other modes of service delivery (e.g. waiting for a face-to-face consultation at the community site, traveling to the referral site etc.). The use of telehealth should be an informed choice made by the patient.

Top of Page

Communities and their health teams should be aware that technology companies may be knocking on their door to sell them equipment. They should be aware of the many aspects of telehealth implementation that are not purely technical. It is important to inform community leadership on the many steps involved in the effective implementation of telehealth that can include securing the commitment of the local health team, involving other community human resources, training staff and negotiating with external service providers. Community/organizational leadership should determine how to best integrate telehealth into the current practices of health care delivery. Community leadership will need to negotiate Memoranda of Understanding (MOU) or other forms of written agreement with provincial/territorial facilities in order for infrastructure and resources to be shared with their community. Both parties have to agree to an acceptable level of service that will respond to the needs identified by the community and that is also manageable by the staff at the referral site. An agreement must be reached before moving forward with the purchase of equipment. A close relationship with the implementation team of the provincial/territorial telehealth network, if such a network is in place, is also essential for success. This relationship depends on the willingness of provincial/territorial governments, the federal government and First Nations and Inuit communities to collaborate and jointly develop their telehealth initiatives.

Most provincial governments have not set rates of reimbursement for services offered through telehealth. That is, telehealth services are not considered insured services and are, therefore, not reimbursed under provincial health care insurance plans. Governments that have agreed to reimburse telehealth services have done so on an application-by-application basis. Comprehensive telehealth fee schedules do not exist at this time. Costs of the National Project were increased because of the need to compensate specialists for services rendered to the pilot communities through telehealth. These costs cannot be sustained in the long term. As well, federal/provincial jurisdictional issues relating to health service reimbursement in First Nations communities further complicated project implementation. Of course, if salaried providers dispense telehealth services to communities then reimbursement is not an issue. This was the case in Berens River where salaried providers employed by the Northern Medical Unit of the University of Manitoba could provide additional telehealth services with no additional professional fees to take into account. Notably, Nunavut has stipulated in all contracts with health service providers that they must use telehealth to deliver health care where appropriate. Finally, health services reimbursement issues go beyond fee-for-service providers. They also relate to non-insured services such as mental health and rehabilitation services.

Project implementation timetables were difficult to maintain for a variety of reasons:

  • In certain cases, the effort required to implement telehealth successfully was underestimated.
  • Additional community human resources were needed. Current personnel are invested in other responsibilities. Consequently, communities have been very dependent on the contracted project officer to manage and drive the implementation process.
  • Part-time project officers working on contract have other professional commitments. Because they must work at the pace of the community, they have been required to shift time lines and, when possible, rearrange their other workloads.
  • Changes in project governance structures at the community level have caused some difficulties for decision-making.

The National Project has also had to deal with community events/crises that negatively impacted project timetables and successful implementation. To date, here are examples of such events: elections; resignation of nurses and other project champions; health problems of project team members; tragedies such as motor vehicle accidents, forest fires, suicides; the arrival of an early Spring and the loss of the winter/ice road; unavailability of project team members due to rodeo, blueberry picking season, vacations etc. Ergo, it is important to manage community and providers' expectations with regards to timelines.

Communities need expertise in project planning and management. Training is required for community project officers. Or, funding is required to hire external project officers. Project officers are trainers, facilitators, mediators, coordinators and, at times, advisors, but never decision-makers. If possible, project officers should be hired based on their provincial/territorial knowledge and contacts, and familiarity with the First Nations community. However, in order to build economies of scale, centralization of expertise may be considered as an alternative to each community separately contracting external consultants. The structure and organization of this centralization is a matter for ongoing discussions. Centralized activity might include negotiations for telecommunications access, equipment purchase and support, training, program management etc.

The nursing stations/health centers need a telehealth coordinator. A telehealth coordinator is a key resource to promote and operate the telehealth system. A coordinator schedules all uses of the equipment. Coordinators are trained on the basics of setting up a telehealth consultation, on operating the equipment, on establishing the outside connection and on conducting the follow-up work (documentation). It is important for more than one community health provider to be trained in the use of telehealth equipment to ensure that there is always someone able to operate the equipment in case of sickness or turnover of staff. The coordinator trains new staff members to use the equipment. This is critical since most communities face frequent staff turnover. Events can be organized by the coordinator to inform and encourage community members to use the equipment. Communities can choose to train a nurse, a Community Health Representative (CHR) or someone else as coordinator depending on who is available and interested in the position. If a non-certified health professional is selected, there may be liability and scope of practice issues to consider. Identifying community members to be trained as telehealth coordinators is a challenge. This role demands skill in a broad range of areas including clinical practice, administration, scheduling, communication/socialization (people skills), translation, information/file management.

Community leadership must be made aware that they will need to commit significant resources to the purchase of telehealth equipment and, in the case of proprietary equipment, perhaps commit to a long-term relationship with the vendor. Independent legal counsel and, if possible, independent technical expertise should be contracted during the process of negotiation with the equipment supplier. This process can be tied to capacity building at the community level: allowing community members to view demonstrations of telehealth equipment and ask questions, reflect on issues and processes, work out divergent perspectives until a consensus emerges etc. The process may also benefit the vendor who may be better prepared to address the specific needs and settings of First Nations once contracted.

The information management and information technology (IM/IT) requirements of telehealth should not be underestimated. The need for an integrated IM/IT technical support plan should be identified at the national level. The rapid introduction of new technologies and information systems cannot be supported by the current technical support infrastructure. Linkages with other health infostructure initiatives (mainly, the First Nations and Inuit Health Information System and Electronic Health Record) will allow the creation of economies of scale and prevent duplication of effort and information mismanagement.

Initial involvement of the project evaluators in the planning and implementation of the project is crucial. Project evaluators should familiarize themselves with the community sites and be encouraged to develop relationships with community teams sooner rather than later. Provisions of federal and relevant provincial/territorial privacy legislation should be respected and worked into the evaluation component of the project to the agreement of all parties involved. Ethical principles - beneficence, nonmaleficence, autonomy and justice (fairness, confidentiality, integrity, competence, dignity, respect of others) such as those applied in the National First Nations and Inuit Regional Health Surveys - should be included in the design of any telehealth research project. In most cases, an ethics review process should be undertaken. As well, professional codes of ethics and conduct should be respected.

The lack of FNIHB resources at the regional level caused some project delays. In certain cases, FNIHB regional personnel was too busy to invest the time required to participate in community telehealth projects. In regions where third level services have been transferred, there is confusion about the role of regional FNIHB personnel. The expected role of FNIHB regional offices must be further discussed.

All members of the community project team should be regularly updated by the project officer to ensure that information is shared equally among participants. Community teams should also be in contact with federal and/or national and/or provincial/territorial decision-making bodies (in the case of the National Project, the Steering Committee) to foster community ownership. When meetings of decision-making bodies are held, community teams should receive notes of these meetings. Ideally, representatives of community teams should be included in these decision-making bodies. There should be clear guidelines in the Project Accountability Framework that define under what conditions a community project can be abandoned by the funder. As well, such guidelines should define what aspects of the project will be funded and to what extent.

Telehealth is all too new to everyone involved. The lack of community precedents to learn from and the complex and technical nature of the project created obstacles to implementation. This is why it is important to share lessons learned with other communities, for instance, through workshops and conferences (e.g. Assembly of First Nations Health Conference in February 2001). As well, in the context of a larger project involving several communities, bi-annual teleconferences should be held inviting community teams from all participating communities to share their experiences (and not solely reuniting project officers).

Financial Resources

While a full-fledged feasibility study, including a cost-benefit analysis, could in itself be costly and time consuming to conduct, to do so is highly recommended because it enables local health service planners, administrators, government and/or alternative funding sources to consider the telehealth project proposal and to support funding requests.

In preparing the telehealth project proposal, be prepared to estimate the costs for each of the following items, including both one-time and ongoing costs. Ball-park estimates are also provided.

Capital costs - One Time
hardware;
telecommunications infrastructure
software; interfaces; peripherals;
facility upgrades;
one-time software licensing fees.

Non-capital costs - One Time and Ongoing
feasibility, needs analysis, process and outcome evaluation studies;
FTEs (project manager, telehealth site coordinator, technicians etc.);
office facilities and cost of meetings;
telecommunications link (monthly connection fee, rate per minute);
training and skill maintenance costs;
insurance and administrative costs;
installation costs (include facility upgrades, testing, transportation);
technical support and maintenance;
provider remuneration adjustments, service contracts with provincial health care and educational institutions.

Average funding allocations per site by major cost item (based on estimates from the National Project that do not take into account economies of scale)

Project management/Administration - $50,000
Evaluation - $10,000
Community Site Coordinator - $30,000
Technical Expertise/Support/Maintenance - $20,000
Training - $10,000
Service contracts with provincial health and educational facilities - $20,000
Office supplies - $5,000
Telecommunications (equipment if required and usage charges) - $40,000 - $100,000
Telehealth equipment - $60,000

Communities need to purchase telehealth technology (software/hardware/peripherals) to deliver the services that meet their needs. They also need to contract continued technical support and maintenance to update and to keep the equipment running. The nursing stations/health centers need space for the telehealth equipment. The room that houses the equipment must be properly designed and configured for telehealth. Funds may be required to modify rooms to comply with videoconferencing technical standards, such as lighting, paint color, sound proofing etc. In some cases, proper exterior mounts are required for the satellite equipment. Communities may need some minor capital funds for furniture for the telehealth coordinator such as a desk and a chair, no-glare meeting tables, blinds etc.

Communities need telecommunications infrastructure and bandwidth to match selected telehealth applications and the purchased telehealth equipment in order to connect this equipment from the community site to the referral/educational sites and to ensure an adequate quality of service. It is important to know what telecommunications infrastructure is available in the community before planning a budget and selecting telehealth applications. Telecommunications may be the single most expensive item of telehealth implementation in the community. Telecommunications costs can include equipment, line rentals, site preparation and usage charges (such as long distance fees). Installation and maintenance contracts for telecommunications equipment are also required.

Communities need to negotiate service contracts (MOU) with external health care providers and referral centres. These contracts need to provide for reimbursement of fee-for-service providers in cases where the provincial government does not recognize telehealth as an insured service.

The community will need to assess the impact on the local economy, especially on local transportation and accommodation facilities, of introducing telehealth (i.e. especially if a reduction in patient/provider travel is considered likely).

The community will need to estimate sustainability costs, that is, annual costs of supporting and operating telehealth (including telecommunications costs, site coordinator salary, new services planned/equipment required, evergreening plan for aging equipment).

Top of Page

Technical Resources

Communities are concerned that telehealth technologies are easy to use and allow for their gradual adaptation. Initial and ongoing technical support, including 24/7 telephone support and remote troubleshooting, is essential to ensure that these technologies are used correctly It is important for community users to be well trained, comfortable and supportive of these technologies.

Companies may sell telehealth equipment directly to communities without explaining the complications of connecting to health care providers. Communities can benefit from access to adequate and independent technical expertise that is helpful in negotiating with telehealth companies.

Proprietary telehealth equipment developed by various vendors is not typically interoperable. At the time of purchase, it is important to ensure that the equipment will be compatible with the equipment implemented in the sites to which you want to connect.

The request for proposals (RFP) should include a precise description of the project requirements, such as a price range for the various types of services required, a commitment to, and penalties around, fixed delivery dates, the need for training, maintenance and long-term technical support. To save time and legal fees, included in the RFP can be a contract that the selected vendor would be expected to sign with only minor modifications.

More communities are demanding access to high bandwidth telecommunications capacity as they become aware of the potential associated with this higher capacity. The usefulness of telecommunications links in other community sectors such as education, justice and economic development, is being recognized as the Smart Community model. It offers an alternative to the traditional "stovepipe" government service delivery approach. As government departments all endeavour to "connect" to First Nations communities to deliver their services electronically, the deployment of high bandwidth telecommunications will become a priority for different levels of government (federal, provincial/territorial, regional).

There is a direct relationship between the type of health service a community wishes to deliver using telehealth and the necessary bandwidth to deliver this service adequately and effectively. Although there are many technological options to deliver a broad array of telehealth services, including store-and-forward or low bandwidth telecommunications solutions, we have learned that certain applications - for example, mental health services and urgent/emergent services - are preferably not undertaken without a minimal telecommunications capacity of 384 kilobits per second. This capacity enables clarity of picture.

Telecommunications turned out to be the most expensive cost item in two of the five pilot sites of the National Project. Consequently, it had a large impact on telehealth application selection and delivery. In the future, it is recommended that telecommunications planning be part of the initial community priority setting activities and applications selection process. This will safeguard against giving community members the misleading impression that technology is not a determining factor in selecting telehealth applications.

Policy Issues

It was originally planned in the National Project that telehealth service delivery would not disturb existing referral patterns in the five communities. That is, with telehealth, patients would be connected to their usual health care providers and facilities. Notwithstanding, one pilot community decided to change the primary care referral pattern and two other communities are liaising with new facilities to complement their access to speciality services. Of course, telehealth has the potential to connect communities to wherever they may want to go, outside of existing referral patterns. We can anticipate that, in time, more communities will choose to go where the expertise is available to meet their needs. In such cases, FNIHB's Non-Insured Health Benefits' (NIHB) travel policy would be affected.

Are communities expected to reallocate savings that might be incurred from reduced patient travel to sustained funding of telehealth? Or, can communities reallocate these savings to other health related activities, such as increasing nursing staff?

Telehealth will incur increased costs in NIHB Allied Health Services, more specifically in mental health, home care and rehabilitation services. Questions remain as to whether provinces will agree to fund diabetes and other forms of patient education using telehealth, as to whether dental therapy can be delivered using telehealth and as to whether telehealth will dramatically impact the delivery of other NIHB Allied Health Services.

Telehealth companies are interested in establishing partnerships with the federal government to provide technological infrastructure to communities. It is important for FNIHB to develop a clear mandate and strategy to deal with potential private sector partners. Telecommunications companies also wish to partner with FNIHB to provide remote community connectivity. FNIHB will need to review these offers and develop a larger health infostructure strategy that considers the needs of all its current and potentially future initiatives (i.e. the First Nations and Inuit Health Information System, telehealth and electronic health records). In addition, a number of other federal departments are considering the joint delivery of telecommunications solutions to mutually benefit from these connections (i.e. the Connecting Aboriginal Canadian strategy led by INAC).

It is important for FNIHB to examine the impact of telehealth on current nursing practice, especially on training, support, recruitment, retention, liability and scope of practice. FNIHB and provinces are dealing with a constant staff turnover and shortage of nurses. Telehealth can potentially improve nurse retention by addressing some of the difficulties experienced by health providers working in remote areas: lack of support, isolation and lack of continued training opportunities.

It is important for FNIHB to review the socio-economic benefits of earlier diagnoses and improved continuing care made possible through telehealth, such as savings in lost employee productivity.

In order to leverage knowledge, to build economies of scale and to increase the likelihood of success, FNIHB may wish to focus on dealing with "across the board" community health crises (such as respiratory disease or diabetes) if/when implementing telehealth on a larger scale. It may wish to determine how telehealth can contribute to the standardization of care and to the support of health needs in areas such as home care, diabetes management, mental health and continuing education.

It is important for FNIHB to review potential sources of future funding once the National Project is completed, particularly if the evaluated cost-consequence ratio is deemed satisfactory by communities and FNIHB. Of course, ultimately, communities must be allowed to choose whether they wish to use telehealth if it becomes an ongoing FNIHB program. A funding model for sustainable telehealth programs needs to be developed that details what items are funded by federal (national or regional offices) and provincial/territorial governments, partnerships with the private sector, research and educational institutions, or other sources. It is also important to determine whether funding should be earmarked for certain activities (needs assessment/community consultation, evaluation etc.).

Does the implementation of telehealth imply that provinces are to provide insured services on-reserve, the current responsibility of the federal government? While the Canada Health Act may warrant this shift in responsibility, will provinces view telehealth as an increased cost to their health care delivery systems? It is important for FNIHB to review the impact of telehealth on cross-jurisdictional issues, specifically the potential negative impact on FNIHB regional funding envelopes.

Legally, the Canada Health Act provides for universal access to health services for all Canadians. Knowing this, is FNIHB obligated to implement telehealth since it has the potential to even out geographical disparities in access to health services?

Until telehealth equipment is standardized and made interoperable, equipment vendor monopolies established by provincial/territorial telehealth networks can greatly restrict First Nations and Inuit communities from connecting to each other and participating in joint initiatives. These monopolies force them to adhere to the provincial/territorial network standard, a standard that generally centralizes expertise in tertiary - and, at times, secondary - care centres. This trend goes against community capacity-building. As well, if provinces/territories decide to change vendors or upgrade equipment, will FNIHB grant the funds required to keep pace with these network modifications? In cases where provincial/territorial telehealth networks have not yet been implemented, does FNIHB wait to see what will be implemented prior to undertaking a telehealth project in First Nations and Inuit communities within those provinces/territories to ensure compatibility down the road?

Furthermore, it is important to consider the dilemma of who will be responsible for establishing in First Nations and Inuit communities links to provincial/territorial health and educational facilities. What cost-sharing mechanisms can be developed? For instance, the La Romaine community participating in the National Project was denied the subsidization of its telecommunications link to the Quebec telemedicine network (RTSS) because its telehealth project was a federal initiative and not a provincial one. First Nations and Inuit communities have, as of yet, been excluded from this network.

As well, provincial/territorial health information and/or telehealth networks may have developed their own processes for tracking system usage and evaluation. These processes must be taken into account in the implementation of telehealth in First Nations and Inuit communities since they raise issues of ownership, control and access to health research and information.

In conclusion, clearer models of federal/provincial/territorial cooperation should be constructed to guide telehealth implementation in First Nations and Inuit communities. Cooperation will result in cost savings and greater efficiencies in health service delivery.

2. Critical Success Factors

From the many lessons learned, it is possible to extract a list of Critical Success Factors for future potential telehealth implementation in First Nations and Inuit communities.

Project Area

  • Community
    • Critical Success Factors
      • attainable expectations
      • informed
      • readiness
      • stable governance and nursing services
  • Funding
    • Critical Success Factors
      • comprehensive
      • sustained
  • Management
    • Critical Success Factors
      • decentralized
      • needs-based
      • local champion
      • evaluation criteria considered at outset
      • targeted performance goals (preferably quantified)
      • effective change management
      • effective time management
      • effective project management at the community level
      • communications strategy
      • access to technical expertise
      • training/capacity building
  • Health Care/Educational Practice
    • Critical Success Factors
      • comprehensive provincial reimbursement of telehealth services provided by fee-for-service practitioners
      • formal agreements (MOU) with referral and educational centers
      • resolution of liability, licensing, accountability and insurance issues
      • standardized practice protocols and clinical guidelines
      • compliance with academic standards/curricula and accreditation
      • interprovincial licensing agreements
      • evaluations of clinical and educational efficacy
      • legal and technical provisions for privacy and confidentiality
      • ethics review
      • periodical training and 24/7 technical support for telehealth users
  • Technology
    • Critical Success Factors
      • user-friendliness
      • ongoing technical support
      • security mechanisms
      • interoperable, plug-and-play solutions
      • access to the required bandwidth
      • telecommunications planning at the outset
      • sufficient testing and demonstration period
  • Policy
    • Critical Success Factors
      • flexibility/choice in referral patterns
      • harmonization of F/P/T initiatives
      • positive evaluations of telehealth
      • federal coordination of non-insured health benefits/telehealth policies
Top of Page

3. Evaluation Outcomes

All findings of the evaluation - including detailed case studies of each community project - are documented in the Final Evaluation Report attached in Appendix A. These are summarized below according to the main research questions raised during the evaluation.

Access to needed, quality care

To what extent do the telehealth applications respond to community needs, as defined by the needs assessments?

In general, telehealth applications responded to community needs, although this was clearer in some communities than others. At issue are not only the definition of needs, but also how the technology and organizational arrangements can respond to needs. For instance, telehealth can be used to address the issue of diabetes within a community in a number of ways, with some ways being more easily integrated than others.

To what extent do patients and families find each telehealth application acceptable?

It seems overwhelmingly clear that, once initial concerns are overcome with a positive experience, telehealth is acceptable to the vast majority of patients and families who use it. Consistent with the findings in the research literature review, satisfaction levels are high, and almost all patients would use the system again. In addition, although the evaluation design did not permit assessment of the views of those patients who did not use the system, refusals to use the system were infrequent. It should be noted, however, that the quality of many patients' experience with telehealth is due to the quality of the care provided by nursing station staff and the relationships they have with them; when telehealth provides a new service, what is most salient to many patients is not the new technology but the new relationship and the new care received.

To what extent has telehealth improved access to needed, quality care?

The extent to which telehealth has improved access to needed care in the community depends on the extent to which it was used and integrated into ongoing health service delivery. When usage and integration were higher, telehealth certainly improved access to care within the community. Moreover, the quality of care provided was, insofar as can be estimated by this study, of quality equivalent or better to standard care. These findings are consistent with the research literature examined.

To what extent are services provided through telehealth consistent with established means of improving patient health outcomes?

Insofar as can be assessed in this study, services provided through telehealth are consistent with established means of improving patients' outcomes. In the views of the health professionals consulted, in no case was telehealth seen as inconsistent with established professional practice guidelines. Moreover, data obtained from the encounter forms suggest that educational interventions delivered through telehealth to patients were generally consistent with established patient education guidelines, although some aspects were addressed more frequently than others.

Health services delivery

To what extent has telehealth use been organized successfully?

The successful organization of telehealth usage in this project varied among the communities, according to a number of factors. Key among these were the stability of staff during the implementation period and the quality of the relationships established with the remote referral centres. Stable, committed staff in the nursing station was a key success factor for effective implementation of telehealth in these communities. This is an issue that was not identified in the research literature, and may be unique to isolated communities.

To what extent have the professional skills and competencies required for telehealth been identified and successfully addressed through training?

The main issue with respect to the development of professional competencies for telehealth through training was the constant need to provide training to new staff members due to turnover. The adequacy of training received was also a result of the user-friendliness of the technologies involved. Training received for the interactive video-based systems was generally felt to be adequate partly because the systems were very easy to use; this was not the case for the store-and-forward system.

To what extent are telehealth applications used by eligible patients in the community?

It is not really possible for this evaluation to answer this question adequately, as little information was made available on the numbers of eligible patients (those with the health conditions which would make them candidates for using the available applications) who did or did not use telehealth during the study period. In some cases, it is clear that only a small fraction of eligible patients used the systems; while in others, the identification of new patents with health needs that had never before been addressed as a result of the implementation of telehealth suggests a high level of penetration.

To what extent does telehealth improve competencies and confidence of local health personnel?

In all communities, the implementation of telehealth brought new competencies to local health personnel, and in all cases, these were widely welcomed. Telehealth was seen as greatly improving access to outside expertise, reducing feelings of professional isolation, increasing confidence in judgments and improving the quality of patient care decisions made about cases in conjunction with remote experts. These results confirm those of existing studies in the area of tele-education for professionals.

How does telehealth affect staff workload, task allocation and professional practices?

When telehealth coordination responsibilities were assigned to a nurse in the nursing station who also had patient care duties, workload demand slowed full implementation. There were, therefore, advantages to assigning these to a separate individual, although it seems preferred that this person have some medical qualifications in order to facilitate communication with remote providers. Other impacts on task allocation seemed limited, perhaps due to the only partial integration of telehealth into some of the community's practices. To the extent that nursing station staff participate in continuing professional education using telehealth, their scope and quality of practice may be improved.

In terms of workload and practice shifts for remote providers, the overall pattern of responses would suggest that telehealth decreases efficiency. The appointments themselves are longer because of set-up time and perhaps increased attention to patients. The rate of patient no-shows also reduces efficiency and productivity for tertiary care providers. While, in many case,s this has not been an issue so far because of the pilot nature of the project, there are several indications in our data that institutionalization of telehealth will require attention to ensuring adequate compensation to remote partners for the loss of productivity - a critical issue compounded by the general scarcity of resources.

To what extent does telehealth result in cost increases, decreases or shifts for health service delivery at the community level?

Overall, the evaluation suggests that the net effect of telehealth is to generate greater access to care, thereby, increasing costs. Cost increases result both from increases in the numbers of patients receiving services -- services are now available where none were before - as well as in the intensity of services delivered - patients, especially in some applications, are seen more frequently (regularly using telehealth) than they had been before. The increases in care provided are accompanied by increased indirect costs, over and above provider remuneration and telecommunications cost, in terms of auxiliary equipment supplies and maintenance, patient supplies and within-community patient transportation costs. In addition, some of the data suggest that telehealth sessions take longer than equivalent in-person sessions, thus reducing efficiency.

In terms of avoidance of patient transfers and their associated costs, the results suggest that telehealth will result in avoided transfers in about 30 to 40% of patient care utilizations. This is somewhat less than the rates that can be estimated from the few studies available in the literature, but not a striking difference. As a proportion of total telehealth utilization within a community, this rate will depend on the balance between patient care and other types of applications that the system is used for, notably continuing professional or community education. That is, the more a community uses its telehealth system for non-patient-care applications, the less its telehealth utilization will result in patient transfers. In addition, avoiding transfers seems to be more appealing to patients whose lives or health are most disrupted by leaving the community - elders and families with young children -- and least appealing to those patients who are less inconvenienced by transfers and are, in fact, convenienced by them. When a community chooses applications that are concentrated on these two extreme age groups, the proportion of transfers avoided out of all utilizations may be expected to be higher than when a community chooses applications for health problems that affect its population throughout the lifespan.

What is the level of technical success of the platforms, applications and suppliers?

All communities experienced, at minimum, occasional technical problems, but these were resolved with adequate technical assistance in all but one community. In general, the interactive video platforms were found to be reliable and easy to use, although with occasional visual and sound quality limitations, depending on the application. Support provided by the three suppliers involved ranged from excellent to less than satisfactory and was a critical success factor in telehealth deployment.

Linkages among health resources

To what extent is telehealth appropriated, integrated and sustained as a part of the community's self-governed health care system?

The extent to which telehealth was appropriated, integrated and will be sustained varied greatly from community to community. In one community, appropriation and integration have exceeded both the community's and its partners' expectations, and sustainability and expansion of the initiative are almost certain. In the others, varying degrees of integration were associated with varying levels of community mobilization and support, stability within the community's health resources during the study period, technical success, and support provided by both existing telehealth initiatives and by the vendor. In addition, the capacity of the initiative to develop the committed, trusting relationships necessary to ensure good communication and problem-solving was critical to appropriation and integration. Relating to this issue, real-time technologies and applications are advantaged over store-and forward systems.

To what extent have the telehealth applications become linked to and integrated with provincial initiatives?

In those provinces where provincial initiatives exist, the communities became linked with them in accordance with the extent of their resources. Interoperability was not a barrier in any of these sites. These links provided access to a larger community of telehealth users, broader support and development from which these communities benefited. The existence of such provincial networks and their capacity to bring the pilot communities into their fold was a critical success factor in the project.

To what extent does telehealth improve access of secondary/tertiary care and education providers to local health service providers?

Access of education providers to the communities was improved when there was an existing provincial network coordinating educational opportunities for network members, publicizing its activities, and in some cases, covering the costs of the telecommunications link.

Overall, the results of this evaluation showed that telehealth can be successfully implemented in isolated First Nations communities, bringing with it access to needed, quality care, stronger relationships with external health providers, and greater community capacity to undertake major health initiatives. In the long term, telehealth can, therefore, potentially improve health of community members and health service infrastructure within communities. However, successful implementation is contingent on several important factors at the community level: nursing station staff stability, community mobilization, strong relationships with remote providers and provincial telehealth systems, and effective technology and supports.

To what extent does telehealth improve health service providers' awareness and knowledge of local conditions and resources?

In several cases, remote providers did maintain that the relationship created through the telehealth initiative had improved their awareness and knowledge of local conditions and resources, as well as challenges faced by the communities. This has led to increased sensitivity on the part of remote health service providers to the special situations of First Nations communities, as well as to relationships based on mutual trust and respect.

Top of Page

4. Recommendations

  1. A concerted approach to the lack of connectivity in rural and remote communities, and especially Aboriginal communities, is required. This issue is one that cannot be resolved by FNIHB, nor by Health Canada, in isolation. The National Broadband Task Force and the Connecting Aboriginal Canadians strategy will no doubt raise the profile of this issue. However, their effectiveness in increasing infrastructure deployment will depend on the allocation of dedicated funding to this end.

    A concerted approach to connectivity would not be designed to solely benefit the community health care system. Rather, it would adopt the Smart Community model that enables the uptake of technology for community and economic development, education, health, social services, law enforcement, band management etc.

  2. It is recommended that new research be undertaken to further explore issues raised in the context of this project and to build a unique body of knowledge needed for the implementation of successful telehealth initiatives in First Nations and Inuit communities. New research could be used to: develop implementation strategies based on type, needs and capacity of a community; to develop funding models for sustainable telehealth initiatives once again based on the unique community situation; to conduct enhanced cost-benefit analyses; to develop models of F/P/T cooperation guiding telehealth implementation, particularly in rural and remote communities. New research should be undertaken over a longer amortization period to substantially increase its value.

  3. Opportunities to undertake telehealth (including research) should be offered in a manner that is equitable and sustainable across all First Nations and Inuit communities. Many First Nations communities do not have the structure nor resources to undertake major proposal writing. As well, a clear commitment to provide sustainable funding should be made at the outset. New project timeframes should be adapted to the implementation process required in First Nations communities (a minimum of 3-5 years).

  4. New research should study the system-wide impact of telehealth on various funding envelopes and on human resource infrastructures of communities, provinces and FNIHB. Research data will contribute to the building of a Business Case for telehealth in First Nations and Inuit communities. [ The Business Case is a comprehensive analysis of the full potential of what can be achieved by telehealth thanks to identified strategic investments. It is a means of addressing the main concerns of decision-makers and funders and encouraging them to ultimately support an ideal scenario for telehealth implementation. The main components of the Business Case are the Environmental Scan, a list of tangible and intangible benefits, a Strategic Plan and a Costing Model (cost assumptions and estimates). The Strategic Plan determines who, when, where and how telehealth will potentially be implemented in First Nations and Inuit communities. This is critical to determining a costing model for potential future telehealth communities (i.e. how many sites). The Strategic Plan anticipates what would occur if funding is granted for large-scale implementation. The scope of this possible funding is not known and, therefore, the Strategic Plan explores, and remains flexible to deal with, various funding options. ] Sustaining telehealth activity in the long term will have significant impact on current funding levels in the following ways: it will decrease, and in some cases, increase the costs of patient travel; it will increase the costs of certain allied health services; it will introduce new health services (and, thereby, new costs) to the community; it will increase the pressures on human resources at the community level, at the provincial level and at the FNIHB regional office level.

  5. It is recommended that strategies be elaborated to ensure that telehealth effectively contributes to capacity-building, service integration and sustainability in First Nations and Inuit communities. These are shared priorities in First Nations health of FNIHB and of the Assembly of First Nations.

  6. Increased awareness/understanding of, and communication to, First Nations and Inuit stakeholder in matters relating to telehealth will enable them to take advantage of new and existing initiatives and funding opportunities. A rising interest among these stakeholders in the deployment of information and communications technology to benefit health has been demonstrated. However, beyond interest, it is important to gather the knowledge of First Nations and Inuit on why and how this deployment should take place within specific communities, regionally as well as nationally. A primary vehicle for information-sharing and feedback is the creation of a Standing Working Group composed of First Nations and Inuit representatives appointed by national and regional associations, in addition to FNIHB representatives. The primary mandate of this Working Group will be to design a Blueprint and Strategic Plan for potential telehealth implementation.

  7. Linkages between telehealth and other initiatives of the Aboriginal Health Infostructure (such as FNIHIS, EHRs and health research initiatives), as well as with Canadian Health Infostructure initiatives, are critical in order to leverage investments to benefit Aboriginal peoples.
    [ A preliminary vision of the AHI was elaborated by the Advisory Council on Health Infostructure in 1999. It is intended as a distinct component of the Canadian Health Infostructure. Main principles of the AHI were suggested by the Council: self-determination, knowledge as power, and building human resource capacity and autonomous institutional development. Currently, development of the AHI is being undertaken by a Planning Committee composed of representatives of Aboriginal organizations and of FNIHB. ] . A concerted approach to health infostructure development - emphasizing harmonization, linkages and leveraging of investments - will ensure that policy and other issues are addressed concurrently, and that economies of scale are created wherever possible. For instance, a comprehensive information management/technology framework - for health information systems, automated records, telehealth systems etc. - could be made available that is culturally adapted and coordinated with community capacity-building strategies. It is important to ensure that Aboriginal interests are represented in F/P/T discussions and partnerships involved in the development of the Canada Health Infoway. More specifically, awareness should be raised concerning unique federal/provincial/Aboriginal jurisdictional issues.

Top of Page

Dissemination Plan

The dissemination plan is aimed at providing information useful to: the five First Nations communities participating in the National Project to assist them in deciding whether to continue to invest in telehealth; other Aboriginal communities who wish to undertake telehealth initiatives; and FNIHB to help it decide whether to pursue telehealth implementation in other First Nations and Inuit communities.

1. Main Themes

The information can be used as background for building a Business Case for telehealth services, or simply to gain a better understanding of telehealth implementation and use in rural and remote communities, particularly First Nations and Inuit communities. There are three main themes in the information disseminated:

  1. Implementation Process: Tools developed during the National Project such as a project planning and scheduling tool, a community needs assessment tool, an evaluation framework tool, a community Request for Proposals template, a community bid analysis tool, a community MOU and contribution agreement template; and, regular updates on the progress achieved.
  2. Lessons Learned: Potential benefits of telehealth identified by communities during the needs assessment process, telehealth human resource issues, financial resource issues, technical resource issues and policy issues.
  3. Evaluation Findings: Results of the data gathering instruments, key informant interviews, patient satisfaction questionnaires etc.

2. Target Audiences

Target audiences are categorized according to each information theme.

  • Implementation Process
    • Five participating First Nations communities and their partners (provincial facilities);
    • Aboriginal communities;
    • Other rural and remote communities;
    • Telehealth coordinators.
  • Lessons Learned
    • Associations of Aboriginal and other health care providers/managers;
    • Health Canada and other federal departments;
    • National and regional First Nations and Inuit organizations;
    • Provincial/territorial governments;
    • Telehealth coordinators;
    • Researchers;
    • Telehealth industry.
  • Evaluation Findings
    • Five participating First Nations communities;
    • Other Aboriginal communities;
    • Health Canada and other federal departments;
    • Provincial/territorial governments;
    • National and regional First Nations and Inuit organizations;
    • Associations of Aboriginal and other health care providers/managers;
    • Researchers;
    • Telehealth industry.

3. Dissemination Principles

The Project Accountability Framework, developed by FNIHB in consultation with the community project teams, specifies some principles to which the dissemination plan must adhere:

  • We agree that all those involved in the project will respect individual and community privacy, confidentiality and ownership of health data/information as agreed to. We agree that the community will own the health data and information that is collected by the project.
  • We agree that the documentation and communications of this project will be carried out, developed and produced in both official languages of Canada.
  • We agree that communities will own the community health and evaluation data collected during this project and that Health Canada will release information about the community only upon the approval of the communities involved and that Health Canada will not use the data collected for any other purposes other that for which it was collected.
  • We agree as project stakeholders that we will respect individual and community privacy, confidentiality and ownership of health data and information. All information of a personal nature to which the project stakeholders become privy, shall be treated as confidential. All information of a personal medical nature to which the project stakeholders become privy, shall be treated as confidential in accordance with the Privacy Act.
  • We agree that only aggregate data collected throughout the pilot process will be shared with key stakeholders to support the development and management of a Business Case for Telehealth Services in First Nations and Inuit communities that can respond to the gaps and sustainability of telehealth.

4. Dissemination Activities

Activities are categorized according to each information theme. Some activities address more than one theme: the website, the HTF Final Results Report, the Education Primer.

Implementation Process

During the initial implementation process, information packages (including a movie, pamphlet and slide presentation) were disseminated to the five participating First Nations communities.

A news release was disseminated by Health Canada on September 3, 1998 entitled Release of the Final Report of the National Conference on Health Infostructure.

The FNIHB website lists tools available and provides community updates. Tools are available upon request to Aboriginal communities.

Most communities undertook some form of information dissemination during the implementation process to educate community members and promote the project at the regional/provincial level. For example:

  • La Romaine: three radio communiqués, posters displayed in the community, annual updates at the Quebec Native Caucus, two radio news reports in Sept-Iles;
  • Berens River: two articles in the Winnipeg Free Press (September 2000), open house (Summer 2000).
  • Southend: door-to-door community information campaign with pamphlets, open house (Spring 2000).
  • Fort Chipewyan: News release (May 2000), article in The Ottawa Citizen (May 29,2000), presentations at the TecKnowledge Telehealth Coordinators Conference (September 2000), at the National Information-Sharing and Feedback Session on the Potential Future of Telehealth in First Nations and Inuit Communities (October 5-6 2000), open house (October 30, 2000).

No standard communication plan was developed for all communities.

Lessons Learned

The website summarizes the Lessons Learned.

  • FNIHB headquarters have presented Lessons Learned at the following events in 2000: Aboriginal Nurses Association's Annual Teaching Conference (May), the Ontario Centre for Health Promotion Summer School (June), the Building Linkages and the Role of Technology in First Nations and Inuit Health workshop organized by FNIHB (July), a FNIHB Regional Zone Nursing Officers meeting (September), Government and Technology Week (October), the Canadian Society of Telehealth Annual Conference (October), Health Canada's E-Health Conference (October), Smart 2000 (October), InfoHealth 2000 (October), a Democracy Bytes Back workshop (November 2000). Lessons Learned will continue to be presented at conferences/meetings/workshops when opportunities/requests arise. On February 26, 2001, FNIHB was asked to coordinate a live telehealth demonstration at a Plenary Session of the Assembly of First Nations Health Conference. A presentation was made on the National Project. The Project's satellite communications contractor, Telesat, sponsored the event that included three live links to the Berens River Nursing Station, the Winnipeg Health Sciences Centre and the Fort Severn Nursing Station. As well, a video containing testimonials from three of the participating communities was shown at the FNIHB Conference booth.
  • On October 5-6, 2000, FNIHB, in partnership with the AFN and the Inuit Tapirisat of Canada, held a National Information-Sharing and Feedback Session on the Potential Future of Telehealth in First Nations and Inuit communities. Approximately 60 First Nations and Inuit representatives attended the session traveling from most provinces/territories, including the main participants of the National Project community teams. The session was a first step in a broad consultation strategy initiated by FNIHB. It was intended to give participants the opportunity to acquire a general understanding of telehealth and its implications for First Nations and Inuit communities. Participants were also invited to discuss the need for telehealth and the general components of a Blueprint to guide its potential future development. Finally, participants were called upon to identify the next steps required to move forward the telehealth agenda. A Final Report of the Session was widely disseminated to attendees and other interested Aboriginal organizations/communities, as well as within Health Canada.
  • The main recommendation formulated by session attendees was to establish an Ad Hoc Working Group to address next steps in a more detailed fashion and to draft a Vision Statement for First Nations and Inuit Telehealth. Fifteen attendees volunteered to participate in the Ad Hoc Working Group. The Group's first meeting was held on November 23-24, 2000.
  • An Education Primer that is largely based on the Lessons Learned will serve as the main content of a national information-sharing and feedback strategy. This strategy will be developed jointly by national and regional FNIHB telehealth coordinators, in consultation with national and regional First Nations and Inuit representatives sitting on a Standing Working Group. The Primer will target First Nations and Inuit community leadership and health providers. Its goal is to raise awareness, obtain feedback on a Vision Statement and Blueprint for potential future telehealth implementation, and build community capacity in telehealth management/implementation.

Evaluation Findings

  • On March 25-27, 2001, a Final Project meeting was held to reunite the five community project teams and the Peer Review Team, and to present evaluation findings and review the draft HTF Final Results Report.
  • An HTF Final Results Report will be disseminated within Health Canada and distributed to other federal departments, provincial/territorial governments, First Nations and Inuit organizations/communities upon request.
  • Findings will be posted on the website. They will be communicated at national, and potentially international, conferences/workshops and integrated in the Education Primer (see above).
Top of Page

Appendix A: Final Evaluation Report
Evaluation Report
Version 3.1
Submitted by: Communications Infotelmed

Help on accessing alternative formats, such as Portable Document Format (PDF), Microsoft Word and PowerPoint (PPT) files, can be obtained in the alternate format help section.

Portable Document Format(PDF Version - 251 K)

Appendix A: Final Evaluation Report

Executive Summary

Context and Background

Telehealth -- the delivery of health information, resources and services through technology -- is becoming increasingly accessible as part of comprehensive health care systems. For underserved and isolated communities, telehealth offers the promise of reducing the constraints imposed by distance and poor infrastructure while improving health and well-being. As one of several telehealth demonstration and evaluation projects funded through the Health Transition Fund, the First Nations' Telehealth Project deployed applications of telehealth in five isolated First Nations communities. This document reports an independent evaluation of the Project.

The overall objectives of the First Nations' Telehealth Research Project were:

  1. to improve patient and community access to high quality health care, including timeliness of access to medical advice, services and health information;
  2. to improve the delivery of cost-effective health services in the communities; and
  3. to improve linkages of isolated health care centers to secondary, tertiary and educational facilities in each province.

Communities and their Telehealth Applications

The table below summarizes the telehealth applications, which were implemented in each community. These applications were chosen by the communities following a needs assessment involving extensive community consultations about health priorities and issues relating to telehealth. The needs assessment process involved: qualitative interviews with key informants (nursing station personnel, community leaders and opinion leaders, and secondary/tertiary center partners); review of health status information gleaned from local or regional health statistics or records; review of background information on communities' social and demographic characteristics.

  • Community: La Romaine, Québec
    Population: 897 members, 65 off-reserve
    Referral Sites: Sept-Iles Health Center Blanc Sablon Health Center Laval University Hospital, Quebec City
    Telehealth Applications Implemented: Store and forward technology: Specialist consults: Dermatology, ECG; Ear-Nose-Throat
  • Community: Berens River, Manitoba
    Population: 1759 band members
    Referral Sites: Health Sciences Center, Winnipeg North Eastman Health Authority Northern Medical Unit
    Telehealth Applications Implemented: Interactive video technology: Diabetes care and education Specialist consultation: psychiatry, infectious disease Continuing professional education
  • Community: Southend, Saskatchewan
    Population: 918 in community, one of several in Peter Ballantyne Cree Nation
    Referral Sites: La Ronge Health Center Prince Albert Hospital Royal University Hospital, Saskatoon
    Telehealth Applications Implemented: Interactive video technology: Specialist consults Diabetic education and management Staff/community education
  • Community: Fort Chipewyan, Alberta
    Population: 2900 total1864 in area
    Referral Sites: Northern Lights Health Centre, Fort McMurray
    Telehealth Applications Implemented: Interactive video technology Rehabilitation services: Occupational, speech and physiotherapy Televisitation Continuing professional education
  • Community: Anahim Lake1
    Population: 659 band members 400 non band members 5,000 tourist season
    Referral Sites: Williams Lake Hospital
    Telehealth Applications Implemented: Trauma triage and early intervention Cardiology Mental health services

1 Implementation of the Anahim Lake telehealth project was delayed until April 2001 due to the difficulties experienced in obtaining the required telecommunications infrastructure. Evaluation data about this community will be collected over the coming year.

Evaluation Questions and Methods

The evaluation addressed three main questions about the implementation and impacts of telehealth in the communities:

  1. the impacts of telehealth on patient and community access to needed, quality care;
  2. the role of telehealth in health services delivery, including cost-effectiveness and; and
  3. the linkages created through telehealth with existing health resources.

Several data collection methods were used:

  • ongoing monitoring of frequency, nature and implications of telehealth usage through forms completed by staff in both the community and referral sites. Over the evaluation period, information was received about 927 telehealth sessions involving 176 patients. The number of sessions per community varied from 40 to 755, and the number of patients seen from 17 to 59.
  • patient satisfaction assessment, through questionnaires completed by patients using telehealth in each community. A total of 110 questionnaires were received.
  • qualitative interviews with key informants about each community, including telehealth coordinators, Band and nursing station managers, nursing staff, nursing station board member, elders, patients (in one community only), secondary/tertiary providers and management, provincial telehealth representatives, and Health Canada representatives. A total of 43 interviews were conducted with 65 individuals.

These data were used to produce a case study for each community. A cross-case analysis examined the findings in light of the evaluation questions, the consequences of telehealth in relation to costs, and the main lessons learned.

Main Findings

Access to needed, quality care

To what extent do the telehealth applications respond to community needs, as defined by the needs assessments?

In general, the telehealth applications implemented in the project responded to community needs, although this was clearer in some sites than others. At issue are not only the definition of the needs, but also how the technology and organizational arrangements for using it can respond to needs. For example, telehealth can be used to address the issue of diabetes within a community in a number of ways, with some being more easily integrated than others.

To what extent do patients and families find each telehealth application acceptable?

It seems overwhelmingly clear that once initial reticences are overcome with a positive experience, telehealth is acceptable to the vast majority of patients and families who use it. Over 90% of patients in all the communities were satisfied with most aspects of their telehealth experience, and between 75% and 100% of telehealth patients said they would use it again. This is consistent with findings in the research literature. In addition, although the evaluation design did not permit assessment of the views of those patients who did not use the system, refusals to use the system were infrequent. It should be noted however, that the quality of many patients' experience with telehealth is a function of the quality of the care provided by nursing station staff and the relationships they have with them; when telehealth provides a new service, what is most salient to many patients is not the new technology but the new relationship and the new care received.

To what extent has telehealth improved access to needed, quality care?

The extent to which telehealth has improved access to needed care in the community depends on the extent to which it was used and integrated into ongoing health service delivery. When usage and integration were higher, telehealth certainly improved access to care within the community. Moreover, the quality of care provided was, insofar as can be estimated by this study, of quality equivalent or better to standard care. These findings are consistent with the research literature examined.

To what extent are services provided through telehealth consistent with established means of improving patient health outcomes?

Insofar as can be assessed in this study, services provided through telehealth are consistent with established means of improving patients' outcomes. In the views of the health professionals consulted, in no case was telehealth seen as inconsistent with established professional practice guidelines. Moreover, data from the encounter forms Final Evaluation suggest that educational interventions delivered through telehealth to patients were generally consistent with established patient education guidelines, although some aspects were addressed more frequently than others.

Health services delivery

To what extent has telehealth use been organized successfully?

The successful organization of telehealth usage in this project varied among the communities, according to a number of factors. Key among these were the stability of staff during the implementation period and the quality of the relationships established with the remote provider sites. Stable, committed staff in the nursing station was a key success factor for effective implementation of telehealth in these communities. This is a problem that was not identified in the research literature, and may be more specific to isolated, Northern communities.

To what extent have the professional skills and competencies required for telehealth been identified and successfully addressed through training?

The main issue with respect to the development of professional competencies for telehealth through training was the constant need to provide training to new staff members due to turnover. The adequacy of training received was also a function of the user-friendliness of the technologies involved. Training received for the interactive video-based systems was generally felt to be adequate partly because the systems were very easy to use; this was not the case for the store-and-forward system.

To what extent are telehealth applications used by eligible patients in the community?

It is not really possible for this evaluation to answer this question adequately, as we have little information on the numbers of eligible patients (those with the health conditions which would make them candidates for using the available applications) who did or did not use telehealth during the study period. In some cases, it is clear that only a small fraction of eligible patients used the systems; while in others, the identification of new patents with health needs that had never before been addressed as a result of the implementation of telehealth suggest a high level of penetration. In addition, because of the lack of participating specialists in the remote sites, penetration as not as strong as it could have been.

To what extent does telehealth improve competencies and confidence of local health personnel?

In all communities, the implementation of telehealth brought new competencies to local health personnel, and in all cases, these were widely welcomed. Telehealth was seen as greatly improving access to outside expertise, reducing feelings of professional isolation, increasing confidence in judgments and improving the quality of patient care decisions made about cases in conjunction with remote experts. These results confirm those of existing studies in the area of tele-education for personnel in isolated settings.

Top of Page

How does telehealth affect staff workload, task allocation and professional practices?

When telehealth coordination responsibilities were assigned to a nurse within the nursing station who also had patient care duties, workload demand slowed full implementation. There were therefore advantages to assigning these to a separate individual, although it seems preferred that this person have some medical qualifications in order facilitate communication with remote providers. Other impacts on task allocation seemed limited, perhaps due to the only partial integration of telehealth into some of the community's practices. To the extent that nursing station staff participate in continuing professional education through telehealth, their practice scope and quality may be improved.

In terms of workload and practice shifts for remote providers, the overall pattern of responses would suggest that telehealth decreases efficiency. The appointments themselves are longer because of set-up time and perhaps increased attention to patients. The rate of no-shows also reduces efficiency and productivity for secondary/tertiary providers. While in many cases this has not been an issue so far because of the pilot nature of the project, there are several indications in our data that institutionalization of telehealth will require attention to ensuring adequate compensation to remote partners to compensate for the loss of productivity - a critical issue because of scarce resources in general.

To what extent does telehealth result in cost increases, decreases or shifts for health service delivery within the communities?

Overall, the pattern of results obtained in this evaluation suggest that the net effect of telehealth is generate greater access to care, and therefore more care, and therefore more costs. The increases are seen both in the numbers of patients receiving services -- services are now available where none were before - and in the intensity of services delivered - patients, especially in some applications, are seen more frequently and regularly using telehealth than they had been before. The increases in care provided are accompanied by increased indirect costs, over and above provider remuneration and telecommunications cost, in terms of auxiliary equipment supplies and maintenance, patient supplies and within-community patient transportation costs. In addition, some of our data suggest that telehealth sessions take longer than equivalent in-person sessions, thus reducing efficiency.

In terms of avoidance of patient transfers and their associated costs, the results over all the studies converge to suggest that telehealth will result in avoided transfers in about 30 to 40% of patient care utilizations. This is somewhat less than the rates that can be estimated from the few studies available in the literature, but not a striking difference. As a proportion of total telehealth utilization within a community, this rate will depend on the balance between patient care and other types of applications that the system is used for, notably continuing professional or community education. That is, the more a community uses its telehealth system for non-patient-care applications, the less of its telehealth utilization will result in patient transfers. In addition, avoiding transfers seems to be more appealing to patients whose lives or health are most disrupted by leaving the community - elders and families with young children --, and least appealing to those patients who are less inconvenienced by transfers and are in fact, convenienced by them. When a community chooses applications that are concentrated on these two extreme age groups, the proportion of transfers avoided out of all utilizations may be expected to be higher than when a community chooses applications for health problems that affect its population throughout the life span.

Some displacement toward the private sector was observed in one of the sites, where the increase in access to care generated waiting lists.

What is the level of technical success of the platforms, applications and suppliers in the implementing communities?

All communities experienced at least occasional technical problems, but these were resolved with adequate technical assistance in all but one community. In general, the interactive video platforms were found to be reliable and easy to use, although with occasional visual and sound quality limitations, depending on the application. Support provided by the three suppliers involved ranged from excellent to less than satisfactory, and was a critical success factor in telehealth deployment.

Linkages among health resources

To what extent is telehealth appropriated, integrated and sustained as a part of the community's self-governed health care system?

The extent to which telehealth was appropriated and integrated and will be sustained varied greatly from community to community in this project. In one community, appropriation and integration have exceeded both the community's and its partners' expectations, and sustainability and expansion of the initiative are almost certain. In the others, varying degrees of integration were associated with varying levels of community mobilization and support, stability within the community's health resources during the study period, technical success, and support provided by both existing telehealth initiatives and by the vendor. In addition, the capacity of the initiative to develop the committed, trusting relationships necessary to ensure good communications and problems-solving was critical to appropriation and integration. In this context, real-time technologies and applications are advantaged over store-and forward arrangements.

To what extent have the telehealth applications become linked to and integrated with provincial initiatives?

In those provinces where provincial initiatives exist, the First Nations communities in this project became linked with them according to their resources. Interoperability was not a barrier in any of these sites. These links provided access to a larger community of telehealth users and a broad support and development system, from which those communities benefited. The existence of such provincial networks and their capacity to bring the project communities into their fold was a critical success factor in the telehealth initiatives.

To what extent does telehealth improve access of secondary, tertiary and education providers to local health service providers?

Access of education providers to the communities was improved when there was an existing provincial network coordinating educational opportunities for network members, publicizing its activities, and in some cases covering the costs of the telecommunications links into the services.

To what extent does telehealth improve health service providers' awareness and knowledge of local conditions and resources?

In several cases, remote providers did maintain that the relationship created through the telehealth initiative had improved their awareness and knowledge of local conditions and resources, as well as challenges faced by the communities. This has led to increased sensitivity on the part of remote health service providers to the special situations of First Nations communities, as well as to relationships based on mutual trust and respect.

Conclusion

Overall, the results of this evaluation showed that telehealth can be successfully implemented in isolated First Nations communities, bringing with it access to needed, quality care, stronger relationships with external health providers, and greater community capacity to undertake such major health initiatives. In the long term, telehealth can therefore potentially improve health of community members and health service infrastructure within communities. However, successful implementation requires several important conditions at the community level, in terms of nursing station stability and community mobilization, as well as strong relationships with remote providers and provincial telehealth systems and effective technology and supports.

Introduction

1. The First Nations Telehealth Research Project Objectives

Telehealth -- the delivery of health information, resources and services through technology -- is becoming increasingly accessible as part of comprehensive health care systems. For underserved and remote communities, telehealth offers the promise of reducing the constraints imposed by distance and poor infrastructure while improving health and well-being. As one of several telehealth demonstration and evaluation projects funded through the Health Transition Fund, the First Nations' Telehealth Project deployed applications of telehealth in five isolated First Nations communities. This document reports an independent evaluation of the Project.

The overall objectives of the First Nations' Telehealth Research Project were:

  1. to improve patient and community access to high quality health care, including timeliness of access to medical advice, services and health information;
  2. to improve the delivery of cost-effective health services in the communities; and
  3. to improve linkages of isolated health care centers to secondary, tertiary and educational facilities in each province.

The communities involved in this project, each of which received funds to implement three telehealth applications, are diverse. Four have assumed governance of a major portion of their health systems, and the fifth is negotiating its transfer. The health resources available within each community differ, as do their access to secondary and tertiary care.

The table below summarizes the telehealth applications, which were implemented in each community. These applications were chosen by the communities following a needs assessment involving extensive community consultations about health priorities and issues relating to telehealth. The needs assessment process involved: qualitative interviews with key informants (nursing station personnel, community leaders and opinion leaders, and secondary/tertiary center partners); review of health status information gleaned from local or regional health statistics or records; review of background information on communities' social and demographic characteristics.

Table 1: Characteristics of and Telehealth Applications Selected by the Five Communities

  • Community: La Romaine 1
    Population: 897 members, 65 off-reserve
    Referral Sites: Sept-Iles Health Center Blanc Sablon Health Center Laval University Hospital, Quebec City
    Telehealth Applications Implemented: Store and forward technology: Specialist consults: Dermatology, ECG; Ear-Nose-Throat
  • Community: Berens River, Manitoba
    Population: 1759 band members
    Referral Sites: Health Sciences Center, Winnipeg North Eastman Health
    Authority Northern Medical Unit
    Telehealth Applications Implemented: Interactive video technology: Diabetes care and education Specialist consultation: psychiatry, infectious disease Continuing professional education
  • Community: Southend, Saskatchewan
    Population: 918 in community, one of several in Peter Ballantyne Cree Nation
    Referral Sites: La Ronge Health Center Prince Albert Hospital Royal University Hospital, Saskatoon
    Telehealth Applications Implemented: Interactive video technology: Specialist consults Diabetic education and management Staff/community education
  • Community: Fort Chipewyan, Alberta
    Population: 2900 total1864 in area
    Referral Sites: Northern Lights Health Centre, Fort McMurray
    Telehealth Applications Implemented: Interactive video technology Rehabilitation services: Occupational, speech and physiotherapy Televisitation Continuing professional education
  • Community: Anahim Lake2
    Population: 659 band members 400 non band members 5,000 tourist
    season
    Referral Sites: Williams Lake Hospital
    Telehealth Applications Implemented: Trauma triage and early intervention Cardiology Mental health services

1 Although initially conceived as an interactive video-based project, the La Romaine initiative was modified to become store-and-forward system due to the high cost of securing high bandwidth;

2 Implementation of the Anahim Lake telehealth project was delayed until April 2001 due to the difficulties experienced in obtaining the required telecommunications infrastructure. Evaluation data about this community will be collected over the coming year.

Top of Page

2. Project structure

Health Canada First Nations and Inuit Health Branch (FNIHB) assumed overall project management. It assigned a project officer to each community to coordinate the needs assessment and telehealth implementation processes, including facilitating the negotiation of Memoranda of Understanding between the community and provincial authorities, and the vendor selection and contracting processes. Each community identified a telehealth coordinator who assumed responsibility for managing the system and coordinating arrangements with the remote sites (Throughout the report, we use the term "remote" to mean far from the participating First Nations communities, i.e., in the secondary or tertiary centres in larger urban settings.).

3. Literature review of telehealth applications

The research literature on telehealth applications and telehealth assessment has grown considerably in the last decade. A systematic review of this literature was conducted in order to identify findings which could inform expectations about the clinical effects, patient satisfaction, implementation processes and cost-effectiveness of the applications selected in his project. The complete literature review may be found in Appendix 8, but is summarized very briefly below.

Cardiology/ECG (La Romaine)

  • Although there were few relevant studies and none using store and forward technology, there seem to be some significant advantages in the reported clinical outcomes of cardiology patients using tele-ECG as compared to face-to-face (FTF) care, because patients benefit from being treated earlier (Casey et al., 1998; Lusignan et al., 1999).
  • Lusignan et al. (1999) concluded that telemonitoring of ECGs was acceptable to patients.
  • No study examined implementation issues.
  • Cost-effectiveness analyses in two studies suggested that compared to a conventional referral, a cardiac teleconsultation was substantially cheaper (Afset et al., 1996; Shanit et al., 1996).

Continuing Medical Education (Berens River, Southend, Fort Chipewyan)

  • The available studies suggest that educational support through videoconferencing offers support equivalent to FTF instruction (Demartines et al., 2000; Hays et al., 1996).
  • Overall, user satisfaction of tele-education seems high (Burge et al, 1993; Demartines et al., 2000; Sawada et al., 2000; Gul et al., 1999; Gammon et al., 1998).
  • Implementation issues were not examined in the existing studies.
  • Cost-effectiveness analysis was undertaken in one study, showing the tele-education system to be effective after eight sessions (Screnci et al., 1996), when costs included equipment for one system, line charges, testing, and audiovisual preparation but excluded direct labor.

Dermatology (Berens River, Southend, La Romaine)

  • According to the existing studies of teledermatology, it is unclear whether or not a video-conferencing (VC) system is as effective as FTF in reported clinical outcomes (Gilmour et al., 1998; Loane et al., 1998; Oakley et al., 1997; Perednia et al., (1998). The most recent studies (Lamminen, 2000; Wooton, 2000) concluded that there are no significant differences in reported clinical outcomes between VC and FTF. However, the quality of care patients receive was seen to have improved in some cases (Perednia et al., 1998). Other studies (Lowitt 1996; Perednia, 1998; Phillips, 1998) found that the teledermatologist had significantly lower degree of confidence in his diagnosis - often for technical reasons (poor image quality, lack of ability to do a diagnostic procedure).
  • Patient satisfaction with tele-dermatology is high (Gilmour et al., 1998; Loane et al., 1998; Lowitt, 1996), although the latter study showed a slight increase in preference for in-person exams with age.
  • Implementation of tele-dermatology was not addressed in the existing studies.
  • According to two studies, the economic benefit of tele-dermatology is uncertain (Lamminen et al., 2000; Wooton et al., 2000).

Diabetes (Berens River, Southend, La Romaine)

  • The clinical outcome of diabetic patients is positively affected by diabetic education (Brown, 1990; Thompson, 1999; Albisser, 1996; Piette, 1997; Shultz 1992).
  • Although few studies examined patient satisfaction, those that did noted high satisfaction rates (Piette et al., 1997; Mitchell et al., 1996).
  • A successful implementation process is crucial to the effectiveness of diabetic tele-care and tele-education (Mitchell et al., 1996).
  • Only two studies included cost analysis; neither can speak to the costs of current technology. However, Brown's (1990) meta-analysis cautions that the number of hospitalizations, hospital days, sick calls, doctors' office visits, missed work days are not always factored in to cost analyses of diabetic education services.

ENT (La Romaine)

  • The use of telemedicine in ENT is just as effective as FTF in determining clinical outcomes (Furukawa et al., Pederson et al., 1994). However, the quality of care provided can sometimes be compromised by store and forward technology (Stern et al., 1998).
  • Patient satisfaction, although not included in most of the trials, was high in one study (Pedersen et al. 1995).
  • Few of the studies reviewed were concerned with implementation. One study using store and forward technology (Stern et al., 1998), however, argued that since store-and-forward consultations include less information and do not provide immediate feedback, a well defined clinical protocol is needed for assembling the electronic consultation.
  • No study in tele-ENT addressed cost-effectiveness.

Mental health (Berens River, Southend)

  • Six studies (Kennedy, 2000; Gammon, 1996; Ruskin, 1998; Urness, 1999; Zaylor, 1999; McLaren, 1996) compared the effectiveness of a telepsychiatry program with conventional FTF methods; while another (Ball, 1995) examined how the outcome of clinical tasks in a psychiatric unit differ when using four different modes of communication (FTF, telephone, hands-free phone, LCVC). In most studies (Kennedy 2000, Zaylor 1999, Urness 1999) patient outcomes do not seem to be negatively affected by the use of videoconferencing tele-psychiatry, and diagnostic reliability is not affected (Ruskin et al., 1998). However, technical difficulties can compromise the tele-psychiatry sessions (Gammon et al., 1996).
  • Patient satisfaction in tele-psychiatry is generally high (Callahan et al., 1998), although satisfaction is lower for older patients (Montani et al., 1997). Zarate et al. (1997) found that video interviews were well accepted by schizophrenic patients.
  • Many of the articles reviewed on tele-psychiatry address the importance of successful implementation. Doze et al (1997) and Urness et al. (1999) note a series of implementation steps to follow in tele-psychiatry.
  • Many of the tele-psychiatry articles reviewed find the service to be cost effective, although they differ on the utilization rates deemed necessary for cost effectiveness (Mielonen et al., 2000; Doze and Sampson, 1997; Trott et al., 1998). Doze et al. argue for the inclusion of all economic variables and insist on the need to consider the impact of telepsychiatry on existing systems of care into which it would be introduced.

Pediatrics (Southend)

  • According to the available evidence, pediatric care through telemedicine is just as effective as FTF in determining patient outcomes ( Finley et al.,1997; Mulholland et al., 1999). Quality of care in pediatrics seems to improve with the use of telemedicine, and Mulholland et al. (1999) point to the benefits of early diagnosis and the avoidance of unnecessary transfers.
  • Patient satisfaction was favorable in two studies reviewed (Blackmon et al., 1997; Dick et al., 1999).
  • No study addressed the question of implementation for pediatric telehealth.
  • According to several studies, pediatric tele-care is cost effective. (Vincent et al.,1997; Finley et al., 1997; Rendina et al.,1999) . Families have benefited financially from pediatric tele-care (Dick et al., 1999).

Rehabilitation (Fort Chipewyan)

  • Tele-rehabiliation via VC seems to be as effective as FTF consultations in determining patient outcomes (Couturier et al., 1998; Lemaire, 1998; Sparks et al., 1993). Quality of care does not seem to be compromised by the technology used, but Burns et al (1998) suggest that telerehabilitation should not be used to replace the hands-on involvement of clinicians especially for initial assessment.
  • Only one study reviewed mentioned patient satisfaction, finding it to be high (Couturier et al., 1998).
  • Implementation of tele-rehabilitation programs was of concern in quite a number of articles, with concerns arising about standards, technology compatibility, interoperability, networking and Internet; and issues of access and ease of use of these systems by people without technical training (Burns et al., 1998).
  • Whether or not tele-rehabilitation is cost effective is unclear in the studies reviewed (Burns et al., 1998). Couturier et al (1998) reported that orthopedic teleconsultations took much longer than conventional consultations. Although this finding suggested cost implications, the authors did not provide a cost analysis.

In summary, the results of this literature review suggest that quality of care and patient outcomes are generally equal to those obtained in conventional care, although the evidence is stronger for some types of applications than other. Patient satisfaction is uniformly high, although slightly less so in older patients. Cost-effectiveness has been demonstrated for some applications but not for all; however, these analyses tend to include only some of the overall costs.

Top of Page

Project Evaluation

1. Evaluation Questions

The evaluation addressed three issues central to the project objectives:

  • telehealth impacts on patient and community access to needed, quality care
  • role of telehealth in health services delivery, including cost-effectiveness and
  • linkages of telehealth with existing health resources.

Since each community among the five is unique, the evaluation attempted to gather information relevant to each as well as to telehealth in First Nations' communities in general.

Evaluation questions relating to each of the above issues were developed though the literature review, the needs assessments and consultations with project officers, with support from existing general frameworks for evaluation questions, including Treasury Board guidelines2 and other major approaches to evaluation of health and social programs3. The main evaluation questions are shown in Table 2 below, while site specific questions are addressed in later chapters about each community.

2 Treasury Board of Canada, Program Evaluation Branch, Office of the Comptroller General (1991). Program Evaluation Methods: Measurement and Attribution of Program Results. Ottawa: Minister of Supply and Serices; Treasury Board of Canada, Program Evaluation Branch, Office of the Comptroller General (1989). Working standards for the evaluation of programs in federal departments and agencies. Ottawa: Minister of Supply and Services.

3 Stufflebeam, D. (1987). The CIPP model for program evaluation. in G. Madaus, M. Scriven, D. Stufflebeam (Eds.), Evaluation Models: Viewpoints on Educational and Human Services Evaluation. Boston: Kluwer-Nijhoff.

Table 2: Evaluation questions

  • Issue: Access to needed, quality care
    Specific Evaluation Questions:     To what extent do the telehealth applications respond to the community's needs, as defined by the needs assessment? To what extent do patients and families find each telehealth application acceptable? To what extent has telehealth improved access to needed, quality care? To what extent are services provided through telehealth consistent with established means of improving patient health outcomes?
  • Issue: Health services delivery
    Specific Evaluation Questions:     To what extent has telehealth use been organized successfully? To what extent have the professional skills and competencies required for telehealth been identified and successfully addressed through training? To what extent are telehealth applications used by eligible patients in the community? To what extent does telehealth improve competencies and confidence of local health personnel?
  • Issue: Health services delivery (continued)
    Specific Evaluation Questions:     How does telehealth affect staff workload, task allocation and professional practices? To what extent does telehealth result in cost increases, decreases or shifts for health service delivery within the communities? What is the level of technical success of the platforms, applications and suppliers in the implementing communities?
  • Issue: Linkages among health resources
    Specific Evaluation Questions:     To what extent is telehealth appropriated, integrated and sustained as a part of the community's self-governed health care system? To what extent have the telehealth applications become linked and integrated to provincial initiatives? To what extent does telehealth improve access of secondary, tertiary and education providers to local health service providers? To what extent does telehealth improve health service providers' awareness and knowledge of local conditions and resources?

2. Evaluation Methods

The overall approach to the evaluation used multiple methods to assess changes over time from the perspectives of patients, personnel, communities and other stakeholders. Consistent with the overall project philosophy, communities were involved in developing the evaluation methodologies. After developing an initial evaluation plan (Appendix 8), the evaluation team visited each of the communities at the beginning of the implementation period (spring 2000) in order to develop and adapt the proposed evaluation instruments and procedures to each community needs and functioning. As a result, the data collection methods and instruments varied somewhat from community to community.

Monitoring telehealth system usage

Monitoring the usage of the telehealth applications provided information on the nature, level, quality and implications of usage. The main data collection tools were patient encounter forms completed by nursing station personnel and by remote health providers (Appendices 2 and 3).

Nursing station patient encounters. During the study period, nursing station staff recorded basic information about each encounter with patients using the telehealth applications, on a checklist-type form immediately after each telehealth usage. The forms included:

  • date, time and length of usage, as a proportion of total encounter
  • the type of health problem prompting the consultation
  • who was present, at the local and remote sites
  • what was done during the telehealth encounter
  • the results of the visits in terms of subsequent actions
  • any technical problems during the usage
  • the implications of using telehealth in terms of costs incurred or avoided.

The section of the forms recording what was done during the visit provided indicators of quality of care. For the telehealth applications that addressed conditions for which guidelines for appropriate primary clinical practice have been established (diabetes, mental health, and cardiology), the forms included checkpoints for the recommended components of appropriate care.

The forms were also used to record usage of telehealth for patient education, continuing professional education, and community development.

In Fort Chipewyan, a different system was used, based on a utilization record developed by the vendor and modified to accommodate the evaluation.

Each patient was assigned an identifier code, used on all visits to the nursing station during the study period. The telehealth coordinators in each community were responsible for assigning codes to patients and for maintaining a master list of patients' names and codes. No nominative information was sent outside the nursing station.

The telehealth coordinator in each site faxed the completed encounter forms every two weeks to the evaluation team. These were received at a secure fax site at McGill University.

Over the evaluation period, information was received about 927 telehealth sessions involving 176 patients. The number of sessions per community varied from 40 to 755, and the number of patients seen from 17 to 59.

Remote centre patient encounters. Practitioners (nurses or physicians) in the remote centres completed brief patient encounter form after each telehealth encounter for patients in the study group in each site. This encounter form included:

  • date, time and length of usage
  • what was done during the telehealth encounter
  • the results of the visits in terms of subsequent actions
  • any technical problems during the usage
  • the implications of using telehealth in terms of costs incurred or avoided.

These forms were also regularly faxed to the evaluation team, using the same patient identifier as in the community form. Remote encounter forms were not completed for the Southend project.

Patient satisfaction

Patients using telehealth in each community were asked to complete a brief satisfaction questionnaire about their reactions to and comfort with the telehealth system. This questionnaire was based on an instrument developed by Saskatchewan's Northern Telehealth Network (see Appendix 4 for the different versions of this questionnaire used in each community). A total of 110 questionnaires were received.

Qualitative interviews

Qualitative interviews were conducted at the end of the project during in depth data-gathering visits to each community (in February and March 2001). They were conducted with stakeholders in each community and in the participating health systems, using semi-structured interview guides. The stakeholders were asked to respond as key informants giving their views on the evaluation questions from their perspectives within the project and the communities. They were identified in collaboration with project leaders and nursing station staff. The interview guides may be found in Appendix 5.

The interviews lasted from one half hour to three hours in length. Some were conducted as group consultations, and some were conducted by telephone or videoconference. If participants gave permission, they were tape-recorded.

The table below summarizes the qualitative interviews conducted about each community:

Table 3: Summary of interviews conducted about each community

  • Community: La Romaine
    Number of Interviews: 9 interviews with 9 individuals
    Types of respondents: Telehealth coordinator, nursing staff, director, remote providers, remote telehealth coordinator, provincial telehealth representatives, vendor
  • Community: Berens River
    Number of Interviews: 9 interviews with 14 individuals
    Types of respondents: Telehealth coordinator/project officer, telehealth supervisor, nursing staff, community workers, remote providers and educators, remote telehealth coordinator
  • Community: Southend
    Number of Interviews: 13 interviews with 20 individuals
    Types of respondents: Telehealth coordinator, nursing station board members and management, nursing and mental health staff, community workers visiting and remote providers, remote telehealth coordinator, provincial telehealth representative, project officers
  • Community: Fort Chipewyan
    Number of Interviews: 12 interviews with 22 individuals
    Types of respondents: Telehealth coordinator, Band and nursing station managers, nursing staff, nursing station board member, elders, patients, tertiary providers and management , provincial telehealth representatives, Health Canada representative

3. Ethical Issues

The conduct of the evaluation respected the principles and assumptions of the Project Accountability framework, as well as the Ethical Principles for Research with First Nations Communities set forth in Chapter 6 of the Tri-Council Policy Statement on Ethical Conduct for Research Involving Humans. To protect community privacy, the procedures were designed so that the evaluation team had no access to any patient identification information.

In its initial visits to the communities, the evaluation team discussed ethical issues with community representatives, and where deemed appropriate, obtained formal authorization from the Band for the study according to the agreed-upon ethical principles.

In those communities that required it, each patient using telehealth completed a consent form for participation in the project and/or the evaluation, at the time of their first visit. The telehealth system was explained, stating that the care provided would be equivalent to usual care. The evaluation procedures and the procedures for ensuring confidentiality were explained, as was the voluntary nature of participation without prejudice to care or services. The signed consent forms were retained in nursing station files.

Key informants were not asked to sign a consent form, as participation in this type of assessment was considered as part of their normal roles or professional responsibilities. However, they were formally asked for consent to participate and told that their responses would be kept confidential, and that no respondent would be identified in the evaluation reports.

A complete operational research protocol was prepared for the entire project, for submission to Research Ethics Review Committee in research and medical institutions, which required it. This may be found in Attachment 6.

4. Analyses

All data from the patient encounter forms and satisfaction questionnaires were entered into databases and analysed using SPSS. Qualitative data from the key informant interviews was transcribed and analysed using matrix analysis techniques. For the economic analysis, the cost-consequence analysis matrix developed by McIntosh & Cairns was used (1999).

Top of Page

Case study : La Romaine, Québec

Community description

La Romaine is a community of about 900 Montagnais (Innu) people, located on Québec's North Shore at the mouth of the Olaman River. Its band council, the Conseil Unamen Shipu, assumed governance of its health system in 1998. Nursing staff at the nursing station are linked in terms of first-line medical authority to the health center in Blanc Sablon.

La Romaine's telehealth project

The needs assessment for La Romaine was conducted in spring 1999 by the project officer. The La Romaine community had initially intended to implement interactive video applications for the health issues identified as priorities: diabetes, cardiovascular disease, dermatology and ENT problems. Supplied by regular telephone service, it sought to reach an agreement with the provincial secure health telecommunications network but this could not be achieved at an affordable cost. The project thus re-oriented its choice of technology to store-and-forward system using internet to transmit digitized images. Imaging equipment was installed in the nursing station in La Romaine, and the necessary decoding software was installed in the remote offices : Blanc Sablon (the general practitioners servicing La Romaine, for reading of ECGs); in Québec City (for reading of dermascope images); and in Sept- Iles (for reading of otoscope images). The equipment was deployed and staff trained in spring 2000, with the first encounter forms received in April 2000. The implementation period coincided with a staff crisis within the nursing station and the departure of the director and some long-term staff.

Case study results

Utilization levels

The telehealth initiative in La Romaine was beset by a number of technological problems, which were never completely overcome. During the study period, from April 2000 to the middle of March 2001, forms were received for a total of 58 telehealth transmissions. Fifty-five of these were for ECG readings; however due to telecommunication problems (described below), all of these were sent by fax to the physicians on duty in Blanc Sablon. This physician was not aware that they had been generated through the equipment purchased for the telehealth project. The other three forms were for transmissions of dermatological images: these were sent to Québec City in November 2000, but not found and read until January 2001. Finally, one test ENT transmission was sent to the specialist in Sept-Iles, but he found it of inadequate technical quality; he received no further transmissions. These transmissions pertained to a total of 56 unique patients.

The table below shows the type of health problem that led to each transmission. Nineteen of 54 visits were for urgent problems.

La Romaine: Purpose of visits using telehealth
Purpose Purpose No. of telehealth visits %
Medical or surgical follow-up or medication check 15/54 28
Other health problem 17/54 31
Routine periodic health examination 1/54 2
Other 2/54 4

Technical performance

Problems in maintaining communications on the principal line were the main difficulty encountered: the connection would drop partway through transmission for unknown reasons. Despite visits from the vendor's technician and numerous telephone support sessions, this problem was never resolved. In addition, nursing staff felt that the software involved in file transmission was not user-friendly enough (requiring file manipulation and programming skills that they did not have) for them to be comfortable with it, especially with long time lapses between patients. (Other telehealth experts consulted seconded this opinion of the software.) Moreover, the relationship between the telehealth staff and the vendor cannot be described as supportive or trusting: the vendor stated that the staff had been meddling in the software, while the staff said they had been accused of sabotage. This led to another change of coordinator. Other problems, such as with the ECG printer, were more easily resolved, although one of these happened during an emergency case. In that situation, the nursing staff had to describe the ECG readout to the physician over the telephone.

Acceptability of telehealth to patients and the community

In the opinion of those interviewed, the telehealth project is not well known in the community. Despite the presence of posters promoting the service in the nursing station, according to nursing staff, no patient has come forward to ask to receive care through telehealth. When transmitting ECGs, the nursing staff do not generally explain to patients that this is a potential telehealth application.

Thirty-three patients completed satisfaction forms; these data are summarized in the table below in the form of the number of dissatisfied patients on each item.

La Romaine: Proportion of dissatisfied patients on all items (scores 0,1,2 together)
Questionnaire item # of responses %
De votre état de santé général 8/31 26
Du délai d'attente pour l'utilisation de l'équipement de télésanté 0 0
Du délai d'attente pour les résultats de la séance de télésanté 0 0
Du respect accorde par le personnel a votre vie privée 0 0
De la maniére dont le personnel a répondu à vos questions au sujet de l'équipement 0 0
Du respect avec lequel le personnel vous a traité 0 0
De votre expérience de la télésanté en général 0 0

(Note that this questionnaire was generally translated to patients verbally, as French is not their first language.)

Thirty of thirty-three patients said they would use telehealth again, and thirty-one of thirty-two would recommend it to others, but only 11 of 32 would choose telehealth over a face-to-face visit with the doctor.

Quality of care delivered through telehealth

In terms of image quality, the nursing station staff found it to be generally excellent, although the ENT specialist was not satisfied with the quality of the test image he received. The nursing staff pointed out that better quality ECG images could be obtained from other types of non-telehealth equipment. Since they were not using the ECG machine in a telehealth mode anyway, they felt that for the same cost, they could have access to better quality images. However, this did not affect the quality of care received by patients.

Impacts on patient outcomes

Key informants working in the community felt that the ECG machine had had significant impacts on patient outcomes in several cases, where either transfers that would have turned out to be unnecessary had been avoided, or where a chest pain situation was revealed to be an urgent heart problem and transfer was done immediately. According to Band management, these latter situations are credited with saving lives in the community.

Impacts on access to health within the community

Both patients and community members generally saw transmission of ECG images to the physician in Blanc Sablon as a positive extension of their existing services from that hospital. No other impacts on access to health in the community have been observed, although nursing centre staff believe that telehealth has the potential to do this.

Administrative, organizational and human resource issues

As stated above, the implementation period for the telehealth project coincided with an unstable situation within the nursing station due to a conflict between nursing station and band management. The individuals initially responsible for implementing the telehealth initiative were at the core of this situation. The Band representatives interviewed felt that their responsibility was to first resolve the conflict and so directed their energies towards this; the telehealth initiative became of secondary priority. The staff turnover associated with this crisis meant that responsibility for telehealth coordination was shifted several times during the implementation period. It was suggested that had the community been able to wait to implement the telehealth initiative until the nursing station situation was stabilized, it might have been more successful. However, at this point, responsibility for coordination of the telehealth system has been re-assigned, and efforts are being made to increase integration into nursing station practices. Support being provided by the telehealth coordinator in the Québec City hospitals is facilitating the organizational arrangements for transmission and interpretation of images there; however, the mandate of this person in the overall project is not clear.

The partnership arrangements for links to specialists from La Romaine are also problematic. For the few patients who had images transmitted to specialists, these lines of communication create a professionally uncomfortable if not untenable situation for nursing station staff, whose normal channels of referral must first involve the generalists at the Blanc Sablon Hospital. Sending images directly to other specialist was tantamount to going over the generalists' head, which not only threatened to disrupt the existing relationship between the nurses and their front-line physicians, but also to discredit these physicians in the eyes of patients. Nursing staff were especially concerned that this changed pattern of referrals not jeopardize the development of a more trusting perception of health staff among community members.

Linkages within provincial health systems

According to the key informants interviewed, Québec is in the process of implementing the telecommunications infrastructure of a province-wide telehealth program, and an inter-ministerial committee within the provincial government is currently developing a policy which addresses some of the legal and medico-professional issues involved. Another committee is addressing technical problems and user needs. However, the refusal of the provincial health telecommunications network to provide service to La Romaine at an affordable rate in the initial stages of the project suggests that the inclusion of First Nations communities within this provincial system may not be automatic.

As suggested above, linkages of the La Romaine project within the overall provincial health system are tenuous. While on the one hand, the centre of telehealth activity in the province, in the Québec City university hospital system, is keen to work with La Romaine and supply both technical expertise and links to specialists, this connection cannot really be fully established without full partnership for all applications of the primary referral site, because of the line of medical authority referred to in the above section. Several key informants suggested that the project should have established a telehealth centre in Blanc Sablon, so that the physicians there could be come involved in the telehealth referrals of patients to the specialists in other locations (Sept Iles and Québec City).

Cost effectiveness

The level of true usage of telehealth in La Romaine was too low to make any valid statements about its cost-effectiveness. Although twenty-nine out of 54 visits resulted in transfers being avoided during the twelve months of operation, these were all through use of the ECG equipment in La Romaine with the results faxed to the remote medical facility rather than being read through the store-and-forward software.

Sustainability

It seems clear that the telehealth initiative in La Romaine is unlikely to be sustainable, at least in its present form. According to nursing centre staff interviewed, other avenues of increasing access to specialist will be pursued, including more frequent in-person visits from a larger number of specialists. Although all those involved see potential for telehealth to complement health services available in the community, it is unlikely to be a first priority for health care delivery in the community, at least using store and forward technology, or until the primary referral centre becomes more involved.

Top of Page

Case Study: Berens River, Manitoba

Community description

Berens River is an Ojibway community of about 1800 members on the northeastern shore of Lake Winnipeg, at the mouth of the Berens River. It assumed governance of its health system in April 1999.

Berens River telehealth project

The needs assessment in Berens River was conducted in winter 1999 by the project officer; it was also informed by an existing survey of health conditions in the community and services utilization data. Following the needs assessment, the Berens River community selected real-time video-conferencing applications to address diabetes care and patient education, specialist consults with infectious disease and psychiatric physicians, as well as continuing professional education. Prior to the project, the community's telecommunications access was limited to regular telephone service. For the project, a satellite communication link was established with the Winnipeg Health Sciences Center. Staff were trained and the system was deployed in spring 2000, with the first encounter forms received in July 2000. During the implementation period, the community was in the process of opening a new Health Center, resulting in the movement of the satellite uplink and telehealth station in the fall of 2000.

Case study results

Utilization levels

Number and length of telehealth sessions

During the evaluation period, from July 2000 to mid-March 2001, a total of 40 telehealth sessions were held: 8 for patient care (infectious disease specialist and psychiatry consults), 10 for diabetic care and education, 5 for diabetic education only and 17 for continuing professional education. A total of 17 unique patients were seen: 6 in patient care, 7 in diabetes care and education and 4 in diabetes education. Thirty-five percent of patients (6) had repeat visits using telehealth.

The average number of visits per month was 4.5 with a high of 12 in November 2000. Visits lasted on average, about one hour (one hour and three minutes according to the community encounter forms, and one hour and eight minutes according to the remote encounter forms). According to the remote site, 61% of sessions started on time, and 11% of sessions had scheduling problems. This latter proportion was 5% according to the community forms.

Types of care and education provided through telehealth

The proportion of patient care visits for which each type of personnel was present in the community and remote locations are shown in the tables below.

Berens River: Types of Personnel Present at Patient Visits (Community data)
Type of Personnel # of
telehealth
sessions		 %
Patient 18/18 100
Nursing station Nurse 14/18 78
CHR 0  
Mental Health Worker 0  
Physician 0  
Translator 0  
Family Member 0  
Other (Health Care Aid 2, Nutrition Worker 2) 4/18 22

Berens River: Types of Personnel Present at Patient Visits (Remote sites data)
Type of Personnel # of
telehealth
sessions		 %
Infectious disease specialist 2/18 11
Psychiatrist 2/18 11
Pediatrician 0  
Gynecologist/obstet. 0  
Nurse 11/18 61
Health Educator 0  
Social worker, counselor 0  
Translator 0  
Family Member 0  
Other (Dermatologist 3, Diabetes Educator 4, Diabetic Nutritionist 6) 13/18 72

For patient education, five individual sessions and 4 group sessions were held, with participants ranging from 2 to 9 (total 32).

For continuing education, two individual and 12 group sessions were held, with participants ranging from two to eight (total 51). The types of participants present in the continuing education sessions are shown in the tables below.

Berens River: Types of Personnel Present at Continuing Education Sessions (Community Data )
Type of Personnel Present # of
individuals
Staff 50
Community Members 1
Translator 0
Other (Health Care Aid Nurses, Nutrition Worker)  
Berens River: Types of Personnel Present at Continuing Education Sessions (Remote site data)
Type of Personnel Present # of
individuals		 %
Specialist 0  
Psychologist 0  
Diabetes Educator 14/17 82
Other educator 0  
Nurse 8/17 47
Social worker or counselor 0  
Translator 0  
Other (diabetic nurses, inhalant abuse coordinator, psychiatrist)? 4/17 23

For patient education, five individual sessions and 4 group sessions were held, with participants ranging from 2 to 9 (total 32).

For continuing education, two individual and 12 group sessions were held, with participants ranging from two to eight (total 51). The types of participants present in the continuing education sessions are shown in the tables below.

Berens River: Types of Personnel Present at Continuing Education Sessions (Community Data)
Type of Personnel Present # of
individuals
Staff 50
Community Members 1
Translator 0
Other (Health Care Aid Nurses, Nutrition Worker)  
Berens River: Types of Personnel Present at Continuing Education Sessions (Remote site data)
Type of Personnel Present # of
individuals		 %
Specialist 0  
Psychologist 0  
Diabetes Educator 14/17 82
Other educator 0  
Nurse 8/17 47
Social worker or counselor 0  
Translator 0  
Other (diabetic nurses, inhalant abuse coordinator, psychiatrist)? 4/17 23

The types of care provided in the patient and diabetic care and education sessions are shown in the tables below, for the community and remote locations.

Berens River: Types of care provided in the patient and diabetic care and education sessions (Community Data)
Type of Personnel Present # of
individuals		 %
Specialist Consult 3/18 17
To discuss or confirm diagnosis 6/18 33
To follow up on previous visit 9/18 50
To discuss case management 13/18 72
Other (diabetic education, exercise, gestational diabetes) 3/18 17
Prenatal Care 1/18 6
Other patient care (nutrition) 0  
Berens River: Types of care provided in the patient and diabetic care and education sessions (Remote site data)
Type of Personnel Present # of
individuals		 %
Assessment/ Diagnosis 9/15 60
Treatment/management 13/15 87
Information/ education 10/15 67
Follow up 2/15 13
Other 0  
Other patient care 0  
Top of Page

According to the community encounter forms, in 11 of 18 patient care visits, follow-up was required, 7 with telehealth and 4 without. According to the remote forms, eleven of 15 visits required follow up with telehealth, 1 without telehealth, and 1 with a patient transfer.

According to the community forms for patient care visits, without telehealth, 2 patients would have received no services at all, and three patients would have been transferred. For diabetic care and education visits, seven patients would have received no services at all, three would have waited until services came to Berens River, and four patients would have been transferred. Of the total 18 patient care visits for which this information was complete, 44% of visits resulted in avoiding a transfer.

For the diabetes education sessions, the table below shows the topics covered.

Berens River: Topic covered in diabetes care and education sessions
Type of Intervention # of sessions
in which each
occurred		 %
Diabetes Education 14/14 100
Diet/nutrition 13/14 93
Smoking 5/14 36
Insulin 7/14 50
Foot Care 5/14 36
Hypertension 3/14 21
Exercise 11/14 79
Alcohol 2/14 14
Glucose monitoring 12/14 86
Counselling 1/14 7
Other 0  
Other patient education (alternative foods, obesity, gestational diabetes, effect of meds) 7/14 50

Finally, for the continuing education sessions, the table below indicates the topics covered.

Berens River: Topic covered in continuing education sessions
Topics covered during session... # of sessions
in which
covered		 %
Mental health 1/17 5
Diabetes for renal failure 2/17 12
Foot Care 3/17 18
Gestational Diabetes 1/17 6
Nutrition 6/17 35
FSS, alcohol, solvent abuse 1/17 6
Organization/ Planning 3/17 18

Technical performance

The proportion of visits with each type of technical problem, for the community and remote sites, is shown in the tables below.

Berens River: Technical problems (Community data)
Type of Technical Problems # of sessions
in which each
occurred		 %
Establishing Communication 5/38 13
Maintaining Communication 3/39 8
Operating the camera 3/39 8
Sound quality 5/39 13
Visual quality 0/39  
Other problems 3/39 8
Berens River: Technical problems (Remote data)
Type of Technical Problems # of sessions
in which each
occurred		 %
Establishing Communication 13/34 38
Maintaining Communication 11/34 32
Operating the camera 5/33 15
Sound quality 7/34 21
Visual quality 1/39 3
Other problems 0/22  

Acceptability of telehealth to patients and communities

According to the key informant interviews among community respondents, telehealth is generally well-accepted in the community. No patient refused to use telehealth, although some did not keep their appointments. According to one of the specialists interviewed, patients seem to find telehealth a little strange at first but then quickly get used to it. The positive reaction is echoed in the 15 completed patient satisfaction questionnaires, for which the data are summarized below in terms of numbers of dissatisfied patients.

Berens River: Proportion of dissatisfied patients (scores 0,1,2 together)
Questionnaire item # of responses %
General Health 8/15 53
Length of time to get an appointment with telehealth 2/15 13
Length of time waiting in the office at telehealth 4/15 27
Length of time with the specialist you saw 3/15 20
The explanation of your condition by the specialist 1/15 7
The explanation of your treatment by the specialist 1/15 7
The thoroughness, carefulness and skillfulness of the specialist you saw 2/14 14
The courtesy, respect, sensitivity and friendliness of the specialist you saw 0  
How well the staff here respected your privacy 0  
How well the staff here answered your questions about the equipment 1/14 7
How well the staff here treated you with respect 0  
Your overall treatment experience at telehealth 0  

All patients stated they would use telehealth again, and all stated they would recommend it to others.

Within the community, it was suggested that many community members are not yet aware of the telehealth service, and that more publicity could be carried out.

Quality of care delivered through telehealth

According to nursing station staff, telehealth has improved quality of care because of quicker access to specialists, especially in terms of diagnostics. A comment was made that for psychiatry consults, the lack of physical proximity hindered empathetic responses. No other positive or negative impacts on quality of care were noted.

According to the data provided on the encounter forms for diabetes education (a proxy measure of quality of care), the issues most often addressed were diet, exercise and glucose monitoring. The topics most infrequently addressed were counselling/social support, hypertension, and alcohol consumption.

Top of Page

Impacts on patient outcomes

The diabetes education program has, in the eyes of both community and local diabetes workers, improved patient knowledge of nutrition issues (dietary fibre, sugar substitutes). Similarly, one key informant felt that the psychiatric services have improved patient outcomes because of decreased waiting time. However, the nursing staff stated that the main factor in determining patient outcomes was the competency of the staff involved, rather than the equipment. Moreover, remote providers felt that turnover in staff had greater (negative) impact on patient outcomes than the telehealth technology. Other key informants noted that the lack of continuity in staff has created general problems for quality of basic care (such as lack of dispensation of prenatal vitamins, although stocked) that telehealth cannot address.

Through the continuing professional education program, workers in the community are able to access information on a variety of topics. There were however mixed views about the value of this for community personnel: some felt that it was a valuable source of information for local staff which could indirectly improve patient outcomes, while others felt it was not well-adapted to their needs.

Impacts on access to health within the community

The telehealth program in Berens River has, according to the key informants interviewed, improved access to health services within the community, in particular to specialist care and to information about diabetes management. It does not seem to have produced changes in the overall approach to self-determination of health within the community: telehealth is seen as an adjunct or complement to existing services, which patients have the choice to use. One specialist interviewed echoed this view stating that face-to-face services are preferable, and that telehealth should be viewed as a complement to existing services rather than a substitute.

Organizational, administrative and human resource issues

The main organizational issue for the Berens River telehealth project has been the turnover in key nursing, medical and mental health staff. These changes coincided with the transfer of health governance to the community, and were followed by a period of little or no nursing service or by short-term personnel. Although a community health representative was designated as the telehealth coordinator early in the implementation period, the lack of stable personnel disrupted existing relationships with secondary/tertiary providers and affected uptake of telehealth.

In general, once established or re-established, for patient care and education, the linkages with remote sites have evolved positively throughout the course of the evaluation period. Although secondary and tertiary providers of all forms of service acknowledged that there have been some frustrations and difficulties, the linkages have generally gone smoothly.

Scheduling difficulties have been minimal, although tertiary providers attribute this to the pilot nature of the program and the low usage levels. Appointment cancellations are a problem for some of the tertiary providers and practitioners, although it is recognized that failure to keep appointments is also a problem in FTF services.

The key informant interviews showed that another difficult issue lies in the availability of other forms of specialist expertise for which telehealth services could be offered. Staff expressed frustration that some of their more pressing needs for access to specialists through telehealth (for example, in radiology) were not being met because of lack of participating specialists in the remote site.

The telehealth system seems to have little impact on the nursing station in terms of information flow and storage. In terms of other administrative issues, staff turnover has required additional training but no other issues or impacts were noted.

Linkages within provincial health systems

According to the key informants interviewed, there are no other significant telehealth initiatives in Manitoba, so this is a new model. It is felt, however, that the future model should work toward integrating telehealth services within the regional health authorities, as is the case for the diabetes education program, rather than work through the Health Sciences Centre. This will provide greater integration within the provincial system.

In terms of integration into the provincial health care system in general, respondents felt that some new linkages had been created, notably with the regional diabetes education program and between psychiatric services and the solvent abuse worker.

Cost effectiveness

The level of usage in Berens River is as yet too low to make any valid statements about cost-effectiveness of telehealth. Practitioners in the remote sites expect that while some travel costs may be reduced, the increased access to care may increase overall costs.

Sustainability

Nursing centre and remote staff stated that the key to sustainability and eventual health impacts in the community lies in the stabilization of the local health care system and the provision of good clinical and preventive care with or without telehealth. One key informant maintained that the same problems would be faced in achieving health impacts even if specialists were available to fly in to the community regularly; another felt that the social issues facing the community would not be solved through provision of more ineffective preventive measures. Other informants mentioned that the success of education intervention in particular depends on the ability to effect broader changes in the community as a whole; for example, in the availability of the health foods that the diabetes education program encourages patients to eat, exercise opportunities, etc.

Case Study: Southend Saskatchewan

Community description

Southend is one of eight communities in the Peter Ballantyne Cree Nation, which has total membership of about 6,500. Southend, in north central Saskatchewan on the southern Shores of Reindeer Lake, has a population of just less than 1000. Its health services are managed by Peter Ballantyne Cree Nation Health Services Inc.

Southend's telehealth project

The needs assessment was conducted in Southend in spring 1999 by the project officer and community members and included a door-to-door survey of residents. Following the needs assessment, Southend selected real-time video-conferencing applications for specialist consults in psychology, pediatrics and dermatology; diabetic education and management, and staff and community education. The project was designed to link into the existing Northern Telehealth Network, a large provincial initiative. Staff were trained and the system was deployed in late spring 2000, with the first encounter forms received in June 2000.

Case study results

Utilization levels

Number and length of telehealth sessions

During the evaluation period, from June 2000 to mid-March 2001, a total of 74 telehealth

sessions were held: 53 for patient care (family physician, psychologist and other specialist consults), 6 for patient education, and 15 for staff or community. A total of 44 unique patients were seen: 38 in patient care and 6 in patient education. Six patients had repeat visits using telehealth.

The average number of visits per month was 6.9 with a high of 25 in September 2000. Visits lasted on average, one hour and 37 minutes. Five of 74 sessions had scheduling problems.

Types of care and education provided through telehealth

The proportion of patient care visits for which each type of personnel was present in the community and remote locations are shown in the tables below. For 21 of the sessions, the remote location was La Ronge, while for 16 it was Saskatoon and 13 of the sessions, it was Prince Albert and only two sessions in Pinehouse. Four visits were for urgent problems.

Southend: Types of Personnel Present at Patient Care Telehealth Sessions (Community site)
Type of Personnel # of sessions
in which
present		 %
Patient 50/53 94
Nursing station Nurse 28/53 53
CHR 0  
Mental Health Worker 6/53 11
Physician 0  
Translator 8/53 15
Family Member 8/53 15
Other (Telehealth coordinator 15, Group home worker 6) 21/53 40
Southend: Types of Personnel Present at Patient Care Telehealth Sessions (Remote sites)
Type of Personnel # of sessions
in which
present		 %
Family physician 23/53 43
Psychologist 17/53 32
Specialist (Dermatologist 7, Pediatrician 1, Psychiatrist 1) 10/53 19
Nurse 7/53 13
Health Educator 0  
Social worker, counselor 0  
Translator 0  
Family Member 0  
Other (Intern 6) 6/53 11

For patient education, five individual sessions and 1 group session (with six participants) were held. (total 11 participants). Three of these sessions were held in the telehealth office, while one was held in the mental health room.

For staff /community continuing education, a total of 15 sessions were held. The types of participants present in these sessions are shown in the tables below.

Southend: Types of Personnel Present at Staff/Community Education Sessions (Community site)
Type of Personnel # of Participants
Staff 41
Community Members 24
Translator 0
Other (telehealth coordinator 1, ICFS staff 1) 3
Southend: Types of Personnel Present at Staff/Community Education Sessions (Community site)
Type of Personnel # of visits
Psychologist 1/12
Diabetes Educator 3/12
Other educator 4/12
Nurse 2/12
Social worker or counselor 1/12
Translator 0
Other (diabetic nurses, inhalant abuse coordinator, psychiatrist, nutritionist)? 8/12

The types of care provided in the patient care sessions are shown in the table below.

Southend: Types of Patient Care Provided in Telehealth Sessions (Community data)
Type of Care # of sessions %
Specialist Consult 21/53 39
To discuss or confirm diagnosis 20/53 38
To follow up on previous visit 27/53 51
To discuss case management 28/53 53
Other (1 counseling, 1 regular MD 4/53 7
Other patient care (regular clinic held by telehealth due to poor weather) 22/53 41

According to the community encounter forms for patient care, in 41 of 53 patient care visits, follow-up was required, 26 with telehealth and 16 without. Eighteen patient care visits of 53 resulted in a transfer being avoided (with five additional "maybe" responses).

The topics covered in the patient education sessions are shown below.

Southend: Topics Covered in Patient Education Sessions
Topics covered # of sessions %
Diabetes Education 1/6 17
Diet/nutrition 0  
Smoking 3/6 50
Insulin 0  
Foot care 0  
Hypertension 0  
Exercise 0  
Alcohol 0  
Glucose monitoring 5/6 83
Counseling or support 2/6 33
Other (transplants 1) 1/6 17
Other patient education 0  

Finally, for the staff and community education sessions, the table below indicates the topics covered.

Southend: Topics Covered in Staff and Community Education Sessions
Topics covered # of sessions %
Child Abuse 2/15 13
Nutrition 2/15 13
Diabetes Prevention 2/15 13
Gambling 1/15 7
Issues in rural health 1/15 7
Management of gynecologic emergency 1/15 7
Violence in the emergency room 1/15 7
Substance abuse in pregnancy 1/15 7
Pediatric trauma 1/15 7
Management of patients - burn injuries 1/15 7
Demonstrations 2/15 13

Technical performance

The proportion of visits with each type of technical problem, for the community and remote sites, is shown in the tables below.

Southend: Technical Problems

Type of Technical Problem # of sessions
in which
each occurred		 %
Establishing Communication 14/72 19
Maintaining Communication 1/72 1
Speed 0 0
Operating the camera 0 0
Sound quality 3/72 4
Visual quality 6/72 8
Other problems 2/72 3
Top of Page

In the key informant interviews, one remote provider mentioned that although there had been some technical difficulties, a session had never been cancelled because of them. He did note however, that room arrangements, camera angle and background colour were all important to his capacity to deal with the patient properly. Two others noted that audio problems had occurred fairly frequently; it was felt that better microphones and better placement of them would help.

Acceptability of telehealth to patients and communities

According to the key informant interviews among community respondents, patients have given positive feedback about using telehealth. No patient had refused to use telehealth (although one has consistently demurred), and no negative feedback had been received by the nursing station's management. Not all providers had received feedback from Southend about patients' experiences, but they felt that it seemed to be well-accepted. The team providing psychological services felt it was easier for children to be comfortable using the system if the had seen the practitioner in person first and then could recognize them on the screen. One provider expressed concern about a 50% rate of no-shows for appointments, and wondered if it was an indication of dissatisfaction. Forty-seven patients who had received either patient care or education completed patient satisfaction questionnaires, for which the data are summarized below in terms of numbers of dissatisfied patients.

Forty-seven patients who had received either patient care or education completed patient satisfaction questionnaires, for which the data are summarized below in terms of numbers of dissatisfied patients.

Southend: Proportion of dissatisfied patients (scores 0,1,2 together)
Questionnaire items # of responses %
General Health 11/46 24
Length of time to get an appointment with telehealth 11/45 24 The ease of getting to the telehealth site 4/44 9
Length of time waiting in the office at telehealth 15/46 33
Length of time with the specialist you saw 7/46 15
The explanation of your condition by the specialist 5/45 11
The explanation of your treatment by the specialist 4/42 9
The thoroughness, carefulness and skillfulness of the specialist you saw 2/46 4 The courtesy, respect, sensitivity and friendliness of the specialist you saw 1/46 2 How well the staff here respected your privacy 1/46 2
How well the staff here answered your questions about the equipment 4/46 9 How well the staff here treated you with respect 1/46 2

Forty-two of 56 patients stated they would use telehealth again, and 44 of 46 stated they would recommend it to others.

Within the community, it was suggested that many community members are not yet aware of the telehealth service, and that more publicity could be carried out. According to key informants from the community, the telehealth system has not as yet become integrated into the community's health system: about a two on a scale of one to ten.

Quality of care delivered through telehealth

Nursing station staff and management stated that they feel telehealth has improved quality of care, by increasing the frequency of mental health sessions as well as the amount of information received by diabetic patients. However, they caution that it has only been in operation for five months, so it is too soon to tell what the impacts will be.

In the mental health area, there is consensus that telehealth has improved quality of care by increasing timeliness and continuity of care. Although it is more of a challenge for practitioners to make contact with patients, according to the practitioners, this can be overcome with ingenuity. A community worker recounted a story about a girl who had received counselling through telehealth, stating that the bond of trust with the therapist had developed much more quickly than if she had had to travel. Quality of care in mental health has also been improved because local staff are able to observe sessions and learn from this.

Remote and local telehealth coordinators and nursing staff noted that in some ways telehealth has improved quality of care in the community, because the specialists concentrate more on the patients and are more likely to ask the patient if he or she has understood. In addition, the presence of local personnel and/or translators helps remote personnel in understanding what patients are saying.

The remote providers outside of mental health were more reserved in their assessment of quality of care through telehealth. One practitioner felt that telehealth represents a clinical compromise, which is fine for most situations but may not be adequate for some others. In dermatology, the provider mentioned that telehealth provides an excellent tool in first-level screening, when the diagnosis is obvious and there is no major clinical problem. In these cases, telehealth certainly complies with quality of care. Similarly, a family physician noted that some situations are more appropriate than others for the use of telehealth: problems such as abdominal pain which require palpation are difficult to deal with over the link because the doctor and nurse may have different frame of reference when describing what the nurse is feeling, whereas a chest problem is more easily described in terms of what is being heard. A pediatric surgeon gave a theoretical example explaining that he felt that a hernia diagnosis conducted by a family physician with him attending over the telehealth link could provide quality service. It was noted that, for remote providers, there are significant trust issues in interacting with a practitioner who is conducting the examination on their behalf. Areas such as telepsychiatry and dermatology lend themselves best to telehealth, and the project had focussed on these strength areas.

One provider noted that it is important to have staff with medical training at both ends of the system; non-medical staff in the community site may not be experienced with patient handling and may not understand what the specialist requires. The non-medical telehealth coordinator also noted that it was important for her to have nursing staff available during the sessions, in order to be able to explain what the physician was saying to the patients. For providers, the shortened gaps in between patient visits helps them recall better the patient's condition. For both remote and community practitioners, using the system more often would make them more familiar with it, and would correct some quality problems such as blurry ECGs sent by fax, when they could be sent by the document scanner.

According to the data provided on the six encounter forms for diabetes education (a proxy measure of quality of care), the issue most often addressed was glucose monitoring.

Impacts on patient outcomes

Key informants interviewed stated that the main benefit to patients has been by improving the access time to specialists. For youth and children with mental health problems, community workers and the mental health coordinator reported that telehealth avoids having to send patients out of the community for assessments, which increases timeliness of treatment and lessens disruption to schooling. According to two interviewees, the fact that there are now two professionals involved in these assessments, instead of only the specialist, improves the process. One respondent also stated that she was able to access expertise from the remote providers on occasions when this was needed to support her interventions.

Through the staff and community education program, workers and community members are able to access information on a variety of topics, some of which have provided valuable new information to nursing and other health staff.

Impacts on access to health within the community

According to all key informants interviewed, telehealth has improved access to health within the community. This has occurred in several ways. First, the wait times to see specialists have been reduced in some areas (most notably psychiatry and dermatology: the usual three month rate is reduced to a few weeks), although providers caution that if the service is more widely used that this advantage may not be maintained. Second, telehealth represents an improved service for short follow-up specialist visits, especially appreciated by elderly patients and those with children. Third, in situations such as psychological services which benefit from frequent interaction between the patient and provider, telehealth can allow more frequent appointments and speed the course of treatment. Finally, in the mental health area, telehealth provides an important advantage in allowing immediate screening of problems as either psychological or physiological, allowing appropriate orientation of treatment and, in particular, avoiding using mental health resources and problems that are of physiological origin requiring medical treatment.

Some of the nursing station staff interviewed felt that impacts in the community could be enhanced if specialists were available to deal with some additional prevalent health problems through telehealth. The main example given was in ear-nose-throat consults, along with dentistry and optometry. The remote mental health practitioners interviewed also suggested that development of enhanced assessment and screening skills for early childhood development could be facilitated through telehealth.

Top of Page

Organizational, administrative and human resource issues

The telehealth coordination duties in Southend were initially assigned to a nurse within the nursing station. Following her departure, they were assigned to a non-medical staff member, and have now been re-assigned to a newly-arrived nurse who also has other responsibilities. According to key informants, each of these changes required some adjustment time and extra training resources. The nursing staff are very busy and find it difficult to take hours away from their other work to devote to telehealth; they state that while they would have liked to see the system get more usage, they have been too busy to do so. It was stated that increasing the familiarity of all personnel with the system would reduce reliance on the coordinator and contribute to increased usage.

For the nursing station staff, one of the lessons learned was that implementing telehealth successfully took much more time than expected. The role of the project officer, with adequate time dedicated to moving the project forward, was critical. Many hurdles were overcome and enthusiasm maintained throughout the long months of planning and negotiation because of this resource.

The physical arrangements for telehealth in the Southend nursing station are less than satisfactory for its users. The main telehealth room is a small office; very cramped when a table is also used as is required in some assessments. The mental health room, used for group sessions, as a multi-purpose room and suffers from a lack of privacy. The equipment can also be used in the emergency room, but must be cleared out immediately if an emergency arrives.

Missed or cancelled appointments have been an issue in this project, with one specialist dropping out of participation because of the lost revenue incurred from it. Other remote providers also expressed concern about the rate of missed appointments, although one felt it was not more prevalent that in his face-to-face practice. The nursing station staff feel that patients need to be made more aware of the importance of keeping their appointments: there is a perception that because the system is so accessible, missed appointments or late arrivals can be made up easily. They have now required patients to get a new referral if they miss an appointment.

Remote providers interviewed varied in their views of the effects of telehealth on their practice. According to one, seeing patients takes more time using telehealth than in face-to-face consults, because of the time required for patients to be prepared for the examination and to properly orient the camera. This reduces the number of patients that can be seen in the same time period, and would affect revenues if the sessions were not part of a pilot project. Another stated that he is used to doing telephone consults, and telehealth merely adds another dimension to that practice.

Linkages within provincial health systems

The Southend project has had linkages with the provincial Northern Telehealth Network, with strong relationships between the telehealth coordinators in Southend, La Ronge, Prince Albert and Saskatoon. This was facilitated by the choice of the same vendor for the Southend as for the provincial system. According to key informants, the experience of the provincial program seems to have benefited Southend, especially in terms of setting up the program, developing operational procedures and clarifying the role of telehealth coordinators. Human resources from other sources such as the NTN network and the Regional Health Authority in La Ronge have also willingly contributed to this project and helped make it work. Moreover, the NTN offers a very active program in continuing medical and health education, of which Southend staff are regularly informed. This program has reached over 2000 people including workers from Southend who participated, for example, in sessions offered by the Canadian Diabetes Association. However, the provincial program representatives feel that linkages could be strengthened further if there were a clear mandate and dedicated time for the local coordinator to participate in provincial coordination meetings and maintain relationships with the other sites.

The mental health practitioners consulted noted that the relationships to be built with the community have to work to overcome years of previous bad experiences with culturally insensitive services, lack of continuity and engagement. This represents an additional challenge for telehealth, when the relationship is established through remote technology.

Cost effectiveness

The level of usage in Southend is as yet too low to make any valid statements about cost-effectiveness of telehealth. The total number of visits which resulted in transfers being avoided was 18 during the nine months of operation; this would not constitute a significant offset to the capital and human resource costs of the system. The provincial program representatives interviewed noted that the same services could also likely be achieved with lower cost equipment. Maintenance costs would then also be reduced accordingly.

Sustainability

In general, the key informant interviews suggested that Southend's telehealth project has the potential for sustainability but that it is still in its infancy as far as integration into the community's health system is concerned. Community workers remarked that the system could be expanded in community education, as nurses are too busy to fulfill this role. Areas of need mentioned were: AIDS, cancer prevention, and healthy sexuality. One tertiary provider remarked that telehealth is still being driven by administrators and physicians' interests, not by patient demand. Sustainability, in his view, will require more awareness and active interest from patients. Another noted that telehealth still has to prove itself in the eyes of many of his colleagues, and that this will hamper expansion into other needed areas. This assessment was echoed by nursing station staff. According to one respondent, telehealth has become part of everyone's everyday business in order to be effectively used for a wide variety of applications. However, the nursing station management as well as the provincial representatives are convinced that sustainability and expansion of the system are in the best interests of the community.

Case Study: Fort Chipewyan, Alberta

Community description

Fort Chipewyan, located on the western shore of Lake Athabasca in northern Alberta, is a community of about 2000 people belonging to the Athabasca and Misikew Cree First Nations. Health services are delivered by the Nunee Health Authority (NHA).

Fort Chipewyan's telehealth project

The needs assessment, completed in winter 1999, followed on prior identification by the NHA of rehabilitation services as a priority for the community, on existing mobilization of the nursing station in support of using telehealth in this area, and on a prior technologically unsuccessful telehealth initiative. The telehealth project adopted by Fort Chipewyan enabled the provision in the community of physiotherapy, occupational therapy and speech and language therapy by trained rehabilitation assistants under the supervision of rehabilitation specialists located at the Northern Lights Health Centre in Fort McMurray. One of the two rehabilitation assistants is also the telehealth coordinator. After undergoing an assessment in Fort McMurray, patients receive rehabilitation services in Fort Chip on an ongoing basis according to an established treatment plan. Every fifth session is observed through the telehealth system by the remote practitioners. The rehabilitation assistants assure that patients are able to attend the appointments, usually by driving them to and from their sessions. The community also selected televisitation as an application, through which family and friends in can visit with hospitalized patients in Fort Chip. The final application selected was continuing professional education.

In the Fort Chip project, staff were trained and the system was deployed in early spring 2000, with the first encounter forms received in March 2000. Speech and language therapy was implemented first, with physical therapy beginning in June 2000 and occupational therapy following in July 2000.

Case study results

Utilization levels

Number and length of telehealth sessions

In Fort Chipewyan, telehealth has enabled the delivery of rehabilitation services in the community which, although they use the telehealth equipment only one-fifth of the time, would not have been possible without the presence of the telehealth link. In the data provided below, all rehabilitation sessions, whether or not observed through the telehealth link, are counted as telehealth sessions.

During the evaluation period, from March 2000 to the end of February 2001, a total of 755 telehealth sessions were held: 696 rehabilitation and 57 televisitation and 2 telelearning. Among the rehabilitation sessions, 367 were speech therapy, 237 were physical therapy and 92 were occupational therapy. Ninety of these 604 sessions involved use of the telehealth link. A total of 59 unique patients were seen, of which 46 (78%) had repeat visits.

The average number of visits per month was 61.7 (28.9 in speech therapy, 19.5 in physical therapy, 6.5 in occupational therapy and 5.0 in televisitation), with a high of 121 in November 2000. Sessions lasted, on average, 42 minutes (54 minutes for physical therapy, and 30 and 32 minutes for speech and occupational therapy, respectively.) Over all types of rehabilitation sessions, 89% started on time, and 8% had scheduling problems. For 142 scheduled sessions, patients did not keep their appointments.

Types of care enabled by telehealth

The table below shows the types of rehabilitation interventions conducted, according to the community encounter data for each type of therapy.

Fort Chipewyan: Types of Rehabilitation Services Provided
Type of Intervention No. of sessions
ST		 No. of sessions
PT		 No. of sessions
OT		 Total %
(out of 657)
Initial Assessment 1 4 20 4
Ongoing Therapy 327 204 56 89
Adjustment of Therapy 18 14 14 7
Reassessment 1 2 0 .5
No Therapy Needed 0 0 0  
1 1 1 1
No Show 34 63 14 17

The table below shows the types of follow-up indicated after each telehealth-supervised rehabilitation session, according to the remote encounter forms data. Note that all three recommended transfers were in the area of physical therapy.

Fort Chipewyan: Type of follow-up indicated after observed rehabilitation sessions
Type of follow-up # of sessions Total %
(out of 47)
No further sessions are required 1 2
Continuing therapy 42 89
Same telehealth Supervision 31 66
Change in telehealth supervision 4 8
Patient is to be transferred 3 6
Other 7 15

Data were also provided on the remote encounter forms about what would have happened for each session had telehealth not been available. These data are shown in the table below. Of the 15 patients for whom transfer had been avoided through the use of telehealth, none were among the 31 in speech therapy. Transfer was avoided for six of seven patients in physical therapy and all patients in occupational therapy.

Fort Chipewyan: Type of consequences if telehealth had no been available
Type of consequences # of visits Proportion
(out of 47)
No rehab services 0  
Wait for rehab service to come to FC 31 66
Transfer patient out of Fort Chip 15 32
Other    

Televisitation sessions

The average number of family members and friends using televisitation per month, including those in the remote and community locations, was 17.5.

Technical performance

The number and proportions of rehabilitation sessions with each type of technical problem, according to the remote site data, are shown in the table below.

Fort Chipewyan: Technical problems
Type of Technical Problems # of sessions %
Establishing communication 2/47 4
Maintaining communication 8/47 17
Operating the camera 0/47 0
Sound quality 9/47 19
Visual quality 14/47 30
Other problems 3/47 6

According to key informants, any technical problems have generally been quickly resolved with help from the vendor's technical assistance desk. For both sites, progress would have been impossible without this support, as in-house technical staff would not have been able to provide it. The visual quality problems seem to be related to lighting control in the telehealth rooms, where windows have to be covered to lessen glare. The sound problems are sometimes related to inability to connect at the highest speed, which affects the capacity to achieve the quality of sound required for speech therapy.

Top of Page

Acceptability of telehealth to patients and communities

The key informant interviews found that telehealth in Fort Chipewyan is widely accepted in the community. It has been highly publicized, and according to key informants, community members are both generally aware of it and proud of its success in improving access to health services. The Board members, band management and elders interviewed are highly supportive of the initiative, and are very satisfied with its level of success in Fort Chip. Nursing station staff are committed to making it part of the regular services offered in the community, as well as to expansion to other areas. The project has also been recognized as a success story among telehealth initiatives, and the team has been asked to make presentations or attend meetings with several different groups interested in similar issues across the country.

Telerehabilitation

Fifteen patients who had received either occupational therapy or physical therapy completed patient satisfaction questionnaires, for which the data are summarized below in terms of numbers of dissatisfied patients. (Satisfaction questionnaires were not given to speech therapy clients because of time constraints: most of these clients are children who are taken out of school for their sessions.)

Fort Chipewyan: Number of dissatisfied rehabilitation patients (scores 0,1,2 together)
Questionnaire items # of responses
Voice quality 1/14
Visual quality 1/14
Personal comfort 1/14
Length of time to get an appointment 1/14
Ease of getting to telehealth department 0
Length of time with therapist or family member 0
Explanation of treatment by telehealth staff 2/15
Thoroughness, carefulness and skillfulness of telehealth staff 1/15
Courtesy, respect, sensitivity and friendliness of telehealth staff 0
How well telehealth staff respected your privacy 0
How well staff answered your questions about the equipment 0
Overall treatment experience at using telehealth 0

The rehabilitation staff in both the community and remote settings reported that telehealth is very well received by patients. Because the initial assessment occurs in Fort McMurray with the follow-up treatment in Fort Chip, patients are comfortable with the rehabilitation supervision when it occurs. Physical therapy staff reported that some patients are a little shy at the first session, especially about disrobing in front of the camera, but this shyness is overcome. According to key informants, three patients who had initially refused telerehabilitation later came to use the services. One patient's family refused, citing concerns about confidentiality issues.

The patients interviewed were very enthusiastic about the rehabilitation services they had received. It was clear that for them, the access to these services which telehealth had allowed was more salient to them than the technology itself: they were strongly appreciative of the quality of care they were receiving and of the supportive relationship with the rehabilitation assistants.

Televisitation

Forty-seven televisitation users completed satisfaction questionnaires. The number of dissatisfied users for each of the dimensions assessed is shown in the table below.

Fort Chipewyan Number of dissatisfied televisitation users (scores 0,1, and 2 together)
Questionnaire items # of responses
Voice quality 3/42
Visual quality 0
Personal comfort 3/44
Length of time to get an appointment 1/32
Ease of getting to telehealth department 0
Length of time with therapist or family member 0
Explanation of treatment by telehealth staff 0
Thoroughness, carefulness and skillfulness of telehealth 0
Courtesy, respect, sensitivity and friendliness of telehealth staff 0
How well telehealth staff respected your privacy 2/31
How well staff answered your questions about the equipment 3/30
Overall treatment experience at using telehealth 1/42

Televisitation users are also very happy with the service, according to both the remote and community televisitation coordinators. Initially, users have a tendency to think they are on live television and to speak as though being interviewed, but this is overcome with familiarity. In several cases, televisitation had allowed relatives to meet for one last time before a patient passed away. The patients interviewed who had used telehealth had found comfort and relief in seeing their hospitalized relative. Demand for televisitation sessions is lower in the winter, when road access to Fort McMurray is possible. According to community representatives, televisitation is an important service because it supports the community value of keeping family ties strong.

Quality of care delivered through telehealth

According to the remote rehabilitation staff, the quality of the telehealth-enabled rehabilitation care is excellent. Staff at both ends are comfortable in their roles, and are confident that the treatment plans are appropriate and well-delivered. In the case of uncertainty about a particular aspect of a patient's treatment, the rehabilitation assistants ask for guidance from the remote staff, which they are usually able to give within a relatively short response time. There is mutual trust and respect on both sides: rehabilitation assistants appreciate knowing that their interventions are supported, and the remote staff are confident that therapy is proceeding according to appropriate standards. Remote staff mentioned this as a critical success factor in the telehealth program, as they are responsible for patients under their care through telehealth.

According to the remote rehabilitation staff, the telehealth project has also resulted in more targeted and judicious use of their resources. Because of the involvement of the rehabilitation assistants in the decisions to transfer patients back to the remote centre, more informed decisions are made and patients are more likely to come back when they really need to and not just on a arbitrary date. Although the process is now more complicated to manage, this ensures that the best possible use of made of the patients' and providers' time.

Impacts on patient outcomes

According to the key informant interviews, telehealth in Fort Chipewyan has brought significant health benefits to patients. First, for speech therapy clients, telehealth has meant that they can receive regular therapy sessions twice per week, instead of once every several months. Their progress has advanced accordingly, with significant gains for many in their language. This progress is evident to all that the patients come in contact with. As many of these patients are young children, the preventive impact on their school performance and social integration may be enormous. The therapy may also have impacts on self-perception and self-esteem, risk factors for a host of social, psychological and behavioural problems: for example, the rehabilitation assistants reported a case of a 13 year- old girl who reported that because of the therapy, she was no longer being laughed at in school; her self-esteem and school performance had improved as a result.

In terms of physical and occupational therapy, impacts may be found on two levels. First, transfers out of the community tend to be hard on these patients. The discomforts of the travel sometimes worsen their condition and erase the benefits of the health visits. To the extent that receiving rehabilitation inside the community avoids those transfers, their heath outcomes are improved. This is especially marked for short sessions such as the fitting of orthotics. Second, the rehabilitation itself has positive effects on outcomes (or outcomes as positive as they would be if the patients were receiving care directly: for many of the chronic cases, benefits of rehabilitation are slow to accrue and difficult to assess, according to the rehabilitation specialists). According to the patients interviewed, the rehabilitation services received have benefited their health. One of the patients interviewed, a woman in her 70's, had recovered enough mobility through the rehabilitation program to be able to leave her house; she was looking forward to being able to walk to see her 92 year-old mother in the spring. This woman stated that without the program, she would have had to be going out to the McMurray hospital all the time, which she did not like to do. Another patient interviewed had seen significant relief from her condition, and said that before the rehabilitation program came, she had been doing no exercise at all.

Impacts on access to health within the community

According to all key informants interviewed, telehealth has unequivocally improved access to health within the community. The provision of rehabilitation services through the telehealth link has enabled patients who were receiving some services before to receive them more often, more regularly and with more professional support. It has also enabled some patients who were not receiving rehabilitation services before to access them: there have been no occupational therapy services in the community for 14 years.

Telehealth has also had important indirect benefits in terms of health access in the community. The very active role of the rehabilitation assistants in promoting not just telehealth but patient health has mobilized the community around the telehealth project. Moreover, support from band and nursing station management has mobilized community support. Effects related to this mobilization were noted at several levels, by several different key informants both within and outside the community. Most directly, the rehabilitation assistants have extended their roles within the community, offering for example a weekly exercise program for elders at the elders' lodge, and more generally becoming advocates and supports for patients who can be helped through their actions (for example, in securing donation of a computer for a handicapped man). At the level of the nursing station and community management, the success of the project has led to a strong sense of accomplishment and ownership of the project, which had helped develop capacity for undertaking health initiatives.

Top of Page

Organizational, administrative and human resource issues

A key factor in the success of this project has been the commitment and dedication of the staff involved, as well as their stability within the community. All those interviewed gave high praise to the individuals involved, stating that the project would not have achieved so much if not for their work.

During the negotiation phases of the project, some frustrations were experienced due to the perceived lack of timely responsiveness of the project officer appointed by Health Canada. This led, according to key informants interviewed, to delays and complications in the signing of the Memorandum of Understanding and the project start-up. Withdrawal of this officer was seen as a satisfactory result by all parties. As for the MOU itself, there were mixed views on its ultimate usefulness: the community management had not found it particularly useful, whereas the remote centre had referred to it a number of times to verify orientations and set policy direction.

During the initial phases of the project, the vendor was very actively involved in developing and documenting procedures to facilitate workflow and information transfer and storage. According to the remote and community interviewees, their role was invaluable in designing the procedural part of the telehealth system. With this assistance, it was felt that many operational problems were foreseen and avoided; it was also acknowledged that remote centre staff would not have had the time to fully develop these procedures without the vendor's support. According to the remote centre management, this support was especially important concerning the definition of professional roles and tasks within the system and the specification of procedures for dealing with patient information. A wish was expressed that resources be available to keep updating the service design manual produced by the vendor, in order to ensure that ongoing decisions and new policies, for example around appointment cancellations, were recorded. The model developed for the telehealth project may serve in other initiatives as well.

Since the project has been fully implemented, the main organizational issue that has arisen in the project is a direct result of the improved access to health it has generated: so much demand for services had been created that, given the capacity of the remote centre to perform assessments and initiate the therapy programs, waiting lists of up to several months are now a reality. This is particularly acute in physiotherapy, where the remote centre has experienced a staff shortage. Patients on the waiting list in the community are dissatisfied with this situation, as are both the community and remote staff. The waiting lists are a concern for quality of care, because of the overall benefit of intervening as early as possible in rehabilitation situations.

To ensure that services are being directed most appropriately, the remote and community rehabilitation and nursing staff have worked together to prioritize patients in the waiting list, so that when an opening occurs, it can be given to patients who can benefit most. However, this creates even longer waits for other patients. Some of these, according to the remote staff, have sought services in private clinics instead.

The remote providers of rehabilitation services in this initiative, although generally satisfied with their participation, noted that it has created a strong pressure to provide services to patients in Fort Chip, in part to contribute to a successful demonstration of the potential for telehealth and in part to develop their relationship with this First Nation community. Faced with staff turnover and shortages in their own institution, the Fort Chip project has significantly affected their workload. Moreover, because of general resource shortages, they feel that this pressure has negatively affected their ability to respond to the clienteles outside of Fort Chip who are also part of their mandate. In this context, missed or cancelled appointments have caused frustrations for the remote providers, as they are usually unable to replace the Fort Chip patients with patients from their waiting list because the notice provided has been too short. This reduces their overall productivity at a time when demands for increased productivity are high. In addition, the cost-sharing arrangement for the provision of services has not, in the view of the remote hospital administrators, been able to offset the considerable indirect costs associated with the telehealth services, including training and administration. It was estimated that the true costs are approximately double the current allocation. However, the community administrators estimate that from their end, the project has come very close to its budget.

Scheduling the sessions has created additional secretarial workload in the remote centre, related not only to the patients and providers but also the scheduling of the different rooms in which the equipment may be used.

Both the remote and community providers feel that more resources would benefit response to community need for rehabilitation services. According to community staff and management, more resources for speech therapy would free up time to develop occupational and physical therapy. In addition, the physical arrangements of the current rooms are not completely adequate, as some forms of therapy require large pieces of equipment in the room. As well, the original budget did not foresee the cost of renewing supplies associated with therapy, nor for the costs of meetings and presentations which have turned out to be quite numerous. The amount allocated to the rehabilitation assistants for patient transport is also felt by them to be inadequate. In the remote centre, more resources are needed to overcome the backlog of cases requiring assessments.

Linkages within provincial health systems

Links to the regional health organization

As a results of this project, stronger links, based on the development of rapport and trust, have grown between the regional nursing station and the Fort Chip community. Both parties feel that this new relationship is mutually beneficial. However, the current bottleneck and waiting list situation is difficult for both parties to deal with.

Links to the provincial telehealth program

In Alberta, a major provincial telehealth initiative called Alberta Wellnet supports the development of telehealth throughout the province, including making funds available to each regional health authority to initiate telehealth services. Although each health authority is autonomous in its choice of telehealth applications, interoperability is ensured by the provision of guidelines from the provincial coordinating body. The vendor selected for the Fort Chip project is among those most strongly recommended by Wellnet, and the Fort Chip site is fully included as a member of the provincial telehealth network.

Although prior to the Fort Chip project, the Northern Lights Health Authority had not yet become involved in the provincial initiative, it is currently on the brink of doing so - a possible result, according to provincial officials interviewed, of the stimulation provided by the Fort Chip project.

Alberta Wellnet also coordinates access to a program of continuing professional education, in which rehabilitation and other nursing station staff have recently begun to participate. This program is seen as offering many potential benefits in terms of professional and personal development and, according to nursing station managers, may facilitate retention of workers in the community. The remote center staff also expressed interest in participating in these programs.

Cost effectiveness

The issue of cost-effectiveness is difficult to address in the Fort Chip telehealth project, because its main impact has been to generate significant levels of care and demand for care, which in turn of course increase costs to the overall system despite the reduction in costs of patient transfers. From the community's perspective, the benefits of telerehabilitation resemble those of in primary prevention: they will be seen in long-term outcomes such as improved school achievement, leading to improved productive capacity and fewer health and social problems for children in speech therapy, as well as longer-term autonomy maintenance and improved quality of life for the elderly. Because the greatest benefits of telehealth in the community seem to be occurring among these populations, immediate impact on standard economic benefits such as days lost from work due to disability are less relevant. However, this situation may change as the number of patients in physical and occupational therapy increases, relative to the number in speech therapy. In general, health system managers interviewed about the Fort Chip initiative felt that a long-term time horizon, from a health rather than a financial perspective, would be needed to adequately capture cost-effectiveness.

Sustainability

The telehealth initiative in Fort Chip is very likely to be sustained: it has significant support from within the community, from the nursing station management, from the band administration, as well as from the relevant provincial and federal agency representatives. Many new uses for the equipment have become apparent, and there is great interest in developing further applications to respond to the community's health needs. Those mentioned included telecounselling and telepsychiatry, especially for children, remedial education, vision screening in diabetes, genetic counselling, teledermatology, teleradiology, and teleconsultations in general care. According to those interviewed, plans are being developed to seek funding for continued rehabilitation services, as well expansion into the provincial diabetes program and perhaps other areas. Sustainability within the community's health services will also be ensured by developing staff capacities for telehealth, so that all are able to use the systems and there are backup resources available.

Top of Page

Findings across communities: Lessons learned

In this chapter, results from all four case studies are considered in light of what they reveal about the evaluation questions, as well as critical success factors and main lessons learned for implementing telehealth in remote First Nations communities.

1. Evaluation questions

Access to needed, quality care

To what extent do the telehealth applications respond to community needs, as defined by the needs assessments?

In general, the telehealth applications implemented in the project responded to community needs, although this was clearer in some sites than others. At issue are not only the definition of the needs, but also how the technology and organizational arrangements for using it can respond to needs. For example, telehealth can be used to address the issue of diabetes within a community in a number of ways, with some being more easily integrated than others.

To what extent do patients and families find each telehealth application acceptable?

It seems overwhelmingly clear that once initial reticences are overcome with a positive experience, telehealth is acceptable to the vast majority of patients and families who use it. Over 90% of patients in all the communities were satisfied with most aspects of their telehealth experience, and between 75% and 100% of telehealth patients said they would use it again. This is consistent with findings in the research literature. In addition, although the evaluation design did not permit assessment of the views of those patients who did not use the system, refusals to use the system were infrequent. It should be noted however, that the quality of many patients' experience with telehealth is a function of the quality of the care provided by nursing station staff and the relationships they have with them; when telehealth provides a new service, what is most salient to many patients is not the new technology but the new relationship and the new care received.

To what extent has telehealth improved access to needed, quality care?

The extent to which telehealth has improved access to needed care in the community depends on the extent to which it was used and integrated into ongoing health service delivery. When usage and integration were higher, telehealth certainly improved access to care within the community. Moreover, the quality of care provided was, insofar as can be estimated by this study, of quality equivalent or better to standard care. These findings are consistent with the research literature examined.

To what extent are services provided through telehealth consistent with established means of improving patient health outcomes?

Insofar as can be assessed in this study, services provided through telehealth are consistent with established means of improving patients' outcomes. In the views of the health professionals consulted, in no case was telehealth seen as inconsistent with established professional practice guidelines. Moreover, data from the encounter forms suggest that educational interventions delivered through telehealth to patients were generally consistent with established patient education guidelines, although some aspects were addressed more frequently than others.

Health services delivery

To what extent has telehealth use been organized successfully?

The successful organization of telehealth usage in this project varied among the communities, according to a number of factors. Key among these were the stability of staff during the implementation period and the quality of the relationships established with the remote provider sites. Stable, committed staff in the nursing station was a key success factor for effective implementation of telehealth in these communities. This is a problem that was not identified in the research literature, and may be more specific to isolated, Northern communities.

To what extent have the professional skills and competencies required for telehealth been identified and successfully addressed through training?

The main issue with respect to the development of professional competencies for telehealth through training was the constant need to provide training to new staff members due to turnover. The adequacy of training received was also a function of the user-friendliness of the technologies involved. Training received for the interactive video-based systems was generally felt to be adequate partly because the systems were very easy to use; this was not the case for the store-and-forward system.

To what extent are telehealth applications used by eligible patients in the community?

It is not really possible for this evaluation to answer this question adequately, as we have little information on the numbers of eligible patients (those with the health conditions which would make them candidates for using the available applications) who did or did not use telehealth during the study period. In some cases, it is clear that only a small fraction of eligible patients used the systems; while in others, the identification of new patents with health needs that had never before been addressed as a result of the implementation of telehealth suggest a high level of penetration. In addition, because of the lack of participating specialist in the remote sites, penetration as not as strong as it could have been.

To what extent does telehealth improve competencies and confidence of local health personnel?

In all communities, the implementation of telehealth brought new competencies to local health personnel, and in all cases, these were widely welcomed. Telehealth was seen as greatly improving access to outside expertise, reducing feelings of professional isolation, increasing confidence in judgments and improving the quality of patient care decisions made about cases in conjunction with remote experts. These results confirm those of existing studies in the area of tele-education for remote personnel.

How does telehealth affect staff workload, task allocation and professional practices?

When telehealth coordination responsibilities were assigned to a nurse within the nursing station who also had patient care duties, workload demand slowed full implementation. There were therefore advantages to assigning these to a separate individual, although it seems preferred that this person have some medical qualifications in order facilitate communication with remote providers. Other impacts on task allocation seemed limited, perhaps due to the only partial integration of telehealth into some of the community's practices. To the extent that nursing station staff participate in continuing professional education through telehealth, their practice scope and quality may be improved.

In terms of workload and practice shifts for remote providers, the overall pattern of responses would suggest that telehealth decreases efficiency. The appointments themselves are longer because of set-up time and perhaps increased attention to patients. The rate of no-shows also reduces efficiency and productivity for tertiary providers. While in many cases this has not been an issue so far because of the pilot nature of the project, there are several indications in our data that institutionalization of telehealth will require attention to ensuring adequate compensation to remote partners to compensate for the loss of productivity - a critical issue because of scarce resources in general.

To what extent does telehealth result in cost increases, decreases or shifts for health service delivery within the communities?

Overall, the pattern of results obtained in this evaluation suggest that the net effect of telehealth is generate greater access to care, and therefore more care, and therefore more costs. The increases are seen both in the numbers of patients receiving services -- services are now available where none were before - and in the intensity of services delivered - patients, especially in some applications, are seen more frequently and regularly using telehealth than they had been before. The increases in care provided are accompanied by increased indirect costs, over and above provider remuneration and telecommunications cost, in terms of auxiliary equipment supplies and maintenance, patient supplies and within-community patient transportation costs. In addition, some of our data suggest that telehealth sessions take longer than equivalent in-person sessions, thus reducing efficiency.

In terms of avoidance of patient transfers and their associated costs, the results over all the studies converge to suggest that telehealth will result in avoided transfers in about 30% of patient care utilizations. This is somewhat less than the rates that can be estimated from the few studies available in the literature, but not a striking difference. As a proportion of total telehealth utilization within a community, this rate will depend on the balance between patient care and other types of applications that the system is used for, notably continuing professional or community education. That is, the more a community uses its telehealth system for non-patient-care applications, the less of its telehealth utilization will result in patient transfers. In addition, avoiding transfers seems to be more appealing to patients whose lives or health are most disrupted by leaving the community - elders and families with young children --, and least appealing to those patients who are less inconvenienced by transfers and are in fact, convenienced by them. When a community chooses applications that are concentrated on these two extreme age groups, the proportion of transfers avoided out of all utilizations may be expected to be higher than when a community chooses applications for health problems that affect its population throughout the life span.

Some displacement toward the private sector was observed in one of the sites, where the increase in access to care generated waiting lists.

What is the level of technical success of the platforms, applications and suppliers in the implementing communities?

All communities experienced at least occasional technical problems, but these were resolved with adequate technical assistance in all but one community. In general, the interactive video platforms were found to be reliable and easy to use, although with occasional visual and sound quality limitations, depending on the application. Support provided by the three suppliers involved ranged from excellent to less than satisfactory, and was a critical success factor in telehealth deployment.

Linkages among health resources

To what extent is telehealth appropriated, integrated and sustained as a part of the community's self-governed health care system?

The extent to which telehealth was appropriated and integrated and will be sustained varied greatly from community to community in this project. In one community, appropriation and integration have exceeded both the community's and its partners' expectations, and sustainability and expansion of the initiative are almost certain. In the others, varying degrees of integration were associated with varying levels of community mobilization and support, stability within the community's health resources during the study period, technical success, and support provided by both existing telehealth initiatives and by the vendor.

To what extent have the telehealth applications become linked and integrated to provincial initiatives?

In those provinces where provincial initiatives exist, the First Nations communities in this project became linked with them according to their resources. Interoperability was not a barrier in any of these sites. These links provided access to a larger community of telehealth users and a broad support and development system, from which those communities benefited. The existence of such provincial networks and their capacity to bring the project communities into their fold was a critical success factor in the telehealth initiatives.

To what extent does telehealth improve access of secondary, tertiary and education providers to local health service providers?

Access of education providers to the communities was improved when there was an existing provincial network coordinating educational opportunities for network members, publicizing its activities, and in some cases covering the costs of the telecommunications links into the services.

To what extent does telehealth improve health service providers' awareness and knowledge of local conditions and resources?

In several cases, remote providers did maintain that the relationship created through the telehealth initiative had improved their awareness and knowledge of local conditions and resources, as well as challenges faced by the communities. This has led to increased sensitivity on the part of remote health service providers to the special situations of First Nations communities, as well as to relationships based on mutual trust and respect.

Top of Page

2. Cost consequences analysis

The cost-consequences methodology for assessing the cost-effectiveness of telehealth proposed by McIntosh & Cairns (McIntosh, E., Cairns, J. (1997). A framework for the economic evaluation of telemedicine. Journal of Telemedicine and Telecare, 3, 132-139.) is used below to provide an initial assessment of the potential cost-effectiveness of telehealth. While primarily qualitative, this methodology allows inclusion of the many intangible consequences of telehealth in the consideration of cost-effectiveness. Because of the low uptake levels in some sites, it should not be used at the community level.

The consequences and cost entries in the matrix were identified by reviewing all interview data from the evaluation, across all participating communities.

Cost-consequence matrix

Health consequences

  • Consequence of telehealth: More frequent care for chronic conditions, better progress/management
    Reduces costs (to: ):
    Little difference in costs:
    Generates costs (for: ): SELECTED (community and remote health service providers)
  • Consequence of telehealth: More timely care, decreased wait times
    Reduces costs (to: ):
    Little difference in costs: SELECTED
    Generates costs (for: ):
  • Consequence of telehealth: More effective screening into appropriate care streams
    Reduces costs (to: ):
    Little difference in costs:
    Generates costs (for: ): SELECTED (community and remote health service providers)
  • Consequence of telehealth: Access to new types of services
    Reduces costs (to: ):
    Little difference in costs:
    Generates costs (for: ): SELECTED (community and remote health service providers)
  • Consequence of telehealth: Prevention of morbidity and disability
    Reduces costs (to: ): SELECTED (community health services: long term)
    Little difference in costs:
    Generates costs (for: ):
  • Consequence of telehealth: Increase in patient knowledge and healthy lifestyle
    Reduces costs (to: ): SELECTED (community and remote health service providers)
    Little difference in costs:
    Generates costs (for: ):
  • Consequence of telehealth: Reduced health risk from travel
    Reduces costs (to: ): SELECTED (community and remote health service providers)
    Little difference in costs:
    Generates costs (for: ):
  • Consequence of telehealth: Prevention of loss of autonomy
    Reduces costs (to: ): SELECTED (community service providers, family: long term)
    Little difference in costs:
    Generates costs (for: ):
  • Consequence of telehealth: Improved attention from specialists
    Reduces costs (to: ): SELECTED (community and remote health service providers)
    Little difference in costs:
    Generates costs (for: ):
  • Consequence of telehealth: Better understanding by local staff of how to manage patient
    Reduces costs (to: ): SELECTED (community and remote health service providers)
    Little difference in costs:
    Generates costs (for: ):
  • Consequence of telehealth: Creation of unmet demand for service, increased wait time, condition degradation
    Reduces costs (to: ):
    Little difference in costs:
    Generates costs (for: ): SELECTED (community and remote health service providers)

Non-health consequences

  • Consequence of telehealth: Less travel
    Reduces costs (to: ): SELECTED (patients, community, FNIHB )
    Little difference in costs:
    Generates costs (for: ):
  • Consequence of telehealth: Decreased anxiety due to shorter wait, visitation
    Reduces costs (to: ):
    Little difference in costs: SELECTED
    Generates costs (for: ):
  • Consequence of telehealth: Improved access to outside expertise
    Reduces costs (to: ):
    Little difference in costs:
    Generates costs (for: ): SELECTED (community and remote health service providers)
  • Consequence of telehealth: Staff education and development/ improved competencies
    Reduces costs (to: ): SELECTED (community and remote health service providers)
    Little difference in costs:
    Generates costs (for: ):
  • Consequence of telehealth: Staff retention
    Reduces costs (to: ): SELECTED (comunity health service providers)
    Little difference in costs:
    Generates costs (for: ):
  • Consequence of telehealth: Closer relationships with remote providers/organizations
    Reduces costs (to: ):
    Little difference in costs: SELECTED
    Generates costs (for: ):
  • Consequence of telehealth: More judicious use of resources
    Reduces costs (to: ): SELECTED (community and remote health service providers)
    Little difference in costs:
    Generates costs (for: ):
  • Consequence of telehealth: Training need
    Reduces costs (to: ):
    Little difference in costs:
    Generates costs (for: ): SELECTED (community health service providers, local and remote telehealth staff)
  • Consequence of telehealth: Additional time per patient
    Reduces costs (to: ):
    Little difference in costs:
    Generates costs (for: ): SELECTED (community and remote health service providers)
  • Consequence of telehealth: Need for practice protocols
    Reduces costs (to: ):
    Little difference in costs:
    Generates costs (for: ): SELECTED (community and remote health service providers)
  • Consequence of telehealth: Scheduling systems
    Reduces costs (to: ):
    Little difference in costs:
    Generates costs (for: ): SELECTED (community and remote health service providers)
  • Consequence of telehealth: Duplicate records coordination and management
    Reduces costs (to: ):
    Little difference in costs:
    Generates costs (for: ): SELECTED (community and remote health service providers)
  • Consequence of telehealth: Loss of efficiency due to non replaceable missed appointments
    Reduces costs (to: ):
    Little difference in costs:
    Generates costs (for: ): SELECTED (community and remote health service providers)
  • Consequence of telehealth: Development of community capacity to take on major health initiatives
    Reduces costs (to: ):
    Little difference in costs: SELECTED
    Generates costs (for: ):

These qualitative findings suggest that, in the short term for the isolated Northern communities, telehealth generates more costs than it reduces. Its main cost reducing benefit will be seen as some proportion of travel reduced, but more importantly, in terms of the prevention of morbidity and disability, as long-term savings for communities because of their healthier populations.

Top of Page

3. Main lessons learned for future telehealth development in remote First Nations communities

Telehealth is about people, not technology

The experience gained in this project showed that telehealth, when successfully implemented, is merely technology used to enhance a human service or an adjunct tool which can become available as part of a range of services. Its successful implementation in communities and in links to remote providers, as well as its acceptance by patients and families, depends to a very large extent on the commitment and capacity of individual people in the community to make it happen, in service to the community. Implementation of telehealth in this pilot project was thus facilitated to the extent that such individuals were present and involved throughout the study period; in future implementations, it would be advisable to ensure, insofar as can be predicted, that such people will be available to support and nurture them.

Telehealth needs to be founded on and build good relationships

Telehealth needs to be founded on and build relationships, involving trust, commitment and mutual respect. This applies at a number of levels:

  • First, patients must have a trusting relationship with their local providers; this will facilitate their initiation into using telehealth.
  • Second, especially in the case of chronic health conditions, patients must be able to develop rapport and trust with the remote providers they deal with through telehealth. These relationships are facilitated when remote providers are able to visit the community and meet patients and local providers in person.
  • Third, local and remote practitioners must be able work together well, as they are dependent on each others' professional judgment to ensure that their mutual responsibility for patient care can be upheld through each others' actions. The development of relationships founded on trust and mutual respect is key to ensuring that the remote-community provider link can be successfully maintained. The development of a cohesive inter-site team, through opportunities for interactions and discussion, can facilitate the relationship-building process. In this context, real-time technologies and applications are advantaged over store-and forward arrangements.
  • In another more literal sense, successful implementation of telehealth requires good local-remote relationships: one of the limitations experienced by these communities was lack of willing remote specialists to provide services, and in one case, the lack of perseverance of a specialist due to unfavorable financial conditions associated with telehealth. Simply put, there can be no telehealth in First Nations communities if there are no providers at the other end. Locating those providers and developing and maintaining relationships with them is both a prerequisite for successful implementation and a challenge given their scarcity and therefore their expectations of practice conditions which best suit their requirements.
  • The organizations and agencies involved must also be able to develop relationships based on mutual respect of mandates and capacities, and trust each other to be able to work in their mutual best interests and those of their mutual patients. These relationships can be challenging, as they involve resource issues in times of constraints and fragility in most provincial health systems, as well as within the contexts of transfers of health management to First Nations communities. However, the development of these relationships will be key to ensuring that when the inevitable operational difficulties do arise, that the parties will be able to work them out satisfactorily.
  • Finally, the overall context of the relationships between Health Canada-FNHIB and participating communities is also a backdrop to successful implementations; requiring a foundation of trust based on transparency and flexibility as a basis for project development.

Appropriation is a long, organic process : you have to grow it

Although it may seem a misplaced metaphor, our impression of the communities' processes of bringing telehealth into their communities and working to ensure that they become part of the health care system was more organic than technological. Like a plant slowly taking root in a new environment, appropriation by the community was facilitated by stable local conditions, without political or organizations storms; it was facilitated by the fertilizer provided by the injection of support and resources from outside, most notably the provincial telehealth initiatives and vendors; it is was more easily accomplished in the fertile soil of communities who had already become prepared for and mobilized toward telehealth. Sustainable growth cannot be expected to happen overnight, and it must be nurtured and protected in its vulnerable early phases. However, once established, the telehealth plant can sprout in all sorts of new direction, providing unexpected benefits for patients and communities.

Telehealth generates care, so it generates costs

As stated in the previous sections, the net effect of telehealth is to generate care and therefore costs, as least in the short to medium term. In the long term, its effects in terms of prevention, quality of care, and community development may offset the initial capital and organizational costs, but this is not a reasonable expectation in the short term in most communities.

Telehealth is vulnerable to existing instabilities in First Nations health services

If we step back and examine the overall picture that emerges about implementing telehealth in these communities, the single most important contributor to success was the presence of stable and committed staff throughout the implementation period. Staff turnover in Northern communities has a high background rate to start with; the implementation period for this initiative coincided with periods of additional instability in some communities. While telehealth is sometimes seen and promoted as a way of compensating for the difficulties that northern communities have in accessing stable sources of quality care, it is clear from this study that telehealth will be just as subject as any other form of care provided through the community, to the forces which produce frequent turnover among nursing station staff. Operating an effective telehealth service requires a long-term organizational and staff commitment, a stable care environment, and conditions to support continuity of care. Telehealth cannot directly address a main existing problem in First Nations health services: the lack of permanent local capacity, and the resulting reliance on external staff with the resulting discontinuities. However, its successful deployment will respond to improvements in these areas, and will be more certain to succeed in communities which have been able to more effectively address these issues.

Conclusion

Overall, the results of this evaluation showed that telehealth can be successfully implemented in isolated First Nations communities, bringing with it access to needed, quality care; stronger relationships with external health providers; and greater community capacity to undertake such major health initiatives. In the long term, telehealth can therefore potentially improve health of community members and health service infrastructure within communities. However, successful implementation requires several important conditions at the community level, in terms of nursing station stability and community mobilization, as well as good connections with remote providers in relevant health domains and with provincial telehealth systems and effective technology and supports.

References

Cardiology

Afset JE, Lunde P, Rasmussen K. Accuracy of routine echocardiographic measurements made by an inexperienced examiner through tele-instruction. Journal of Telemedicine and Telecare 1996;2(3):148-54.

Casey F, Brown D, Corrigan N et al. Value of a low-cost telemedicine link in the remote echocardiographic diagnosis of congenital heart defects. Journal of Telemedicine and Telecare 1998 A27; 4 Suppl 1 :46-8.

De Lusignan S, Meredith K, Wells S et al. A controlled pilot study in the use of telemedicine in the community on the management of heart failure. The impact of Telemedicine on Health Care Management. Eds. M. Nerlich and R. Kretshmer. IOS Press, 1997:126-137.

Shanit D, Cheng A and Greenbaum RA. Telecardiology : supporting the decision-making process in general practice. Journal of Telemedicine and Telecare 1996; 2(1) :7-13.

Continuing Medical Education

Burge EJ, Smythe CL, Roberts JM et al. The audioconference: delivering continuing education for addictions workers in Canada. Journal of Alcohol and Drug Education 1993; 39(1):78-91.

Demartines N, Mutter D, Vix M et al. Assessment of telemedicine in surgical education and patient care. Ann Surg 2000;231(2):282-91.

Gammon D, Sorlie T, Bergvik S, Hoifodt TS. Psychotherapy supervision conducted by videoconferencing: a qualitative study of users' experiences. J Telemed Telecare 1998;4 Suppl 1:33-5.

Gul YA, Wan AC, Darzi A. Undergraduate surgical teaching utilizing telemedicine. Med Educ 1999;33(8):596-9.

Hays RB and Peterson L. Options in education for advanced trainees in isolated general practice. Australian Family Physician 1996 Mar; 25(3):362-6.

Sawada I; Sugiyama A; Ishikawa A et al. Upgrading rural Japanese nurses' respiratory rehabilitation skills through videoconferencing. Journal of telemedicine and telecare 2000; 6 Suppl 2:69-71.

Screnci D, Hirsch E, Levy K et al. Medical outreach to Armenia by telemedicine linkage. Journal of Medical Systems 1996; 20(2):67-76.

Dermatology

Gilmour E, Campbell S, Loane M et al. Comparison of teleconsultations and face-to-face consultations: preliminary results of a United Kingdom multicentre teledermatology study. British Journal of Dermatology 1998 Jul; 139(1):81-7.

Lamminen H, Tuomi ML, Lamminen J. A feasibility study of realtime teledermatology in Finland. Journal of telemedicine and telecare 2000; 6 (2):102-7.

Loane MA, Bloomer SE, Corbett R et al. Patient satisfaction with realtime teledermatology in Northern Ireland. Journal of Telemedicine and Telecare 1998 J15; 4(1):36-40.

Loane MA, Corbett R, Bloomer SE et al. Diagnostic accuracy and clinical management by realtime teledermatology. Results from the Northern Ireland arms of the UK Multicentre Teledermatology Trial. J Telemed Telecare 1998;4(2):95-100.

Lowitt MH, Kessler II, Kauffman CL, et al. Teledermatology and in-person examinations: a comparison of patient and physician perceptions and diagnostic agreement. Archives of dermatology 1998;134 (4):471-6.

Oakley AM. et al. Practising dermatology via telemedicine. New Zealand Medical Journal 1998 J15; 111(1071):296-9.

Oakley AM, Astwood DR, Loane M, et al. Diagnostic accuracy of teledermatology: results of a preliminary study in New Zealand. New Zealand Medical Journal 1997 Feb 28; 110(1038):51-3.

Perednia DA, Wallace J, Morrisey M et al. The effect of a teledermatology program on rural referral patterns to dermatologists and the management of skin disease. Medinfo 1998; 9 Pt 1:290-3.

Phillips CM, Burke W, Allen M et al. Reliability of telemedicine in evaluating skin tumors. Telemedicine Journal 1998; 4(1):5-9.

Wootton R, Bloomer SE, Corbett R et al. Multicentre randomised control trial comparing real time teledermatology with conventional outpatient dermatological care: societal cost-benefit analysis. BMJ 2000;320(7244):1252-6.

Diabetes Management

Albisser MA, Harris RI, Sakkal S, et al. Diabetes intervention in the information age. Med Inf 1996; 21(4):297-316.

Brown S. Studies of educational interventions and outcomes in diabetic adults: a meta-analysis revisited. Patient Education and Counseling 1990; 16:189.

Mitchell BR et al.. User adoption issues in renal telemedicine. Journal of Telemedicine and Telecare 1996; 2(2):81-6.

Montani S, Bellazzi R, Larizza C et al. Protocol-based reasoning in diabetic patient management. International Journal of Medical Informatics 1999; 53(1):61-77.

Piette JD, Mah Connie. The feasibility of automated voice messaging as an adjunct to diabetes outpatient care. Diabetes Care 1997 Jan; 20(1) :15-21.

Shultz EK, Bauman A, Hayward M et al. Improved care of patients with diabetes through teleocmmunications. Annals of the New York Academy of Sciences 1992; 670:141-145.

Thompson DM, Kozak SE, Sheps S. Insulin adjustment by a diabetes nurse educator improves glucose control in insulin-requiring diabetic patients: a randomized trial. CMAJ 1999; 161(8):959-62.

ENT

Furukawa M, Furukawa MK, Mizojiri G et al. Telemedicine in laryngology. Telemedicine Journal 1998; 4(4):329-33.

Pedersen S, Holand U. Tele-endoscopic otorhinoloaryngological examination: preliminary study of patient satisfaction. Telemedicine Journal 1995; 1:47-52.

Pedersen W, Hartviksen G, Haga D. Teleconsultation of patients with otorhinolaryngologic conditions. Arch Otolaryngol Head Neck Surg 1994; 120: 133-6.

Stern J, Heneghan C, Sclafani A et al Telemedicine applications in otolaryngology. Journal of Telemedicine and Telecare 1998; 4 Suppl 1:74-5.

Mental Health/ Counselling

Callahan EJ. Hilty DM. Nesbitt TS. Patient satisfaction with telemedicine consultation in primary care: comparison of ratings of medical and mental health applications. Telemedicine Journal 1998 Winter; 4(4):363-9.

Clarke PHJ. A referrer and patient evaluation of a telepsychiatry consultation-liaison service in South Australia. J Telemed Telecare 1997; 3(suppl 1):14.

Doze S and Simpson J. Telepsychiatry : Pilot Project evaluation. Alberta Provincial Mental Health Advisory Board 1998.

Doze S, Simpson J, Hailey D et al. Evaluation of a telepsychiatry pilot project. Journal of Telemedicine and Telecare 1999; 5:38-46.

Gammon D, Bergvik S, Bergmo T et al. Videoconferencing in psychiatry: a survey of use in northern Norway. Journal of Telemedicine and Telecare 1996; 2(4):192-8.

Kennedy C, Yellowlees P. A community-based approach to evaluation of health outcomes and costs for telepsychiatry in a rural population: preliminary results. Journal of telemedicine and telecare 2000; 6 Suppl 1 pS155-7.

McLaren PM, Laws VJ, Ferreira Ac et al. Telepsychiatry: outpatient psychiatry by videolink. J Telemed Telecare 1996;2(suppl 1):59-62.

Mielonen ML, Ohinmaa A, Moring J, Isohanni M. Psychiatric inpatient care planning via telemedicine. J Telemed Telecare 2000;6(3):152-7.

Montani C, Billaud N, Tyrrell J et al. Psychological impact of a remote psychometric consultation with hospitalized elderly people. Journal of Telemedicine and Telecare 1997; 3(3):140-5.

Ruskin P, Reed S, Kumar R et al. Reliability and acceptability of psychiatric diagnosis via telecommunication and audiovisual technology. Psychiatric Services 1998 Aug; 49(8):1086-8.

Urness D. Evaluation of a Canadian Telepsychiatry Service. The Impact of Telemedicine on Health Care Management. Eds. M. Nerlich and R. Kretschmer. IOS Press, 1999:262-269.

Zarate C, Weinstock L, Cukor P et al. Applicability of Telemedicine for Assessing Patients with Schizophrenia: Acceptance and Reliability. J Clinical Psychiatry 1997; 58:22-25.

Zaylor C. Clinical outcomes in telepsychiatry. Journal of telemedicine and telecare 1999; 5 Suppl 1:S59-60.

Neo/Post-natal and Pediatric Assessment

Blackmon LA, Kaak HO, Ranseen J. Consumer satisfaction with telemedicine child psychiatry consultation in rural Kentucky. Psychiatric Services 1997; 48(11):1464-6.

Dick PT, Filler R, Pavan A. Participant satisfaction and comfort with multidisciplinary pediatric telemedicine consultations. Journal of Pediatric Surgery 1999;34(1):137-41.

Finley JP, Sharratt GP, Nanton MA et al. Pediatric echocardiography by telemedicine - nine years' experience. Journal of Telemedicine and Telecare 1997; 3(4) :200-4.

Mulholland HC, Casey F, Brown D et al. Application of a low cost telemedicine link to the diagnosis of neonatal congenital heart defects by remote consultation. Heart 1999; 82(2):217-21.

Rendina M, Carrasco N. Neonatal telecardiology shows cost benefits. Telehealth Magazine June 1999: 24-27.

Vincent JA Et al. Diagnostic and cost effectiveness of telemonitoring the pediatric pacemaker patient. Pediatric Cardiology 1997 Mar-Apr; 18(2) :86-90.

Rehabilitation

Burns R, Crislip D, Daviou P et al. Using Telerehabilitation to Support Assistive Technology. Assistive Technology 1998; 10 (2):126-133.

Couturier P, Tyrrell J, Tonetti J et al. Feasibility of orthopaedic teleconsulting in a geriatric rehabilitation service. Journal of Telemedicine and Telecare 1998; 4 Suppl 1:85-7.

Lemaire ED, Jeffreys Y. Low-bandwidth telemedicine for remote orthotic assessment. Prosthetics and orthotics international 1998; 22 (2):155-67.

Sparks KE et al. Alternatives for cardiac rehabilitations patients unable to return to a hospital-based program. Heart and Lung. July/Aug:298-303.

Temkin A, Vesmarovich S, Burns R. Following patients at home through telemedicine. SCI Psychosocial Process, 11(2), 7-9.

Top of Page

Help on accessing alternative formats, such as Portable Document Format (PDF), Microsoft Word and PowerPoint (PPT) files, can be obtained in the alternate format help section.

Portable Document Format(PDF Version - 46 K)

Attachment 1: Consent Forms

Berens River Telehealth Consent Form

1. Purpose and Description

The purpose of this project is to obtain information about the use of telehealth technology in supporting and enhancing the care that patients in Berens River receive and in increasing the health care choices available to them. The telehealth system uses the television to let you/your child talk to a specialist doctor or a health educator in Winnipeg on a television set.

If you agree the nursing station staff will fill out a form about you/your child's visits. You/your child might be asked to fill out a questionnaire to let us know how the telehealth session went.

All the information will be sent to a research team at McGill University in Québec who will compile the questionnaires for this project.

2. Confidentiality

Your name/your child's name will not be put on any of the questionnaires. No one will have access to any information about your health status or your use of the telehealth system.

3. Benefits

You/your child may be able to see the doctor or health educator sooner.

You/your child's followup treatments could be done at the Nursing Station.

You/your child might not have to travel to Winnipeg for treatment as often.

If the telehealth equipment is useful, it will stay in your community at the end of the project.

4. Risks and Discomfort

The doctor or health educator might not be able to see or hear you/your child as well as usual. This might make him or her miss something about your/your child's health problem. It might make him want to do more tests.

It is possible that the tests or treatment that you/your child needs will require you to travel to Winnipeg anyway.

You may feel that it is not as private as seeing the doctor or health educator in person.

5. Voluntariness

You/your child do not have to participate in this study.

If you don't, you/your child will receive the same care that you/your child would have received if we did not have this equipment, and you/your child will be able to see the same specialists as usual.

You/your child have the right to stop participating at any time.

You/your child can use the telehealth system without having the forms or questionnaires filled out.

6. Contact Persons

Your telehealth contact person here in Berens River is Joephine Berens. . You can reach her at: 204-382-2366.

This study has been explained to me.
I agree to participate:

Yes No I agree to use/let my child use the telehealth system.

Yes No I agree to have the forms filled out.

Signature: Date:
(Client/Parent/Legal guardian)

Signature: Date:
(Health staff member)

Name of translator:

Fort Chipewyan Telehealth Consent Form

1. Purpose

The purpose of this project is to obtain information about the use of telehealth technology in improving communication and community access to Tele-rehabilitation, Tele-visitation and Tele-spirituality in a timely and cost-effective manner.

2. Description

The telehealth system uses the television to let you/your child talk to the Service Provider, family member or friend in For McMurray on a television set. The session might be video-taped.

If you agree the nursing station staff will fill out a form about you/your child's visits. You/your child might be asked to fill out a questionnaire to let us know how the telehealth session went.

All the information will be sent to a research team at McGill University in Québec who will compile the questionnaires for this project. Your name/your child's name will not be put on any of the questionnaires.

3. Benefits and Risks

You/your child may be able to see the Service provider, family member or friend sooner.

You/your child's follow-up treatments could be done at the Nursing Station.

You/your child might not have to travel to Fort McMurray for treatment as often.

If the telehealth equipment is useful, it will stay in our community at the end of the project.

You may feel that it is not as private as seeing the Service provider, family member or friend in person.

4. Voluntariness

You/your child do not have to participate in this study.

If you don't, you/your child will receive the same care that you/your child would have received if we did not have this equipment.

You/your child have the right to stop participating at any time.

You/your child can use the telehealth system without having the forms or questionnaires filled out.

5. Contact Persons

Your contact persons here in Fort Chipewyan can be reached at 697-3091.

Cookie Simpson - Telehealth Coordinator/ Tammy Buchanan - Rehabilitation Assistant:

This study has been explained to me.
I agree to participate:

Signature:   Date:
  (Client/Parent/Legal guardian)

Signature:   Date:
(Telehealth/Telerehab assistant)

Name of translator:

La Romaine Telehealth Consent Form

1. Purpose and Description

The purpose of this project is to obtain information about the use of telehealth technology in improving communications and community access to specialized care in the fields of diabetes, cardiology and otorhinolaryngology in a timely and cost-effective manner.

The telehealth system uses computer and communications technology to transmit images to Sept-Îles or Quebec City, in order to obtain diagnoses.

If you agree, the nursing station staff will fill out a form about your/your child's visits. You/your child might be asked to fill out a questionnaire to let us know how the telehealth session went.

All the information will be sent to a research team at McGill University in Montreal that will compile the questionnaires for this project.

2. Confidentiality

Your name/your child's name will not be put on any of the questionnaires. No one will have access to any information about your health status or your use of the telehealth system.

3. Benefits

Use of this technology could make your medical record more complete.

Your/your child's follow-up treatments could be done at the nursing station.

You/your child might be able to avoid travelling to Sept-Îles or Quebec City for treatment.

If the telehealth equipment proves useful, the community will be able to keep it at the end of the project.

4. Risks

Transmission of information by the telehealth system might not be secure.

It is not very likely, but information could be lost or images could be damaged.

There might be unusual delays in receiving the diagnosis from a specialist.

You may feel that this approach is less private than seeing a specialist or other care provider in person.

5. Voluntariness

There is no obligation for you/your child to participate in this study.

If you don't, you/your child will receive the same care that you/your child would have received if we did not have this equipment.

You/your child may stop participating at any time.

You/your child may use the telehealth system without the forms or questionnaires being filled out.

6. Contact Persons

You can reach Daniel Goudnault, Telehealth Co-ordinator, at (418) 229-2042.

This study has been explained to me.
I agree to participate:

Yes No I agree to use/let my child use the telehealth system.

Yes No I agree to have the forms filled out.

Signature: Date:
(Client/Parent/Legal guardian)

Signature: Date:
(Health staff member)

Name of translator:

Top of Page

Southend Telehealth Consent Form I

1. Purpose

The purpose of this project is to obtain information about the use of telehealth technology in improving communication and community access to specialist consultations and patient education in a timely and cost-effective manner.

2. Description

The telehealth system uses the television to let you/your child talk to the Service Provider, family member or friend in Prince Albert on a television set.

If you agree the nursing station staff will fill out a form about you/your child's visits.

You/your child might be asked to fill out a questionnaire to let us know how the telehealth session went.

All the information will be sent to a research team at McGill University in Québec who will compile the questionnaires for this project.

3. Confidentiality

Your name/your child's name will not be put on any of the questionnaires. No one will have access to any information about your health status or your use of the telehealth system.

4. Benefits and Risks

You/your child may be able to see the Service provider, family member or friend sooner.

You/your child's follow-up treatments could be done at the Nursing Station.

You/your child might not have to travel to Prince Albert for treatment as often.

If the telehealth equipment is useful, it will stay in our community at the end of the project.

You may feel that it is not as private as seeing the Service provider, family member or friend in person.

5. Voluntariness

You/your child do not have to participate in this study.

If you don't, you/your child will receive the same care that you/your child would have received if we did not have this equipment.

You/your child have the right to stop participating at any time.

You/your child can use the telehealth system without having the forms or questionnaires filled out.

6. Contact Persons

Your contact persons here in Southend can be reached at 306 758-2063. Jeanne Clarke - Telehealth Coordinator

This study has been explained to me.
I agree to participate:

Yes No I agree to use/let my child use the telehealth system.

Yes No I agree to have the forms filled out.

Signature: Date:
(Client/Parent/Legal guardian)

Signature: Date:
(Health staff member)

Name of translator:

Southend Telehealth Consent Form II (video)

1. Purpose

The purpose of this project is to obtain information about the use of telehealth technology in improving communication and community access to specialist consultations and patient education in a timely and cost-effective manner.

2. Description

The telehealth system uses the television to let you/your child talk to the Service Provider, family member or friend in Prince Albert on a television set.

The session will be videotaped.

If you agree the nursing station staff will fill out a form about you/your child's visits.

You/your child might be asked to fill out a questionnaire to let us know how the telehealth session went.

All the information will be sent to a research team at McGill University in Québec who will compile the questionnaires for this project.

3. Confidentiality

Your name/your child's name will not be put on any of the questionnaires. No one will have access to any information about your health status or your use of the telehealth system.

The videotape of the session will be stored under lock and key and will be destroyed at the end of the research project (March 2001).

4. benefits and Risks

You/your child may be able to see the Service provider, family member or friend sooner.

You/your child's follow-up treatments could be done at the Nursing Station.

You/your child might not have to travel to Prince Albert for treatment as often.

If the telehealth equipment is useful, it will stay in our community at the end of the project.

You may feel that it is not as private as seeing the Service provider, family member or friend in person.

5. Voluntariness

You/your child do not have to participate in this study.

If you don't, you/your child will receive the same care that you/your child would have received if we did not have this equipment.

You/your child have the right to stop participating at any time.

You/your child can use the telehealth system without having the forms or questionnaires filled out.

6. Contact Persons

Jeanne Clarke is the telehealth coordinator for Southend and can be reached at 306 758-2063.

This study has been explained to me.

I agree to participate:

Yes No I agree to use/let my child use the telehealth system.

Yes No I agree to have the forms filled out.

Signature: Date:
(Client/Parent/Legal guardian)

Signature: Date:
(Health staff member)

Name of translator:

Top of Page

Help on accessing alternative formats, such as Portable Document Format (PDF), Microsoft Word and PowerPoint (PPT) files, can be obtained in the alternate format help section.

Portable Document Format(PDF Version - 57 K)

Attachment 2: Patient Encounter Forms

First Nations Telehealth Project: La Romaine

  • Patient code, Date of visit, Person who completed the form, Time use of telehealth system began, Time use of telehealth system ended
  • What Is The Purpose Of The Patient's Visit To The Health Centre?
    • urgent problem
    • medical or surgical follow-up or medication check
    • health problem
    • routine preventive examination
    • other
  • Why Was The Telehealth System Used?
    • confirmation of diagnosis
    • justification of a transfer
    • routine follow-up
    • case management without transfer
    • request for appointment
    • Was there a previous meeting using the telehealth system?
      If so, when?
    • other reason (specify)
  • The Telehealth Data Were Transferred By:
    • nurse (name)
    • technician (name)
    • physician (name)
    • patient
    • other
  • Who Received The Data From The Telehealth System Remote Site?
    • nurse family physician
    • medical specialist (what specialty?)
    • other?
    • at which site(s)?
  • If the telehealth service was not available, what would happen with this patient today?
    • No service
    • Wait for visit to La Romaine by the physician/specialist
    • Transfer of patient
    • Other
  • What Is To Be Done Now?
    • No further action is required
    • Follow-up is required
    • Other
    • The patient is to be transferred
    • The patient is to be seen again by the telehealth service
  • Why Was The Telehealth System Used?
    • Data transferred by the patient (user of a blood glucose monitor)
    • System used during a visit to the health centre. Specify the reason
    • ECG. Specify the reason
    • Specific examination
      • ears
      • nose
      • throat
      • mouth
      • other:
    • Specify
  • Did Any Logistical Or Co-ordination Problems Arise In The Use Of Telehealth?
    • No
    • Yes. Specify the reason
  • Did Any Problems Arise In Connection With:
    • the operation of the equipment?
    • the recording and storing of data?
    • interpretation by the staff at the remote site?
    • access to the telehealth system?
    • transmission time?
    • data transmission?
    • image quality?
    • Other
  • Additional Information On The Patient
  • Please Fax The Duly Completed Form TO 514-398-1531.
    If you have any questions, call 514-398-3247.
Top of Page

Southend Telehealth Session Form Fax To: 514-398-1531

Date of visit, Time session began, Time telehealth system disconnected, Person Completing Form, Time telehealth system connected, Time Session Ended

  • Why Was The Telehealth System Used?
    • Patient care: Fill in box 1
    • Patient education: Fill in box 2
    • Staff/community education or development : FILL In box 3
    • 0ther: Write details on back of form
  • Box 1: Patient Care
    • urgent health problem OR
  • Patient Code
    • non-urgent health problem
  • Who was there at the telehealth session? In Southend
    • Patient, Health centre nurse, CHR, Mental health worker, Physician, Translator, Family Member, Other
  • Other site: where?
    • Family physician, Psychologist, Specialist Type, Nurse, Health educator, Social worker, counselor, Translator, Family Member, Other
  • What was done during the session?
    • Specialist consult
      • to discuss or confirm diagnosis, to follow up on previous, to discuss case management, Other
    • Other patient care: describe
  • What will happen next?
    • No further action is required
    • Follow-up is required
      • with telehealth, without telehealth
    • Patient is to be transferred to, Other, Did this session result in avoiding a patient transfer? (Yes/No/Maybe)
  • Box 2: Patient Education
    • individual OR group session, how many attended? Where? Telehealth office OR Mental health room
  • What was done during the session?
    • Diabetes education, what topics?
      • Diet/nutrition, Smoking, Insulin, Foot care, Hypertension
      • Exercise, Alcohol, Glucose monitoring, Counseling or support, Other
      • Other patient education , what topics?
  • Box 3: Staff/community Education Or Development
    • Who was there at the telehealth session?
      • In Southend, Other site: where?
        • Staff : how many?, Community members: how many?, Translator, Other
        • Psychologist, Diabetes educator, Other educator, Nurse, Social worker, counselor, Translator, Family Member, Other:
  • What topics were covered during the session?
    • Briefly describe
  • Were There Any Problems In Scheduling Or Coordinating The Telehealth Visit?
    • No/Yes, Describe
    • Establishing communication?, No/Yes
      • At what speed were you able to connect?
        • 112, 128, 168, 224, 256, 336, 384
      • Maintaining communication?, No/Yes
      • Operating the camera?, No/Yes
      • Sound quality?, No/Yes
      • Visual quality?, No/Yes
      • Other technical problems?
  • Additional Comments On This Telehealth Session
  • Please Fax The Completed Forms TO: 514-398-1531
    If You Have Any Questions Or Comments Please Call Genevieve At 514-398-3247
Top of Page

Berens River Telehealth Session Form Fax To: 514-398-1531

Patient code, Date of visit, Time telehealth system disconnected, Person completing form, Time telehealth system connected, Time session ended

  • Why Was The Telehealth System Used?
    • Patient care: Box 1, Patient education: Box 2, Continuing education: Box 3, 0ther: Write on back of form
  • Box 1: Patient Care
  • Who was there at the telehealth session?
    • In Berens River
      • Patient, Health centre nurse, CHR, Mental health worker, Physician, Translator, Family Member, Other
    • In Winnipeg
      • Infectious disease specialist, Psychiatrist, Pediatrician, Gynecologist/obstet., Nurse, Health educator, Social worker, counselor, Translator, Family Member, Other:
  • What was done during the session?
    • Specialist consult
      • to discuss or confirm diagnosis, to follow up on previous visit or on test results
    • to discuss case management (medication review/adjustment)
      • Other:
    • Prenatal care, Other patient care: describe
  • What will happen next?
    • No further action is required
    • Follow-up is required
      • with telehealth, without telehealth
    • Patient is to be transferred to
    • Other
    • Did this session result in avoiding a patient transfer? (Yes/No/Maybe)
  • Box 2: Patient Education
    • individual OR group session - how many attended?
  • What was done during the session?
    • Diabetes education - what topics?
      • Diet/nutrition, Smoking, Insulin, Foot care, Hypertension
      • Exercise, Alcohol, Glucose monitoring, Counseling or support, Other
    • Other patient education - what topics?
  • Box 3: Continuing Education
    • individual OR group session - how many attended?
  • Who was there at the telehealth session?
    • In Berens River
      • Staff : how many?, Community members:how many?, In Berens River, Translator, Other
    • In Winnipeg
      • Specialist, Psychologist, Diabetes educator, Other educator, Nurse, Social worker, counselor, Translator, Other
  • What topics were covered during the session?
    • Briefly describe:
  • Were There Any Problems In Scheduling Or Coordinating The Telehealth Visit?
    • No/Yes - Describe:
  • Were There Any Problems With?
    • Establishing communication? (No/Yes)
    • Maintaining communication? (No/Yes)
    • Operating the camera? (No/Yes)
    • Sound quality? (No/Yes)
    • Visual quality? (No/Yes)
    • Other technical problems?
  • Summary Of Doctor's Comments
  • Additional Comments On This Telehealth Session
  • Please Fax The Completed Forms To: 514-398-1531
    If You Have Any Questions Or Comments Please Call 514-398-3247

Telehealth Research Project In Fort Chipewyan, Alberta

Monthly Report for the Month of

Description -- Stats

  • Total Numbers For The Month
    • Total number of sessions for the month
    • Total number of rehabilitation clients seen this month
    • Total number of patients that used Televisitation
    • Total number of family/friends that used Televisitation
  • Speech Therapy
    • Total number of Speech sessions
    • How many of these were Telehealth
    • Total number of Speech clients seen this month
  • Physiotherapy
    • Total number of Physiotherapy sessions
    • How many of these were Telehealth
    • Total number of Physiotherapy clients seen this month
  • Occupational Therapy
    • Total number of Occupational sessions
    • How many of these were Telehealth
    • Total number of Occupational clients seen this month
  • Televisitation
    • Total number of Televisitation sessions
    • Total number of maintenance/tests/demos of Telehealth sessions

Progress Notes:
A= Initial Assessment
B= Ongoing Therapy
C= Adjustment of Therapy
D= Reassessment
E= No therapy needed
F= Discharged
G= Other

SLP Clients - ST-, PT Clients - PT-, OT Clients - OT -

Top of Page

Help on accessing alternative formats, such as Portable Document Format (PDF), Microsoft Word and PowerPoint (PPT) files, can be obtained in the alternate format help section.

Portable Document Format(PDF Version - 48 K)

Attachment 3: Remote Encounter Forms

Telehealth Rehabilitation Supervision Session Form Fax To: 514-398-1531

PATIENT CODE, PERSON COMPLETING FORM, TIME SESSION BEGAN, DID THE SESSION START ON TIME? (No/Yes), DATE OF VISIT, TIME SESSION ENDED, TYPE OF REHABILITATION: (Speech/language pathology - Occupational therapy - Physical therapy)

  • What happened during the session?
    • Initial assessment
    • Ongoing therapy
    • Adjustment of therapy
    • Re-assessment
    • Comments
  • What will happen next?
    • No further sessions are required
    • Continuing therapy
      • same telehealth supervision
      • change in telehealth supervision, describe:
    • Patient is to be transferred to
    • Other
  • If this service was not available, what would have happened with this patient today?
    • No rehabilitation services at all
    • Wait for rehabilitation services to come to Fort Chipewyan
    • Transfer patient out of Fort Chipewyan
    • Other
  • For this session, which would have been better for the patient?
    • Telehealth-supervised session with rehabilitation assistant
    • Face-to-face session with rehabilitation specialist
  • Technical review
    • Were there any problems in scheduling or coordinating the telehealth visit?
      • No/Yes, Describe:
    • Were there any problems with ?
      • Establishing communication? (No/Yes)
        • At what speed were you able to connect?
          • 112/128/168/224/256/336/384
        • Maintaining communication? (No/Yes)
      • Operating the camera? (No/Yes)
      • Sound quality? (No/Yes)
      • Visual quality? (No/Yes)
      • Other technical problems?
  • Additional comments on this telehealth session
  • Please fax the completed forms to (514) 398-1531
    If you have any questions or comments please call 514-398-3247

Telehealth Session Form Fax To: 514-398-1531

Patient code, Date, Did the session start on time? (No/Yes), Person completing form, Time session began, Time session ended, Were there any problems in scheduling or coordinating the telehealth visit?, (No/Yes): please describe, Type of session: (Specialist consult/Patient education/Continuing education/Other

  • What happened during the session?
    • Assessment /diagnosis, Treatment/management (medication review/adjustment), Information/education, Follow-up, Other, Describe:
  • What will happen next?
    • Follow-up is required
      • Patient to be transferred to:
      • Patient is to be seen again (With telehealth/Without telehealth)
      • No further action is required
      • Other
  • If this service was not available, what would have happened with this patient today?
    • No services at all, Wait for service to come to Berens River, Transfer patient out of Berens River, Other
  • For this session, which would have been better for the patient?
    • Telehealth session / In-person session
  • Technical review
    • Were there any problems with ?
      • Establishing communication? (No/Yes)
      • Maintaining communication? (No/Yes)
      • Operating the camera? (No/Yes)
      • Sound quality? (No/Yes)
      • Visual quality? (No/Yes)
      • Other technical problems?
  • Additional comments on this telehealth session
  • Please fax the completed forms to (514) 398-1531
    If you have any questions or comments please call 514-398-3247

First Nations Telehealth Project

Form for referral site
Complete and return the form to the la romaine health centre

Patient code, Date/time sent, Sent by, Information received at which site?, Date and time received, Person who received the information for evaluation, diagnosis or follow-up

  • What has been done so far?
    • Evaluation / Diagnosis , Prescription / Treatment, Information and instructions to patient , Follow-up , Other
  • What is to be done now?
    • No further action is required, Follow-up is required , The patient is to be transferred to, The patient is to be seen again by the telehealth service, Other
  • If the telehealth service was not available, what would happen with this patient today?
    • No service, Wait for visit to La Romaine by the physician/specialist, Transfer of the patient , Other
  • What consequences did use of telehealth have?
    Did use of telehealth affect:
    • the quality of care given to the patient?
      • higher quality, lower quality, no effect
    • the wait for care?
      • shorter wait , longer wait , no effect
    • the time you spent on care?
      • time saved , more time , no time
    • the care-related costs?
      • économie d'argen, higher costs , no effect
  • Did this visit make it possible to avoid transferring the patient?
    • yes/no/maybe
  • Were there any problems with:
    • data communication or image transfer?
      yes/no/don't know
    • transmission time and downloading of the file?
      yes/no/don't know
    • use of the equipment in general?
      yes/no/don't know
    • image quality?
      yes/no/don't know
    • Other:
    • How satisfied are you with the use of the technology?
      • very satisfied, satisfied , neutral, dissatisfied, very dissatisfied
    • Comments
Top of Page

Help on accessing alternative formats, such as Portable Document Format (PDF), Microsoft Word and PowerPoint (PPT) files, can be obtained in the alternate format help section.

Portable Document Format(PDF Version - 47 K)

Attachment 4: Satisfaction Questionnaire

Telehealth Satisfaction Survey (for Telerehabilitation And Televisitation Sessions) Fax To : 514-398-1531

Speech/language therapy - Occupational therapy - Physical therapy - Televisitation

Patient code, Gender (Male/Female), Age (0 - 20 / 21 - 40 / 41 - 60 / 61 - 80 /80+)

  • How satisfied were you with:
    • The voice quality of the equipment? (Poor / Fair / Good / Excellent)
    • The visual quality of the equipment? (Poor / Fair / Good / Excellent)
    • Your personal comfort in using the telehealth system? (Poor / Fair / Good / Excellent)
    • The length of time to get an appointment in Fort Chip? (Poor / Fair / Good / Excellent)
    • The ease of getting to the telehealth department (circle one: taxi, private, walked, CHR, staff) (Poor / Fair / Good / Excellent)
    • The length of time with the therapist or family member you saw? (Poor / Fair / Good / Excellent)
    • The explanation of your treatment by the telehealth staff? (Poor / Fair / Good / Excellent)
    • The thoroughness, carefulness and skillfulness of the telehealth staff? (Poor / Fair / Good / Excellent)
    • The courtesy, respect, sensitivity and friendliness of the telehealth staff? (Poor / Fair / Good / Excellent)
    • How well the telehealth staff respected your privacy? (Poor / Fair / Good / Excellent)
    • How well the staff answered your questions about the equipment? (Poor / Fair / Good / Excellent)
    • Your overall treatment experience at using telehealth? (Poor / Fair / Good / Excellent)
  • Would you use Telehealth again? (No / Yes)
  • Would you recommend telehealth to another person? (No / Yes)
  • Comments
  • Self-administered - With help By
  • Please fax the completed forms to: 514-398-1531. If you have any questions or comments please call 514-398-3247.
    Based on a form developed by the Saskatchewan Northern Telehealth Network.

Patient Satisfaction Survey (use For Patient Care Sessions) Fax To : 514-398-1531

Patient code, Gender (Male/Female), Age (0 - 20 / 21 - 40 / 41 - 60 / 61 - 80 /80+)

  • How satisfied were you with:
    • Your general health? (Poor / Fair / Good / Excellent)
    • The length of time to get an appointment with Telehealth? (Poor / Fair / Good / Excellent)
    • The length of time waiting in the office at Telehealth? (Poor / Fair / Good / Excellent)
    • The length of time with the specialist you saw? (Poor / Fair / Good / Excellent)
    • The explanation of your condition by the specialist? (Poor / Fair / Good / Excellent)
    • The explanation of your treatment by the specialist? (Poor / Fair / Good / Excellent)
    • The thoroughness, carefulness and skillfulness of the specialist you saw? (Poor / Fair / Good / Excellent)
    • The courtesy, respect, sensitivity and friendliness of the specialist you saw? (Poor / Fair / Good / Excellent)
    • How well the staff here respected your privacy? (Poor / Fair / Good / Excellent)
    • How well the staff here answered your questions about the equipment? (Poor / Fair / Good / Excellent)
    • How well the staff here treated you with respect? (Poor / Fair / Good / Excellent)
    • Your overall treatment experience at Telehealth? (Poor / Fair / Good / Excellent)
  • Did you have any difficulties getting here today? (No/Yes)
  • Would you use Telehealth again? (No/Yes)
  • Would you recommend telehealth to another person? (No/Yes)
  • Any other comments about telehealth?
  • Self-administered / With help / Orally By
    Please fax the completed forms to: 514-398-1531. If you have any questions or comments please call 514-398-3247.
    Used by permission of the Saskatchewan Northern Telehealth Network.

Patient Satisfaction Survey (la Romaine Telehealth Sessions) Fax To: 514-398-1531

Patient code, Date

  • Were you satisfied with:
    • Your general health? (Poor/Fair/Good Excellent)
    • The waiting time for use of the telehealth equipment? (Poor/Fair/Good Excellent)
    • he waiting time to receive the results of the telehealth session? (Poor/Fair/Good Excellent)
    • How well the staff respected your privacy? (Poor/Fair/Good Excellent)
    • How well the staff answered your questions about the equipment? (Poor/Fair/Good Excellent)
    • How well the staff treated you with respect? (Poor/Fair/Good Excellent)
    • Your telehealth experience in general? (Poor/Fair/Good Excellent)
  • Did you find it difficult to get here today? (No/Yes)
  • Is this the first time you have used the telehealth service? (No/Yes)
  • Would you use telehealth again? (No/Yes)
  • Would you choose telehealth over a visit to the doctor? (No/Yes)
  • Would you recommend telehealth? (No/Yes)
  • Any other comments you may wish to make about telehealth?
  • Self-administered / With help / Orally by
  • Please fax the completed forms to 514-398-1531.
    If you have any questions or comments, Please call 514-398-3247.
    Adapted and used with the permission of the Saskatchewan Northern Telehealth Network

Patient Satisfaction Survey (use For Patient Care Sessions) Fax To : 514-398-1531

Patient code, Gender (Male/Female), Age (0 - 20 / 21 - 40 / 41 - 60 / 61 - 80 /80+)

  • How satisfied were you with:
    • Your general health?
    • The length of time to get an appointment with Telehealth? (Poor / Fair / Good / Excellent)
    • The ease of getting to the Telehealth site? (Poor / Fair / Good / Excellent)
    • The length of time waiting in the office at Telehealth? (Poor / Fair / Good / Excellent)
    • The length of time with the specialist you saw? (Poor / Fair / Good / Excellent)
    • The explanation of your condition by the specialist? (Poor / Fair / Good / Excellent)
    • The explanation of your treatment by the specialist? (Poor / Fair / Good / Excellent)
    • The thoroughness, carefulness and skillfulness of the specialist you saw? (Poor / Fair / Good / Excellent)
    • The courtesy, respect, sensitivity and friendliness of the specialist you saw? (Poor / Fair / Good / Excellent)
    • How well the staff here respected your privacy? (Poor / Fair / Good / Excellent)
    • How well the staff here answered your questions about the equipment? (Poor / Fair / Good / Excellent)
    • How well the staff here treated you with respect? (Poor / Fair / Good / Excellent)
    • Your overall treatment experience at Telehealth? (Poor / Fair / Good / Excellent)
  • To use the telehealth service today, did you have to
    • Arrange child care? (No/Yes) , Cost to you:
    • Pay for any costs? (No/Yes), About how much (not child cost)
  • Would you use Telehealth again? (No/Yes)
  • Would you recommend telehealth to another person? (No/Yes)
  • Any other comments about telehealth?
  • Self-administered / With help / Orally By:
  • Please fax the completed forms to: 514-398-1531. If you have any questions or comments please call 514-398-3247.
Top of Page

Help on accessing alternative formats, such as Portable Document Format (PDF), Microsoft Word and PowerPoint (PPT) files, can be obtained in the alternate format help section.

Portable Document Format(PDF Version - 47 K)

Attachment 5: Interview Guides

Sample Interview Guide for Physicians and Nurses

  1. Does telemedicine bring changes in your practice?
  2. Does telemedicine bring changes in the dialysis or nephrology service?
  3. Under what conditions would you be willing to pursue the use of telemedicine?
  4. Is the use of telemedicine in the context of the actual project be enlarged? In New Brunswick? In Canada?
  5. Is the use of telemedicine in the current project an improvement over what existed before?
  6. Do you see any other application for telemedicine in your area?
  7. Under what conditions could such projects be broadened?
  8. Could such projects be considered cost-effective?
  9. What would encourage someone to undertake such a project?
  10. Are you satisfied of the results so far? If yes, why? If not, why not?
  11. What inconveniences and constraints have you experienced in this project?

(Adapted from: - Adaptation de Fortin, Banville: Rapport d'évaluation des projets pilotes en télécardiologie et en téléradiologie, CEFRIO, jan 1998).

Community Leaders

A. Impact of telehealth on the community

General

What is your position within the community? How long have you had this role? What are the main challenges you face?

What are the major health problems your community faces? How long have these health problems troubled your community? How do these health problems affect the daily life of your community members (employment, education, social behavior etc.)?

What percentage of your community members would you say are healthy or in need of consistent medical attention? In your opinion, what type of community member is at risk to suffer a medical illness (age, gender, occupation etc.)?

Do you think telehealth can help your community overcome some of its problems? Which health concerns, in particular, can telehealth be used for?

Do you agree that the main health issues in your community are being addressed in the applications (list them) chosen for this project?

How have community members been involved in the telehealth project? Was there much interest for the project? By whom? Is there still much interest in this project?

Health care quality

Do you expect that telehealth can improve the health care quality in your community?

Have you received any feedback so far from community members about the quality of care they or their family members have received in the telehealth project?

Health care accessbility

Were you satisfied with the implementation of the telehealth applications within your community? Could the process have been improved?

Do you think that telehealth can speed up the process of access to care?

Have you heard any feedback about accessibility to health services from members of your community who are participating in the project?

B. Role of telehealth in service provision and management

To what extent is telehealth appropriated, integrated and sustained as a part of the community's self-governed health care system, or integrated into the negotiations of transfers agreements?

To what extent have the telehealth applications become linked and integrated to provincial initiatives?

To what extent does telehealth improve access of secondary, tertiary and education providers to local health service providers?

To what extent does telehealth improve health service providers' awareness and knowledge of local conditions and resources?

C. Overall positive and negative social and economic impacts and implications

How is telehealth an economic advantage or disadvantage in your community thus far?

As far as you can tell, has the telehealth project decreased or increased travel time and costs for community members?

Have the telehealth applications had any negative impact on your community?

Do you think the telehealth applications chosen for this project are sustainable? What are the factors necessary to keep the telehealth applications working in the future?

What needs does your community have that the telehealth applications are not addressing?

Do you have any other comments about the development of telehealth in your community?

For Political Figures

What do you think are the main priority areas to address with telehealth in your jurisdiction?

Do you think that the main health issues in these communities are being addressed in the applications chosen for this project?

Do you think the telehealth applications chosen for this project are sustainable? What are the factors necessary to keep the telehealth applications working in the future?

What needs does this community have that the telehealth applications are not addressing?

To what extent is telehealth appropriated, integrated and sustained as a part of the community's self-governed health care system, or integrated into the negotiations of transfers agreements?

To what extent have the telehealth applications become linked and integrated to provincial initiatives? What conditions would facilitate compatibility and integration of these systems?

How do these applications affect the health centres linked to the remote communities? In terms of continuity of care? Comprehensiveness of care? Relationships with the community's health resources? Cost effectiveness?

To what extent does telehealth improve access of secondary, tertiary and education providers to local health service providers?

To what extent does telehealth improve health service providers' awareness and knowledge of local conditions and resources?

Do you have any other comments about the development of telehealth in your community?

For Remote Providers

Personal reaction:

Have you been trained to use telehealth? What skills and competencies were required in order to use telehealth? Have you acquired the necessary training? What difficulties might have been avoided with more training?

  • Has the use of telehealth been organized successfully?
  • Have there been any administrative difficulties in using telehealth?
  • Have there been any scheduling difficulties?

What have been the positive and negative effects on your own work efficacy when using telehealth?

Have you become more competent and confident in your job when using telehealth?

Have your colleagues had similar experiences to your own working with telehealth?

How much does telehealth affect your workload, staff workload, task allocation and professional practices?

How many active cases are you involved with?

How many telehealth patients do you see per week?

How much time do you spend on non-transferred patients?

How have your services shifted when using telehealth?

Patient reaction:

In your experience seeing patients, to what extent do they find telehealth acceptable? Have they been comfortable?

  • Have they expressed any concerns regarding telehealth? If so, what were they?
  • Have any patients refused to use telehealth? If so, for what reasons?

How have family members reacted?

Who's using telehealth:

To what extent does telehealth respond to your patients' health needs?

To what extent are telehealth applications used by eligible patients in the community?

What specific health conditions are targetted for the use of telehealth?

What is the proportion of telehealth use according to health condition?

Telehealth efficacy:

How long have patients had to wait for medical care through telehealth?

Do the telehealth interventions meet the accepted standards of care (clinical guidelines)? Have they improved the standard of care?

Has hospitalization been necessary for any of your patients? If so, how did telehealth interventions interact with the process?

To what extent does telehealth result in cost increases, decreases or shifts for health service delivery within the communities?

How many patient transfers have been avoided?

Concerns about equipment:

Is telehealth easy to use? Is the technical quality at an acceptable level? How would you describe the communication flow?

Have you encountered technical problems when using the equipment?

How often have you required technical support?

Top of Page

Help on accessing alternative formats, such as Portable Document Format (PDF), Microsoft Word and PowerPoint (PPT) files, can be obtained in the alternate format help section.

Portable Document Format(PDF Version - 91 K)

Attachment 6: Integrate Ethics Review Document

1. Title of project

First Nations Telehealth Research Project

2. Name and organizational affiliation of principal investigator.

Alexa Brewer
Medical Services Branch
Health Canada
Jeanne Mance Building, Tunney's Pasture
Ottawa K1A OL3

3. Names and organizational affiliations of all co-investigators

Project Manager
Ernie Dal Grande
Medical Services Branch
Health Canada
Jeanne Mance Building, Tunney's Pasture
Ottawa K1A OL3

Contractors responsible for carrying out the evaluation:

Natalie Kishchuk, PhD
Jocelyne Picot, PhD
Infotelmed Communications Inc.
38 Place du Commerce
Verdun, Québec H3E 1T8

A Peer Review Committee, consisting of expert representatives form a number of institutions and associations, oversees the project. Its members are:

Dr. Joe Kaufert University of Manitoba

Dr. Penny Jennet University of Calgary

Dr. James Irvine University of Saskatchewan

Dr. Alain Cloutier Université Laval

Ms. Maria MacNaughton Health Canada

Ms. Lisa Dutcher Aboriginal Nurses Association

Ms. Margaret Neylan British Columbia Institute of technology (retired)

4. Signatures of all investigators

5. Apparent conflicts of interest

No investigator in this study has any interest in any of the telehealth supplier firms.

6. Participating institutions

This project involves the delivery of health services via telehealth linkages through the health centers managed by the Band administrations five First Nations communities, listed below. The personnel involved with these centers are either employees of the Band or, in a minority of cases, Health Canada. The five First Nations communities will be linked with specialized medical staff in the secondary and tertiary institutions, also listed below.

Anahim Lake, B.C. linked with: Cariboo General Hospital, Williams Lake

Fort Chipeweyan, Alberta: Northern Lights Hospital at Fort McMurray

Southend, Saskatchewan: La Ronge Hospital, La Ronge; Prince Albert Hospital, Prince

Albert; Royal University Hospital, Saskatoon

Berens Rivers, Manitoba: Health Sciences Centre, Winnipeg

La Romaine, Québec: Centre de santé Sept-Iles, Centre hospitalier universitaire du Québec, Québec City.

7. Dates of project start and expected completion

March 2000 - March 2001

8. Previous history of the project at this institution

This is a new project at all the participating institutions.

9. Summary of proposed research

Objective and hypotheses, with evidence that justifies this research with human beings at this time.

Telehealth is the delivery of health information, resources and services through information and communications technology. As one of several telehealth demonstration and evaluation projects funded through the Health Transition Fund, the First Nations' Telehealth Project will deploy and evaluate applications of telehealth in five remote First Nations communities. The research objectives are: to assess the extent to which telehealth: 1) improves patient and community access to care, including timeliness of access; 2) renders service delivery in remote communities more cost-effective; and 3) improves linkages between to remote health care centres and secondary, tertiary and educational facilities in each province.

Overall, the research literature in telehealth suggests that it has the potential to improve health services delivery while maintaining patient health outcomes, but that its cost-effectiveness and implementability have yet to be clearly demonstrated. Research to date has tended to concentrate on the accuracy and reliability of information and diagnoses provided through telehealth applications. In general, these studies provide relatively strong evidence that quality of information provided is comparable to that provided through usual channels. However, other aspects of quality of care, including continuity and comprehensiveness, have not been addressed. The organizational implications of implementing telehealth are not well documented, although some studies mention changes in workloads and work organization for health personnel.

It is also not clear as yet whether telehealth represents an overall improvement in the quality and accessibility of care, versus a shifting of the same care to less costly methods of delivery. While many studies have demonstrated the cost-effectiveness of various telehealth applications, they have tended to limit their assessment of costs to the time involved from the specialty physicians. More comprehensive studies including equipment, telecommunications, and organizational costs suggest that cost-effectiveness is not guaranteed, and at the very least must be assessed over a relatively long amortization period. Moreover, usage levels of telehealth systems, a major factor in cost-effectiveness, are often less than expected. No studies have systematically examined the proportion of eligible patients in a given practice population who use telehealth. Studies of cost reductions due to decreased patient travel and wait time show that use of telehealth may diminish patient transfers, but not in all cases. The extent to which telehealth defers rather than replaces in-person consultations has not been addressed.

There is evidence, however, that telehealth may have benefits for both patients and providers. Reactions among local providers (in most studies, general practitioners) are generally positive, and there is some evidence that can improve the quality of their services. Patient satisfaction with telehealth is high, and in studies where it has been assessed, patients report that their quality of life is improved by using telehealth. Moreover, in some types of applications, patients report that they feel more empowered or in control of their interactions with health professionals when using telehealth.

Study design, with scientific justification

Due to the exploratory nature of the hypotheses and impossibility of conducting a controlled trial in these small communities, the evaluation design is essentially descriptive and longitudinal. The evaluation methods to be used will provide information about both the entire project and each specific community.

  1. Monitoring of telehealth system usage: Continuously throughout the study period, nursing station staff and remote health staff will complete logs of patient encounters for all patients eligible to use the telehealth applications, regardless of whether it is used. These logs contain information on the health condition prompting the consultation, the actions undertaken by the local and remote providers using telehealth during the encounter, and follow-up actions required.
  2. Patient satisfaction: In each community, patients will be asked to complete brief questionnaires or interviews assessing their satisfaction with several facets of the encounter and their preferences for using telehealth.
  3. Qualitative interviews with key informants: At two points during the study period, qualitative interviews will be conducted with four types of key stakeholders: nursing station personnel (managers, nurses, CHR, social services providers, translators); remote centre and education telehealth partners (physicians, nurses and technical teams in the nursing stations linked to the participating communities); staff in educational institutions linked to the communities; community leaders (elders, council members and health committee members); federal and provincial agency representatives. The stakeholders will be asked to respond as key informants giving their views on the evaluation questions from their perspectives within the project and the communities. They will be identified in collaboration with project leaders, nursing station staff and other relevant sources such as the Peer review Committee. Approximately ten semi-structured interviews will be conducted in each site at each time point, and will be one half hour to one hour in length. They may also be conducted as group consultations if this is more appropriate in the community.
  4. Cost assessment: Nursing station management will provide cost data on patient transfers for eligible patients during the study period.

    Because 1) many of telehealth application being evaluated target chronic conditions such as diabetes, and 2) of the need to examine the extent to which telehealth defers rather than replaces in-person consultations, individual patients will be followed longitudinally throughout the study period, using blinding procedures described in the section on confidentiality.

Information from these four sources will be aggregated into case studies of each participating community.

10. Research participants in each site and in overall study

The study will enroll a continuous series of volunteer adult and child patients from the beginning of telehealth deployment until at least January 31 2001, with the condition that at least 30 patients in each site will participate, for an overall minimum sample size of 120 patients (see description below: one community will not use the telehealth systems in direct patient encounters). This sample size will permit reliable point estimates at the level of each community as well as reliable aggregate data across the entire study.

The combination of telehealth applications to be implemented in each of the five communities varies, having been selected on the basis of an in-depth needs assessment involving consultations with key community leaders, health staff and other professionals, as well as available health status data. (The specific health conditions are described below). Patients considered eligible for enrollment in the research study (the research population) are thus those:

  • who present to the community nursing station with a complaint related to the health conditions targeted by the telehealth applications available in the community
  • who consent to use the telehealth system (or, for children under 16 years, whose parent or guardian consent to its use).
  • who consent to participate in the evaluation (or, for children under 16 years, whose parent or guardian consent to participation.)

Use of the telehealth application will require consent from each patient (or each patient's parent or guardian) at each health center visit; that is, patients are free to decline telehealth use at any visit. Moreover, based on their clinical judgment, nursing station staff may decide in certain circumstances to not propose use of the telehealth system to eligible patients. Nursing station staff will maintain a record of the number of patients who do not use the telehealth application for which they are eligible, either because they decline to participate or because the nursing station staff do not offer it, but no other information will be collected about these patients.

The eligibility criteria for patients in each community are:

  1. La Romaine
    1. Diabetes monitoring: consenting patients who have been diagnosed as diabetic.
    2. Cardiovascular monitoring: any consenting patient who may require an electrocardiogram, or vital sign monitoring, for routine, follow-up, or emergency reasons, as identified by the CHC nurse.
    3. ENT - any consenting patient who has been identified by the CHC nurse as requiring diagnosis or treatment from an ENT specialist.
  2. Berens River
    1. Patient Care: - consenting patients who have been identified by the local CHC personnel as requiring access to specialist care.
    2. DiabeticEducation: consenting patients who have been diagnosed as diabetic and who may benefit from patient education.
    3. Continuing Medical Education - consenting local health care personnel.
  3. Southend
    1. Access to specialists - consenting patients who have been identified by the local CHC personnel as requiring access to specialist care.
    2. Diabetic education - consenting patients who have been diagnosed as diabetic and who may benefit from patient education.
    3. Mental Health - local health and other personnel participating in community capacity building for mental health.
  4. Fort Chipewyan
    Rehabilitation: consenting patients receiving rehabilitation treatments from an assistant under supervision for physiotherapy, speech therapy or occupational therapy.
  5. Anahim Lake
    Urgent/Emergent cases - comprising of cardiac, diabetic, respiratory ailments as well as major cuts, fractures and burns. The urgent/emergent telehealth will assist the Cariboo Memorial Hospital's emergency services in Williams Lake so that they may be better prepared when the patient arrives from Anahim Lake.

    Because some of the technology involved (notably interactive video) is flexible, it is anticipated that it may be used for patients with other health conditions. To the extent possible, the evaluation will monitor this additional usage.
  6. Exclusions
    Only those patients who do not consent to participate, or for whom no telehealth application has been implemented in the community, are excluded from this study.
  7. Step-by-step description of what will be done with research participants at each stage of the research operations
    In general, the health care for any eligible, consenting patients involved in the telehealth study will follow standard care practice for each medical condition for which the telehealth system is used. This standard will not be altered whether or not the telehealth system is used. The ways in which the means of service delivery will be modified through the use of telehealth are described below, as are the data collection procedures to be used for patients. Because the targeted health conditions, the telehealth technologies deployed and therefore the health care delivery operations vary by community, the are described in detail for each.
Top of Page

La Romaine

Telehealth care

  1. Diabetes - Medical Consultations - In addition to the standard care which is given to diabetic patients, the patients involved in this study will be monitored for glucose levels from their homes.
  2. Cardiovascular monitoring - Patients with suspected or established cardiovascular disease will receive the same standard of care provided at the Community Health Centre (CHC) in La Romaine. In emergencies, the telehealth network will permit patients with emergency cardiac problems to have an electrocardiogram (ECGs) and vital signs recorded by a nurse at the CHC and sent immediately to a physician at the Sept-Iles Regional Hospital (SIRH) for immediate diagnosis, which will be provided by computer-mediated video and audio interaction between the physician and the CHC. The subject will then be cared for in the standard manner, that is, stabilized and medically evacuated if deemed necessary by the physician. On a non-emergency basis, patients with cardiovascular problems may have ECGs done at the CHC and sent to the physician at the Sept-Iles Regional Hospital.
  3. ENT (Ear, nose, throat) - After it has been established by the nurse at the CHC that the patient should see an ENT specialist, the standard procedure would be for the subject to obtain an appointment with the ENT specialist at the Sept Iles Regional Hospital (SIRH). With the telehealth network, the nurse will send ENT images of eligible, consenting patients to the specialist first. On the basis of the information and images received, the physician will provide advice regarding treatment.

Study procedures

  1. Nursing station personnel will determine the eligibility of patients presenting to the nursing station for participation in the evaluation study based on their presenting health problem. They will obtain consent from those patients who are willing to participate in the research study:
    1. If they staff determine that a telehealth consultation could be beneficial to the patient

      And
    2. If the patient consents to telehealth use.
  2. Nursing station personnel will proceed to collect the information necessary, transmit it to the remote health personnel, and arrange for communicating the results (most likely, but not necessarily, in the context of a regularly scheduled consultation, which could happen in real-time or be scheduled for a future communication).
  3. Following the consultations:
    • nursing station personnel will complete the encounter log and
    • remote personnel will complete the encounter log and
    • patients will complete a satisfaction questionnaire or interview.

Berens River

Telehealth care

  1. Patient Care - The standard care provided to patients in need of access to specialists in the Health Sciences Centre is for the nursing station staff to identify the need for a consultation with a general practitioner, who will refer the patients to the specialist clinics as required. The telehealth system will allow consenting patients to consult with a specialist by interactive video. Local nurses will participate in the session as well, ensuring that the patient understands instructions regarding any treatment required.
  2. Patient Education - (Diabetes care, prevention activities and clinical care). In addition to the standard care and information given to diabetic patients and patients at risk, the telehealth network will permit consenting patients and staff at the nursin