BC Telehealth Program

Health and the Information Highway Division, Health Canada
August 2003

Table of Contents

• 1. Introduction
• 2. Project Description
• 3. Achievements
  • 3.1 Goals Reached
  • 3.2 Additional Successes
  • 3.3 Un-reached Goals
  • 3.4 Documents or Products Generated
• 4. Impacts
  • 4.1 Resources, Services and Structure
    • 4.1.1 Human Resources
    • 4.1.2 Services
    • 4.1.3 Structure
  • 4.2 Communities and Delivery Agencies
    • 4.2.1 Communities
    • 4.2.2 Lead Agencies
  • 4.3 Privacy and Protection of Information
  • 4.4 Policy and Research Implications
• 5. The Future
• 6. Communications

1. Introduction

The BC Telehealth Program received Health Canada approval September 2001. The operating and capital budget for the Program was estimated at $7.88M for the period ending March 31, 2003 with $3M in confirmed funding from the CHIPP Program and $3M from the Ministry of Health Services for capital and start up costs. The remainder of the funding support was budgeted in-kind by the various consortium members. The original members included:

• Health Association of British Columbia
• Children's &Women's Health Centre of British Columbia (including Sunny Hill Health Centre for Children)
• Vancouver Hospital and Health Sciences Centre
• University of British Columbia, Faculty of Medicine, Division of Continuing Medical Education
• Canuck Place Children's Hospice (free standing pediatric palliative care centre)
• Okanagan Similkameen Health Region
• Terrace, Bulkley Valley, North Coast and Kitimat Community Health Councils in the North West
• Prince George and Mackenzie in the Northern Interior Health region
• Capital Health region
• Cranbrook, Creston, Invermere, Kimberly, Golden, Fernie and Sparwood Community Health Councils in the East Kootenays
• Kamloops, Bulkley Valley, Kitimat, Prince George, Penticton, Princeton, Kelowna and Oliver Child Development Centres

The governance structure for the Program is through a Steering Committee with a representative from the respective consortium members, the Ministry of Health Services and Health Canada.

2. Project Description

The Project Description has been revised to reflect the health authority restructuring that occurred in mid December 2001 while the Program was being implemented. The previous 52 health authorities merged to form a new governance and management structure with 5 health authorities that govern, plan and coordinate services regionally, and participate with a Provincial Health Services Authority that coordinates and/or provides provincial programs and specialized services, such as cardiac care and transplants.

The BC Telehealth Program is made up of three discrete programs encompassing continuing medical and nursing education and 11 areas of clinical application involving 4 provider organizations and 14 receiving organizations in 12 communities.

The purpose of the BC Telehealth Program is to establish a telehealth network of clinical, continuing education and administrative telehealth applications to nurture and service a community of health professionals, clients, and families. Specific under-serviced communities were identified across British Columbia requiring improved access to a range of specialized maternal and child health and emergency and trauma speciality expertise through clinical and education programs provided by Children's & Women's Health Centre (C&W); Vancouver Hospital and Health Science Centre; the Division of Continuing Medical Education at the University of British Columbia (CME-UBC); and the Canuck Place Children's Hospice.

This telehealth network will allow health providers in rural and remote parts of the province to engage in real-time consultations with medical professionals in the areas of neonatology, perinatology, pediatric oncology, general paediatrics, paediatric mental health, paediatric cardiology, medical genetics, paediatric nutrition and child development and rehabilitation services. An on-demand service to support the acute management of complex emergency, trauma and critical-care patients will be examined, and pending acceptance and success, integrated and delivered within a broader framework to better meet community needs. In addition, an intra-regional orthopaedic service in the East Kootenays will be developed to scan and forward radiology images at two smaller communities to support consultation by specialists at the regional referral centre.

The BC Telehealth Program will further provide health professionals across the province with access to a variety of learning opportunities. The UBC Division of Continuing Medical Education and the clinical departments at the speciality centres will provide rounds, targeted courses, educational programs, and point-of-care learning opportunities via interactive or broadcast videoconference. Access to these educational opportunities should prove successful in overcoming the long-standing barrier that isolation poses for the recruitment and retention of rural physicians.

3. Achievements

3.1 Goals Reached

At the outset of the project, the following goals were established and subsequently achieved as detailed in the Evaluation Report:

• Facilitating the principles of delivering services "Closer to Home" by
  
  
  • improving access in rural and remote areas to specialty services within provincial referral centres; and
  • strengthening the capacity of local health care providers within their own communities in accordance with the province's stated priorities (e.g. improvement of rural health, critical care and trauma services).
• Supporting existing clinical intra- and inter-regional referral patterns while reducing the costs and burdens of having patients travel to regional or provincial centres.
• Supporting the appropriate use and linkage of primary, secondary and tertiary levels of care and community agencies.
• Supporting prevention and early diagnosis and treatment of patients in rural and remote locations in the province.
• Providing real time access to emergency medical expertise for rural health professionals during the management of emergency trauma and critical care cases.
• Supporting the retention and recruitment of physicians and other health care professionals in community and rural areas through increased collaboration and support by their peers in the provincial referral centres, improved access to continuing education opportunities and CME and CNE at point of contact.
• Demonstrating the effectiveness of real-time and store-and-forward telehealth services, and to identify further applications that satisfy clinical and patient needs based on defined objectives and measurable outcomes.
• Conducting an overall program evaluation of telehealth service delivery that focuses on process, impact and cost-effectiveness and uses quantitative and qualitative methods.
• Conducting evaluation research on specific clinical and educational services using qualitative and quantitative methods.
• Utilizing the telehealth infrastructure for real-time coordination, planning and administration of the health care delivery system.
• Beginning to establish a multi-use, provincial telehealth infrastructure and communications network that
  
  
  • supports the principles of inter-operability of equipment among regions, provinces and territories;
  • is expandable;
  • is appropriately monitored and supported to guarantee the required level of service delivery;
  • provides the needed migration paths to enable the transition to new technologies and standards as they evolve or become available;
  • is sustainable both technically and operationally; and
  • is cost effective.
• Scrutinizing the appropriate use of encryption and other technologies to ensure confidentiality of transfer of data image and medical records during telemedicine sessions.

The achievement of these goals is demonstrated by the programs and services implemented:

• A multi-use, provincial telehealth infrastructure and expanded telehealth network that improves access by the communities to selected maternal child and paediatric palliative care services and supports the rapidly expanding use of the telehealth network for administrative and education purposes.
• A network of consulting medical and paramedical specialists able to strengthen and improve the capacity of service providers in rural and remote communities through scheduled and on-demand just-in-time clinical consultations.
• An eight-month trial and proof of concept in the use of advanced ICTs to support rural practitioners in stabilizing and treating complex emergent and trauma cases.
• Continuing professional education programs using the telehealth media including specialized programs as developed by the Division of Continuing Medical Education and broadcasts of selected clinical rounds and specialized education programs by the interdisciplinary team of specialists at the project's lead agencies.
• An external evaluation of the implementation and early usage of the systems.

3.2 Additional Successes

Overall, the project has been deemed a success; particularly considering it was implemented during a period of major health restructuring. In addition to meeting its goals, it has:

• Allowed both patients and clinicians to experience the delivery of health care in a different way.
• Provided, for the first time, participating communities with equal access to specialized resources for the programs and services implemented.
• Facilitated the building of new service partnerships and peer relationships not previously contemplated, which has strengthened the capacity of service providers at all levels.
• Integrated the delivery of services from Health Authorities, Child Development Centres, Canuck Place (an independent palliative care facility) and the UBC Division of Continuing Medical Education into one comprehensive program for rural and remote communities.

Clearly, the impact of health care restructuring in the province on the need for a telehealth network was not anticipated at the outset of the project. However, telehealth is proving valuable and essential in supporting the administration of the larger geographical regions, such as the Northern Health Authority by removing the barriers of distance and geography in this large diverse region and allowing for greater participation in regional Medical Advisory Committee meetings, health service planning and budget meetings, health professional recruitment initiatives, etc.

The Program provided an expanded videoconferencing network in health with established technical standards across the province to support it. This increased capacity allows for provincial programs outside the project scope to have access to a wider range of options for professional education, clinical services, and administrative meetings. Other provincial programs such as Cancer and Cardiac Care may now extend their reach into communities previously not accessible to them or create connections in more effective ways.

3.3 Un-reached Goals

All of the goals set for the project were achieved. As noted in the Evaluation report, there were a number of factors that restricted the overall use of certain applications and limited the success in achieving some of the goals. These factors included:

• Lack of an on-going mechanism to compensate fee for service physicians for telehealth consultations limited the delivery and expansion of clinical services;
• The needs assessment for some of the various applications reflected more of a provider perspective on the need rather than that of the recipient thereby in part limiting the clinical utilization as well as the ability to clearly measure success.

3.4 Documents or Products Generated

The following key documents were prepared during the course of implementing BC Telehealth Program, many of which relate directly to deliverables as outlined in the project plan.

• The primary document describing all elements of the BC Telehealth Program as it was designed and implemented is the Detailed Design Document. This 398 page report consolidates into one place all of the working design documents prepared by members of the project team in collaboration with all of the participating organizations.
• The sustainability reports outline the short and long-term strategies to sustain the applications implemented.
• The ER/Trauma/CME/CNE monthly reports describe the experiences of the ER/Trauma application that was examined during the period of the project.
• The CHIPP Academic Review - Selected Presentations - ER & Trauma Care document and CD are the video based education programs that were designed and delivered during the period of the project's funding.
• The Community Needs Assessment describes the selection and assessment of Whistler as a potential site for the ER/Trauma/CME/CNE Program based on their needs and readiness for this type of service.
• The Privacy Impact Assessment was prepared for the BC Telehealth Program by the Ministry of Health Services.
• The Project Management Evaluation Report was prepared by the Ministry of Health Services and Health Planning Project Management Office at the request of the BC Telehealth Project Manager in order to capture lessons learned in the management of the project.

Document /Product Name	Form (Paper /Electric)	Licence Fee Required (Yes /No)	Previously Provided to Health Canada (Yes /No)	Appendix Name /Number
Detailed Design Document	Paper and Electronic	No	No	Appendix A-BC Telehealth Program Detailed Design Document
Short Term Sustainability Strategy	Paper and Electronic	No	Yes	Appendix B-Sustainability Reports
Long-Term Sustainability Strategy	Paper and Electronic	No	No	Appendix B-Sustainability Reports
CHIPP Monthly and Summary Reports - ER /Trauma /CME Program (February to September 2002)	Paper and Electronic	No	No	Appendix C - ER /Trauma /CME Program Reports
CHIPP Academic Review - Selected Presentations - ER & Trauma Care	Paper and Electronic	No	Yes	Appendix D- ER /Trauma /CME ER and Trauma CME Program
Community Needs Assessment - Vancouver Coastal Health Authority	Paper and Electronic	No	No	Appendix E-Community Needs Assessment
Corporate Privacy Impact Assessment - BC Telehealth Program	Paper and Electronic	No	No	Appendix F-Privacy Impact Assessment
Ministry of Health Planning and Ministry of Health Services - BC Telehealth Program Project Evaluation Document	Paper and Electronic	No	Yes	Appendix J-Project Management Evaluation Report

4. Impacts

4.1 Resources, Services and Structure

4.1.1 Human Resources

Given the number of provider agencies and community partners involved in the various project applications, project staff in the field and in the lead agencies were afforded:

• Experience in the areas of business case development, program development and continued process improvement.
• Training and knowledge in the operation of videoconferencing equipment, troubleshooting technical problems in the use of equipment, and in using videoconferencing in administrative, education and clinical delivery situations.
• Opportunity to collaborate with clinical directors, physicians, nurses, and educators in other organizations within and outside of their Health Authority. These activities not only strengthened professional relationships, but also were invaluable in terms of integrating knowledge of hospital procedures, staffing structures, and clinical issues.
• Experience and skill in development and use of data collection methods (e.g. clinical logs, questionnaires and surveys).

The extent and lasting impact of the changes to clinical and support staff roles and responsibilities is too early to predict because of the emerging nature of the roles and where they report within the organization.

The majority of clinicians and support staff regularly using telehealth as a mechanism to deliver scheduled clinical services and professional education are now fully trained to initiate the technology independently. However, in sessions involving links with multiple communities, usually of a professional education nature, support from a "technical expert" is often required.

Program support and coordination is being achieved through a variety of different mechanisms. Dedicated site based coordinator positions have been established to initiate business development opportunities and manage the use of telehealth services at the facility. In addition, the geographic health authorities have established dedicated regional telehealth coordinators to plan, implement, monitor and promote telehealth services within their Health Authority. Program and provincial coordination of the telehealth activities, particularly services involving multiple sites, is resulting in the establishment of administrative infrastructure to support and schedule sessions, particularly at sites primarily hosting activities. Technical support is being provided by existing and/or dedicated support staff in either Information Systems, Biomedical Engineering or Audiovisual Departments.

4.1.2 Services

The impact of the services implemented varied depending on the nature of the service, the communities' needs and readiness for an alternate approach, and the level of experience of participants with technology.

Clinical applications, including services provided by physicians as well as by nutritionists, therapists and nurses, were the most innovative services implemented but were the most challenging services to implement and integrate into existing health care delivery structures to ensure sustainability and continued growth in utilization. There are a number of clinical applications where demand is continuing to grow such as in the area of fetal ultrasound testing, paediatric echocardiogram interpretation, and patient care planning through multi-site rounds. Physician providers have commented on both the delivery and receiving ends that it is often more work to participate in consultation using telehealth than seeing the patient in their office. This is usually related to scheduling issues that require travel to where the equipment is based to be involved in a telehealth consultation. Other practitioners have also voiced that coordination of discharge planning and family visit sessions require additional work to arrange because scheduling participants to be present at each site is more time consuming than establishing a meeting in one central location. Physician reimbursement also remains a barrier for delivering clinical services via telehealth and will require resolution in order to maintain the existing telehealth applications or expand to other applications provided by fee for service physicians.

Video conferencing has increased access to continuing professional education programs by a wide variety of health professionals in rural and remote communities. This has occurred at reduced costs, resulting in more efficient use of clinician time, and a growing community service capacity as a result of the additional training and peer support network. Education sessions are consistently well received by partner sites with enthusiasm for sustaining and increasing the scope of these events following the project. There is little to no resistance to accessing continuing education through video conferencing from all participating sites. This has been and continues to be a very successful telehealth application.

Administrative applications had the least focus during the project but are proving to be the fastest growing use of video conferencing. The demand is primarily intra-regional and has proven to be a very cost-effective way of receiving input and dialogue on region wide planning, issue management, and communication requirements.

4.1.3 Structure

The BC Telehealth Program was organized specifically around the delivery of three programs: Maternal Child, Paediatric Palliative Care and ER/Trauma CME/CNE to communities participating in a consortium of interested partners. The central support including the Steering Committee for these programs is no longer available in the manner effected through the project funding period. There is agreement, however, that a structure to support efficient and effective means of coordinating and accessing health services through appropriate telehealth technologies is required province-wide.

A provincial scheduling mechanism is needed to improve the efficiency of operating telehealth services, especially for multi-point conferences. As a provincial bridge will be in place this year, the opportunity exists to incorporate a scheduling system along with the technical and human resource supports where required. Effectively coordinating both the technology and the participants is key to maintaining successful telehealth events.

4.2 Communities and Delivery Agencies

The following summarizes the response to a recent informal survey of the regional/program telehealth coordinators about these impacts.

4.2.1 Communities

The Northern Health Authority has had the broadest level of telehealth involvement with five communities (i.e., Prince George, Terrace, Smithers, Kitimat and Prince Rupert) participating in one or more of the telehealth applications implemented. They report that telehealth is making a profound difference by:

• Diminishing the isolation of communities, increasing integration and connectivity of clinicians and service delivery modalities, and introducing new possibilities to improve service delivery by assisting clinicians, staff and management to find ways to be more effective and efficient;
• Providing the public with access to services that they did not have before and building confidence in the health care services provided to their communities;
• Providing community and health care professionals with education opportunities not previously accessible due to lack of time and funds;
• Providing the health authority management teams with more time to carry out their duties through the use of this viable alternative to support the administrative of this large geographic region and reduction in the time spent on traveling to different communities.

The Interior Health Authority's primary involvement outside of the on-going professional education support to Penticton Hospital was in the East Kootenays as part of the ER/Trauma/CME/CNE Program and their own related intra-regional orthopaedic consultation application between Fernie/Invermere and Cranbrook. The benefits to these communities, as reported by the Regional Coordinator include:

• The most appreciated application has been the continuing professional education programs delivered by the lead agencies. This has opened doors to clinicians in rural practice by linking them to their colleagues in the province and strengthening their performance through access to the same learning opportunities as colleagues in urban settings, without having to leave the community.
• The Intra-regional orthopaedic consultation from Fernie and Invermere to Cranbrook has had a positive impact on patient care as a diagnosis is reached promptly and treatment plan started immediately as opposed to having the patient travel and/or wait for one or two days. A number of transfers have been avoided. Orthopaedic surgeons are satisfied with the clinical effectiveness and timeliness of providing the necessary care in this manner.
• The ability of the ICU staff in Cranbrook to link via videoconference to Vancouver General Hospital specialists has provided an added level of support and confidence to nurses and physicians in Cranbrook.

Vancouver Island Health Authority involvement in the BC Telehealth Program has been to enhance pediatric services at Victoria General Hospital through connectivity with C&W. This has provided the impetus for them to strengthen and expand telehealth services within and beyond these applications. They have capacity to provide local access to clinicians to access continuing professional education programs and the basis for expanding clinical services in the area of paediatric oncology and cardiology within the region.

Child Development Centres (CDCs) in Prince George, Kitimat, Smithers, Kamloops and Kelowna participated in the BC Telehealth Program. Predominately these agencies have been using telehealth for Continuing Professional Education sessions. The targets set out at the beginning of the project for increased access to clinical services by the CDCs were in many cases not reached, due to limitations in the capacity of the service provided. Additionally, the potential for service delivery from Sunny Hill at C&W was not accessed, needed or understood by some of the communities involved. The Central Okanagan Child Development Association (COCDA), however, has had an exceptional experience. They have had the advantage of using telehealth for four years prior to the CHIPP Project and have noted that the availability of telehealth technology has:

• Increased the access that families and service providers in the Central Okanagan have to specialized services located in the Lower Mainland.
• Provided local service providers with better and less costly access to professional development opportunities, particularly through the in-service programs offered by Sunnyhill.
• Enabled family members in different locations to keep connected with family members in regional and provincial agencies.
• Built a network of consulting specialists in an environment that typically had been comprised of single isolated community specialists.
• Made it possible for other community groups to access the videoconference equipment on site for new and innovative programs to support local families and children.

Telehealth presents a challenge in terms of ensuring its sustainability by all of the CDCs. While cost recovery strategies could provide the answer to this challenge it also adds administrative overhead that is difficult to meet in this era of fiscal restraint.

4.2.2 Lead Agencies

Telehealth services have been in use at C&W since the mid 1990s. The implementation of the BC Telehealth Program, which increased the number of community sites having access to video conferencing equipment, has already had a dramatic impact on the amount of clinical, education and administrative sessions occurring on a weekly basis. This has resulted in a 100% increase in monthly activity at C&W comparing April 2002 with April 2003.

Examples of C&W activity include medical genetics, cardiology, child development and rehabilitation, maternal-fetal medicine, oncology and neonatology. Some of the applications that were put in place through the project have been scaled back or modified based on user experience. For example, through CHIPP, long-term follow-up oncology clinics were implemented. Several of the oncologists felt, however, that they preferred face-to-face encounters in order to conduct physical exams. Oncology will proceed with other applications such as tumour rounds. Discontinuing the follow-up clinics may address physician preferences, but there are open questions regarding patient preferences for travel or community physician preferences for clinic structure. Several applications will be modified based upon C&W's CHIPP experience, but are still being actively pursued (e.g. neonatology). There are clinics that continue to grow based on increasing demand from remote sites.

Canuck Place Children's Hospice was able to extend its specialized services for children with life threatening disease through the use of the telehealth network. Canuck Place has used Telehealth for specific events on an as needed basis. Its role has been confined for the most part to consultations. In particular, they have had the opportunity to work closely with a physician and family who reside in the Yukon. Given that they are out of province, the family will not likely come to Vancouver yet will have the opportunity to access to the services offered by Canuck Place that are essential for them being able to care for their child at home.

In addition, Canuck Place has participated in multi-site education sessions broadcast by the Telehealth partners. These sessions have been useful and are expected to be more fully utilized in the future, along with its own development and hosting of a series of education events to be broadcast to the partners using the Telehealth infrastructure.

Finally, Canuck Place has used the Telehealth equipment to facilitate remote participation at events such as May 2002 Pediatric Palliative Care Committee meeting and expect to continue to do this whenever the need is presented.

The lessons learned through the joint development and delivery of the ER/Trauma/CME/CNE Program by Vancouver Hospital and Health Sciences Centre and University of British Columbia Division of Continuing Medical Education (UBC Division of CME) has resulted in the establishment of the e-STEP Advisory Committee (Strategic Telehealth Enhancement Partnership) to develop a business model and strategic plan to build telehealth services for the Vancouver Coastal Health Authority (VCHA) by building on the project successes in CME and CNE and focusing clinical service delivery on communities who need and are ready for telehealth services. The e-Step committee also allows VCHA to create a cohesive, unifying mandate in order to partner with the other health authorities to deliver telehealth services and facilitate contact with quaternary centres within VCHA to rural and remote areas of the province. While the clinical component of this project was focused on the delivery of Emergency and Trauma services, it developed champions in many other service specialties and interest is now growing to establish telehealth services beyond those developed during the project. For example, the Departments of dermatology and Geriatrics at Vancouver General Hospital are interested in creating clinical consultation services to rural physicians in British Columbia. Central to the approach going forward is the intent to clearly develop programs based on community needs and priorities as well as understand current referral patterns and the need to develop familiarity within the communities of practicing "telehealth" professionals.

The educational component of the project involved delivery of weekly round for physicians (CME) and nurses (CNE) which were coordinated by staff at UBC Division of CME. Both programs have been enormously successful in extending the educational opportunities afforded urban health professionals to rural communities. For CME the original target audiences were Terrace and Cranbrook who were the rural sites involved in the ER/Trauma clinical component. By the end of the project periods, seven additional sites were attending these weekly rounds with two out of provide groups also connecting on an "ad hoc interest" basis. Similarly, CNE rounds expanded from the original two sites (i.e., Terrace and Cranbrook) to ten sites within the project period.

The success of both of these educational programs is resulting in new initiatives beyond the nursing and medical specialities involved during the project period. For example, weekly surgical rounds which are presented to a "live" audience at Vancouver General Hospital are now being broadcast simultaneously to three remote sites. In this case, pre-existing face-to-face rounds are now accessible to rural and remote physicians. Other speciality rounds, which currently have an "in house" audience, are also being planned for broadcast.

The project was an enormous learning experience for UBC Division of CME in terms of telehealth and technology-enabled education. As one of the first initiatives combining clinical and educational telehealth service delivery, the lessons from this project have yielded positive impact on the Division. Project personnel gained valuable professional development opportunities such as academic publications and conference presentations. Dissemination of project results and lessons learned have begun with three international conference presentations, one article submitted for journal publication and a plan for several more publications to be prepared collaboratively by project collaborators.

The knowledge and resources gained through the BC Telehealth Program are now being used to collaborate on other initiatives related to telehealth and telelearning. Initiatives include CME and CPD needs assessments, delivery and evaluation, innovative telehealth/telelearning projects. Three examples of this expansion follow:

• Based on the assessment of health professionals' continuing professional development needs, the division secured funding to staff a full time videoconference coordinator and clinical director to continue CME rounds to rural communities as an educational program (Using Videoconferencing as a Tool for Facilitating Health Education in Rural British Columbia).
• Extended from project educational initiatives, multimedia presentations were captured in digital format and presented in CD-ROM, along with lists of references, additional materials, and online assessments. (Selected Presentations in Emergency Medicine and Trauma Care).
• Building on our growing expertise in telehealth, UBC Division of CME and the Canadian Institutes of Health Research (CIHR) organized a 'think tank' workshop on Technology Enabled Knowledge Translation, featuring experts in research, education, health, industry, and government from across Canada and the world. Participants were provided opportunity to apply their knowledge and insights related to their respective fields to a common context of re-conceptualizing potential barriers and solutions in health care reform.

4.3 Privacy and Protection of Information

Understanding and mitigating the risks associated with the implementation of telehealth services on the privacy of patient and care provider information was an integral part of the development of the Program. The wide variety of organizations and applications involved made it important to ensure that relevant policies and procedures were either already in place or developed and implemented.

A Privacy Impact Assessment (PIA) was undertaken to address this issue. It was developed during the course of the project and was based on input from the various project partners and participants. Assistance from the Information, Privacy and Records Branch of the Ministry of Health Services was sought on numerous occasions. As well, supporting information was obtained from the Canadian Health Records Association and relevant provincial Acts and legislation. On completion, it was distributed to all Health Authorities and associated agencies to serve as the source document in addressing all privacy concerns with existing and new telehealth initiatives. The intent is for the PIA to be regularly reviewed and updated as technology changes (e.g. the move to an IP based network) and as new applications emerge.

Different facets of privacy protection were considered including:

• The appropriate collection and storage of health information;
• The disclosure practices of health information for agencies covered by FIPPA legislation and for non-public bodies.

The principle of informed patient consent was adopted for telehealth clinical services and procedures, similar to those followed for other clinical encounters for scheduled and emergent care. Informed patient consent for any telehealth encounter is obtained, and the individual is provided with as much information about potential risks (and benefits) as possible. Paper forms are used for this exercise, and copies are kept at both sites involved in the encounter. There were no reported incidences of individuals refusing to sign consent and no breaches of confidentiality reported.

A few health care professionals involved in the ER/Trauma application were not comfortable working "on camera" and having their actions and decisions subject to view by the emergency and trauma care specialists in Vancouver. Consequently, there was a reluctance to invoke a telehealth encounter and this concern will need to be addressed should this application be reinstated.

The use of videoconferencing in emergency and trauma situations highlighted issues related to maintaining privacy for the patient in the Emergency Department environment, which is typically a non-private setting. The additional dimension of videoconferencing participants outside caused some concerns:

• Audio coming from the provider site was significantly louder than regular discussion and could easily be overheard by other patients and families;
• Video images from both sites from time to time revealed images of individuals not directly related to the session in progress.

In one location, the Emergency Room treatment bay was redesigned to enhance privacy during an emergency telehealth session. The use of headsets for the health care team at the local site was also introduced as a way to guard against the input from the specialist team being 'broadcast' too loudly.

The BC Telehealth Project did participate in the CHIPP Privacy and Security Survey conducted in August 2002. The resulting report indicated results only for the emergency/trauma component but may certainly be applied to all components of the project. Plain language privacy policies, obtaining informed patient consent for all disclosures of and secondary uses of information, and providing detailed information on the purpose of collecting information are all recommendations that will be considered for the future. In some situations, through implementing these recommendations, the information provided to patients around the collection and disclosure of their information will be more extensive and specific than is currently provided for non-telehealth encounters.

One of the impacts of implementing the BC Telehealth project is the increased awareness, at many levels and in many organizations, of the issue of protection of privacy, confidentiality and security of patient information. The policies and procedures developed, along with a comprehensive Privacy Impact Assessment, provide for a strong framework for future use.

4.4 Policy and Research Implications

Telehealth holds significant promise for establishing and implementing best practices, improving service quality and standardization, directing and supporting professional development, and planning the effective use of resources. Specialists working in small communities, disconnected from other practitioners in their own discipline, have the potential to connect with a broad network of colleagues and consulting specialists. This, along with the wide range of experiences that we have had in implementing and operating the programs and services of the BC Telehealth Program, has highlighted the need to address the approach to planning and delivering services within our agencies and health authorities.

• The use of telehealth must be built into organizational policy. It must be considered in the overall planning of delivery of health care services and in the allocation of specialty services. This should ideally be done at a provincial level.
• Impact on system capacity, workload and procedures must be considered in the implementation of telehealth applications. The reengineering of service delivery mechanisms requires a rethinking of organizational and provincial level policies and the establishment of processes and procedures that go beyond the normal scope of staff responsibilities and involvement.
• More thorough needs assessment and accounting of market potential needs to be considered prior to developing services. Emphasis should be placed on the applications that have the highest potential for utilization, cost reduction, and patient/community impact.
• For telehealth services to continue to grow and develop, there needs to be a continued focus on establishing and managing a secure, reliable, standards-based video network throughout the province that is integrated with the data networks, not compromising or competing with data applications for bandwidth, and uses interoperable equipment that does not require expensive bridging connections.
• Continued focus on supporting applied research projects that use existing telecommunications technologies in innovative ways or newly developed technologies for the delivery of clinical services.
• Policy and process for physician reimbursement is needed before further expansion of clinical telehealth services will be achieved.

For the UBC Division of CME, the project impacted policy and program expansion resulting in:

• The development of practical strategies for training of project personnel in terms of technology use and project procedure. Training packages (i.e., manuals) were developed and tested, as were strategies for in-person training sessions and technical demonstrations.
• The development of a course (Videoconferencing 101) to provide training for medical educators using videoconferencing as an educational modality in conjunction with the Medical School Expansion.
• The development and evaluation of policies and procedures (both in situ and via focus groups and interviews of providers and end-users) for providing just in time consultations on demand.
• Lessons learned regarding the importance of community readiness and the need for comprehensive needs assessment. These have been incorporated into current projects run by the division of CME (e.g., Evaluating community readiness of First Nations communities in BC for future telehealth service).

Under the restructuring of British Columbia's health care system, C&W became part of the Provincial Health Services Authority (PHSA). The success of C&W in building diverse and sustainable telehealth services, in large part through CHIPP, will serve as a basis for PHSA to further develop clinical, education and administrative applications for other core clinical agencies within the PHSA as part of its provincial mandate to deliver accessible quality service to people living throughout British Columbia.

5. The Future

The future of the BC Telehealth Program including key barriers, sustainability plans and on going leadership, coordination and development of telehealth services in the province is addressed in the BC Telehealth Program Sustainability for Telehealth Services Report of May 2003 (see Appendix B).

6. Communications

Communications were a constant challenge in this project, particularly because of the changing stakeholders and project team members. Public events were intentionally limited as many of the participating sites and clinicians wanted to wait until the services were properly established before publicly announcing their availability and success. Most of the formal events were held to demonstrate what had been accomplished to internal and external stakeholders.

Methods or Tools	Date	Target Audience	Documents or Presentations	Appendix Name /Number
Publications /Presentations to External Stakeholders	10-Dec-01	Remote and Rural Aboriginal Health Services Committee	BC Telehealth Program	Appendix G-Publications and Presentations
Media Event	31-Jan-02	Health Canada, Ministry of Health, stakeholders and Media	ER /Trauma Program (verbal presentation)
Publications /Presentations to External Stakeholders	04-Mar-02	Premier's Technology Council	BC Telehealth Program	Appendix G-Publications and Presentations
Publications /Presentations to External Stakeholders	14-Jun-02	Premier's Technology Council	Telemedicine Examples	Appendix G-Publications and Presentations
Open House	19-Jun-02	Health Canada, MOHS and Internal stakeholders	Maternal Child Program (C&W)	Appendix G-Publications and Presentations
Website	Jul-02	Health Authorities and Project Team	www. bctelehealth.ca	See web site
Newsletter	May 2002 and July 2002	Project Team and Stakeholders Telemed Project News - ER /Trauma /CME Telemedicine Project	Appendix I-Newsletters
Brochures	Sep-02	Health Authorities, Clinicians and Patients	Maternal Child BC Telehealth Program Brochure	Appendix H-Brochures
Brochures	Sep-02	Patients	Patient Brochure	Appendix H-Brochures
Brochures	Sep-02	Clinicians	Clinician Brochure	Appendix H-Brochures
Brochures	Sep-02	Stakeholders and users	Bulkley Valley Child Development Centre-Telehealth Program	Appendix H-Brochures
Publications /Presentations to External Stakeholders	Sep-02	Royal College of Physicians and Surgeons Annual Conference	Just-in-time clinical consultations on demand: Creating continuing professional development opportunities through the use of trauma and emergency telemedicine interactions	Appendix G-Publications and Presentations
Publications /Presentations to External Stakeholders	03-Oct-02	International Conference of the Society for Telehealth (CST) - Pre-Conference Workshop	Building Blocks for a Provincial Telehealth Network	Appendix G-Publications and Presentations
Publications /Presentations to External Stakeholders	03-Oct-02	International Conference of the Society for Telehealth (CST)	Just In Time Support: Understanding the Impact on Rural Communities Through Physicians' Perceptions of On-demand Emergency and Trauma Tele-consultations	Appendix G-Publications and Presentations
Publications /Presentations to External Stakeholders	03-Oct-02	International Conference of the Society for Telehealth (CST)	Proving Value: How do you demonstrate return on investment?	Appendix G-Publications and Presentations
Publications /Presentations to External Stakeholders	03-Oct-02	International Conference of the Society for Telehealth (CST)	East Meets West: Comparisons in Telehealth	Appendix G-Publications and Presentations
Publications /Presentations to External Stakeholders	03-Oct-02	International Conference of the Society for Telehealth (CST)	BC Telehealth Project Maternal /Child and Paediatric Palliative Care Programs	Appendix G-Publications and Presentations
Publications /Presentations to External Stakeholders	03-Oct-02	International Conference of the Society for Telehealth (CST)	Contextual learning opportunities: The use of telehealth to support continuing professional development for rural physicians and nurses	Appendix G-Publications and Presentations
Publications /Presentations to External Stakeholders	03-Oct-02	International Conference of the Society for Telehealth (CST)	Telehealth as an effective medium for continuing nursing education: Perspectives of e-teachers and e-learners	Appendix G-Publications and Presentations
Open House	16-Oct-02	Health Canada, MOHS (including Minister of Health) and Internal stakeholders	Maternal Child and Paediatric Palliative Care (C&W and Canuck Place)	Appendix G-Publications and Presentations
Publications /Presentations to External Stakeholders	23-Apr-03	3rd Annual UVic BCNet	Evaluation of the BC Telehealth Program	Appendix G-Publications and Presentations
Publications /Presentations to External Stakeholders	25-Aug-03	3rd International Conference on Successes and Failures in Telehealth	BC Telehealth Program-A Catalyst for Change	Appendix G-Publications and Presentations
Publications /Presentations to External Stakeholders	Pending	Journal of Telemedicine and e-health	Just-in-time Consultation on Demand: Physician Perspectives on the Efficacy of Videoconferencing for Rural, Trauma and Emergency Care	Appendix G-Publications and Presentations