Eastern Ontario Telehealth Network

Health and the Information Highway Division, Health Canada
May 20, 2003

Table of Contents

• 1.0 Introduction
• 2.0 Project Description
• 3.0 Achievement
  • 3.1 Goals Reached
  • 3.2 Additional Successes
  • 3.3 Unreached Goals
  • 3.4 Documents or Products Generated
• 4.0 Main Impact
  • 4.1 Human Resources Impact
  • 4.2 Privacy and Protection of Information
  • 4.3 Policy and Research Implications
• 5.0 The Future
• 6.0 Communications
• 7.0 Other
  • 7.1 Major Tasks and Risk Management Plan

1.0 Introduction

The Eastern Ontario Telehealth Network (EOTN) is pleased to submit the Final Project Report to Health Canada as required by the Canada Health Infostructure Partnerships Program (CHIPP). The following documents are submitted under separate cover as part of this Final Report:

1. Project Evaluation Report
2. Project Technology Review and Documentation
3. EOTN Sustainability Plan
4. EOTN Operational Manual
5. In-kind Reports for the last quarter (January 1 - March 31, 2003)

The Eastern Ontario Telehealth Network (EOTN) officially began in June, 2001 as an implementation project with funding from CHIPP. To date, 19 hospitals across Eastern Ontario have received telehealth platforms and are linked via the Smart Systems for Health (SSH) Internet Protocol (IP) network. From January 1, 2002 to May 13, 2003, approximately 420 clinical consultations and 172 educational sessions have occurred within our network.

Telehealth is vital to maintaining the current level of services provided by Ontario's health care system. It is particularly beneficial in helping to alleviate the stressed areas in health care (e.g. nephrology, dialysis satellite centers, and mental health). We need to consider telehealth as a means of sustaining the current health care system as a whole. Telehealth could facilitate the delivery of specialty services, decrease waiting times for patients, improve access to physicians, and assist in the recruitment and retention of health care professionals in rural areas.

We propose taking advantage of the current momentum and building on the existing infrastructure in terms of governance and adapting it to our growing needs. We plan to strengthen existing EOTN sites and expand our clinical and educational services. We must move towards a Regional Eastern Ontario Telehealth Network by including all hospitals in the Ottawa referral area, and extending to those hospitals in the South Eastern region (e.g. Kingston, Belleville and Trenton).

The EOTN gratefully acknowledges the funding received from Health Canada which made all the above possible. The EOTN now provides a vital service to residents in rural and community areas of Eastern Ontario and is part of the new provincial telehealth initiative: the Telemedicine Networks of Ontario (TNO) which encompasses two other CHIPP projects in South Western and Northern Ontario.

2.0 Revised Project Description

The Eastern Ontario Telehealth Network (EOTN) Project was implemented over a 23-month period between June 1, 2001 and April 30, 2003 to facilitate telehealth as a method for the delivery of health care in 19 hospitals in Eastern Ontario via specialized telecommunication technologies. The goal was to support the primary care providers in rural areas through distance access to clinical consultations and specialty services located in three Ottawa hospitals.

The EOTN built on the three-year experience and partnership between the University of Ottawa Heart Institute in providing cardiac care via telehealth to patients in Renfrew County. Hence, Pembroke General Hospital (PGH) was chosen as the lead community hospital in this innovative telehealth initiative. The three tertiary hospitals providing support to PGH and offering clinical consultation services were:

• Children's Hospital of Eastern Ontario (CHEO)
• SCO Health Service
• University of Ottawa Heart Institute (UOHI)

The other 16 rural and community hospitals that make up this unique partnership are:

• Almonte General Hospital
• Arnprior & District Memorial Hospital
• Brockville General Hospital
• Carleton Place & District Memorial
• Cornwall General Hospital
• Cornwall Hôtel Dieu
• Deep River & District Hospital
• Glengarry Memorial Hospital
• Hôpital general de Hawkesbury & District Hospital
• Hospital Pembroke General Hospital
• Kemptville District Hospital
• Montfort Hospital
• Queensway-Carleton Hospital
• Renfrew Victoria Hospital
• St. Francis Memorial Hospital
• Winchester District Memorial Hospital

The primary focus of the project was to provide a full range of clinical consultations services:

• paediatric care including diabetes, mental health, respiratory and clinical genetics,
• cardiac care
• care of the elderly
• complex continuing care
• palliative care.

Specifically, the objectives of the EOTN project were;

1. To enhance the accessibility, quality and cost effectiveness of health care delivery in Eastern Ontario using interactive telecommunication technologies to allow health care providers to diagnose and treat patients in remote and rural areas;
2. To develop a comprehensive and cost-efficient telehealth program in order to ensure that the health care system is integrated, and provided as close to home as possible and accessible to all Ontario residents (Source: 2000 Ontario Budget - Our Health Care Commitment, Ministry of Finance);
3. To help lay the groundwork for an efficient telehealth system as an integral part of the current medical referral pattern in Ontario;
4. To provide health care and scheduled educational services at a distance from Children's Hospital of Eastern Ontario, University of Ottawa Heart Institute and SCO Health Service to rural and community hospitals;
5. To work towards a 24-hour emergency telehealth consultation service based on a critical mass across all sites;
6. To further develop clinical consultations/educational services between smaller non-tertiary hospitals;
7. To assist in the recruitment and retention of physicians and health care professionals in rural and community areas.

A secondary goal was to provide continuing education programs for patients and families and health care professionals in areas such as diabetes, family visitation, heart check, cardiac rehabilitation and palliative care. Continuing education was offered to medical, nursing and allied health personnel, including clinical rounds and peer-to-peer consultations.

The total budgeted cost of the project was $6,000,796. The portion of in-kind and cash contributions from the partners was $3,000,796 and the amount requested from the Canada Health Infostructure Partnerships Program (CHIPP) was $3,000,000.

3.0 Achievements

3.1 Goals Reached

What elements in the originally approved work plan were achieved?

• 19 partner sites were linked via the provincial Smart Systems for Health (SSH-IP) network by Spring 2002
• Over 420 clinical consultations have been offered by 6 consulting and community hospitals (SCO Health Service, CHEO, UOHI, Almonte, Carleton Place and Queensway-Carleton) to 16 community and rural hospitals
• Over 172 educational sessions offered between and among sites including patient/family education, continuing education for medical, nursing and allied health personnel, clinical rounds, peer-to-peer consultations,
• Temporary access to a multi-point bridge was achieved with the South Western Ontario Telehealth Network (SWOT-N) in December 2002
• The Network fostered solid working relationship among the EOTN partners
• New partners in the Ottawa and Kingston region have approached the EOTN and expressed great interest and willingness to participate in post EOTN telehealth services whenever expansion of the network is possible
• Good working relationship and collaboration developed with the other CHIPP projects in the province, particularly NorthNet and SWOT-N, (now known as Videocare)
• A successful sustainability workshop was conducted in October 2002 which resulted in the development of the EOTN Sustainability Plan
• A thorough evaluation plan was developed and a final report was completed as stipulated by Health Canada
• The Final Evaluation Report showed:
  
  
  • High levels of patient, family, and health care professional satisfaction
  • Family physicians in rural communities believed that the EOTN would enhance services in their areas while saving time and money for their patients
  • Educational activities were very well received and deemed an efficient use of time

What were the contributing key factors?

• A strong Management Team who met weekly and overseeing the daily operations
• A well-organized central management office was important for collaboration, coordination and communication between all partners, Health Canada, SSH and MOHLTC
• The Steering Committee met monthly to communicate and address common issues and helped keep the project on track
• There was strong commitment and support by senior management at all sites including the CEO's
• Good organizational infrastructure (weekly Management Team, monthly Steering Committee, quarterly Advisory Council meetings, TH Coordinators and Technical Team meetings).
• The EOTN was built on a three-year experience and partnership between the University of Ottawa Heart Institute and Pembroke General Hospital, where cardiac care has been provided via telehealth to patients in Renfrew County.
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• The network grew from a pilot project initiated between the lead hospital (Pembroke General) and one of the three consulting sites (University of Ottawa Heart Institute - UOHI) to 19 sites.
• New partnerships were forged with other provincial networks; this led to free access to a bridge which enabled us to conduct multipoint sessions.

What were the obstacles or challenges that had an impact on your achievements and how did you deal with them?

• There was an initial delay in signing the CHIPP agreement with Health Canada until August 31, 2001.
• The overall timeframe for the project was too short for the magnitude of the tasks involved.
• The delay in implementation of TH equipment at all sites was due to our decision to switch to the Smart Systems for Health (SSH) Internet Protocol (IP) network. This ultimately resulted in major savings in telecommunication costs for the partners when SSH provided these services in-kind. The SSH infrastructure is integral to the sustainability and interoperability of telehealth in Ontario. At this time, SSH does not allow for multi-point access and therefore, alternative solutions were sought.
• Less TH activity occurring during the first six months due to the delay in equipment and network installation. Therefore, a new goal was set by the Steering Committee in May of 2002 to have each hospital organize 15 clinical consultations per site (for a total goal of 240). By October/November 2002, TH activity was growing exponentially and many sites have since surpassed their goal. It took time for staff to become familiar with the equipment, for the TH Coordinators to promote this type of alternative service to the physicians and patients and to arrange for proper credentialing procedures between the consulting and referring hospitals. While some sites were unable to meet their original target for patient activity, other sites were able to exceed theirs.
• Inadequate staffing or lack of dedicated resources for the TH clinics also affected the activity at many sites. Additional training was provided in March 2003 for all interested staff from the rural and community hospitals. Dedicated site coordinators were also required for organizing educational activities in order to maximize participation. In hindsight, a dedicated Project Clinical Coordinator should have been hired to coordinate clinical activities and training. This will be the next position filled within the EOTN regional office.
• There was limited technical leadership following equipment delivery and installation. CHEO was able to contribute more in-kind time through their technical/biomedical expertise than was originally planned; central technical leadership throughout the project would have been an asset to the project.

3.2 Additional Successes

What elements were achieved beyond the originally approved work plan?

• In order to develop a Sustainability Plan based on Health Canada's guidelines, the EOTN hosted a one-day workshop to obtain input from all the partners and other interested regional stakeholders. (Ottawa Hospital, Community Care Access Centre, MOHLTC, long-term care facilities, Kingston region representatives). Much was accomplished in a short time frame due to the commitment of the partners to maintaining the network post-CHIPP.
• Consultations are being offered between rural and secondary hospitals rather than just with the tertiary hospitals in Ottawa
• Strong linkage/working relationship with other Ontario CHIPP projects, especially SWOT-N
• The number of clinical consultations and educational sessions exceeded our best expectations particularly in the last 6 months

What were the contributing key factors?

• Buy-in from partners, willingness to expand services and build on success
• Great support and enthusiasm from the partners and the Management Team.
• Good working relationship between central office, willingness to share information, lessons learned, policies and procedures, etc.
• Good working relationship with Health Canada and Ministry of Health representatives
• Good working relationship with other provincial networks (SWOT-N and North Net)

3.3 Unreached Goals

What elements from the originally approved work plan were not accomplished or sustained?

• Due to the switch to SSH from ISDN lines, we did not have access to bridging capability during the first 17 months of the project; we currently have a temporary arrangement to access the services of SWOT-N but a formal long-term solution needs to be established.
• A very minor objective included the possibility of providing research opportunities but this did not occur during the short life span of this project.

What were the contributing key factors?

• The initial lack of bridging capability was due to the switch to SSH (which does not yet have this capacity).

What were the obstacles and how did that impact on you not being able to accomplish your objectives?

• The original budget for the project had anticipated accessing commercial bridging services rather than purchasing the bridging equipment.
• The GDC platforms were classified as medical devices by Health Canada, therefore, all sites were equipped with isolation transformers; this resulted in a further delay in the implementation of telehealth activity.
• Firewall problems occurred with SWOT-N following the initial reconfiguration of our telehealth platforms; delays and cancellations of TH activity occurred until the problem was rectified.

3.4 Documents or Products Generated

The table below lists some of the tools and products that we have developed during the course of the project.

Document/ Product Name	Available in Paper and/or Electronic Form	Licence Fee Required for use (Yes/No)	Previously Provided to Health Canada (Yes/No)	Appendix Name /Number
Template(s) for vendor RFP	N/A
Template(s) for vendor contract(s)	N/A
Template(s) for equipment testing				Refer to Technology Review Report
Policy and Procedure / Operational Manual	Draft available in May 2003	No	No	No
Job Descriptions and/or recruitment material	Included in Operational Manual available in May 2003
Software Application(s), includes: EHR application Security/access alert software Telehealth scheduling software Other	N/A
Standards, includes: Data (includes minimal data sets) Image Messaging Other	N/A
Clinical Training Protocols	Included in Operational Manual available in May 2003
Clinical Program Protocol(s) Cardiac Dermatology Mental Health Nephrology Paediatric respiratory and urology Pre admission assessment	Included in Operational Manual available in May 2003	No	No	No
Video Conference Protocols and Etiquette Guide Multi-point etiquette Presentation Tips	Both forms available Included in Operational Manual available in May 2003	No	Quarterly Report Oct-Dec 2002
Consent Forms	See Operational Manual
Sustainability Plan	Yes	No	Submitted with Final Report

4.0 Main Impact

What difference is your project making in your community or your region?

• Enhanced access to specialty care by patients in rural areas of Eastern Ontario: for example, at the SCO Health Service, the dermatology clinic has led to a decreased waiting list for dermatology cases and pre-admission assessments have the potential for improving the utilization of their geriatric rehabilitation beds
• Enhance access to rounds, CME, continuing education by health care professionals
• Increased collaboration and relationship building amongst the partner hospitals
• Physicians believed they were able to avoid unnecessary transfer of patients and make earlier diagnoses
• Physicians believed TH improved the patient management process
• Participants in TH educational sessions believed that such sessions would increase access to topics in health care while making efficient use of their time.

What difference is your project making to your patients, to health care professionals, or to your organization's management and structure?

• Less traveling time and expenses for patients, families, physicians and other health care professionals
• Less unnecessary transfers to tertiary care centres
• Increased contact, improved working relationship between rural and consulting hospitals; this came about from working closely on the project, frequent meetings, common-problem solving, etc.

What changes have you noted in the provision of services?

• Increased access to specialty consultations and education sessions for rural areas
• TH clinics are being integrated into the mainstream of health care
• Improved working relationships between network

4.1 Human Resources Impact

What new skills have staff/health care providers developed? Are these skills transferable to other jobs or situations?

• Staff have received training on the use of telehealth platforms, peripherals, telecommunications, bridging software
• CHEO has taken over the maintenance contract for the EOTN partners resulting in operational savings for the network
• Senior staff and many of the TH coordinators have acquired new project management skills which can be applied to future projects (e.g. managing multi-site operations, tracking in-kind information, collaborating with other hospitals, federal and provincial government representatives)
• Hospital staff (e.g. nursing staff) in many instances have had to learn to access the website, use EXCEL and database software for their activity and in-kind reports as well as adapting many of these procedures to their own internal processes

Have new positions been developed?

• Telehealth coordinator positions were required at each site, generally part-time in the community/rural hospitals and full-time in the consulting hospitals
• Administrative, clinical, technical and medical leadership roles required at each site
• Central Office staff: Project manager, administrative assistant, technical consultant, clinical coordinator/educator, medical director, evaluator, communications.

Has the new technology increased demand on service providers? If so, how is it being managed?

• Yes; consulting hospitals cannot meet increased demand from rural areas; for example, a second dermatologist recruited at SCO is still insufficient to meet the demand. It has been difficult to tell if this demand was already in the system and the introduction of telehealth provided an opportunity for this demand to be quantified.
• We are limited by the lack of a centralized scheduling process
• Logistical issues such as room bookings, patient scheduling, staffing, etc. are currently the responsibility of each site which has significantly increased their workload.

Has job satisfaction changed?

• This is hard to gauge without doing a specific site survey, however, respondents to surveys pertaining to educational sessions report that they found these sessions a good way to 'network' with their colleagues, that it involved less traveling and better access to continuing education and research materials.

Was there resistance to change?

• This is an on-going change management process
• From our experience, there was more resistance to change if there was limited buy-in from senior management and/or the medical staff
• Certain sites were quicker to take advantage of the technology than others; also depended on the personalities - some more at ease with technology than others
• Sites who had a 'champion' to promote the benefits of telehealth, tended to become more active and innovative in their use of telehealth.

4.2 Privacy and Protection of Information

Have there been changes in the behaviour of health professionals/staff with respect to the protection of personal health information?

• There have not been any noticeable changes in the behaviour regarding privacy of personal health information. Clinical service providers identify the same issues in provision of telehealth activity as they do in the traditional face-to-face consult.
• From the overall network perspective, the staff is more aware of the security features built into the network. The original network was based on ISDN technology which provided a secure private connection, however, limited the access to only those partners that had ISDN connectivity. In addition, additional security is provided by the end-equipment (video codecs) as encryption can be enabled on these devices. As the network has now moved to the SSH (Smart Systems for Health) IP( Internet Protocol) network, there are issues with the network security but they are being addressed with new secure IP overlay networks (IPSEC). Each session will now be managed and secure.

Have changes been made to your policies and procedures?

• New policies and procedures were developed by a few of our sites to incorporate TH into their operations
• An EOTN Operational Manual is being prepared as a user guide for all partners to help complete their internal polices; the first draft is scheduled to be distributed at the final Steering Committee meeting, May 30, 2003.

Have you completed a Privacy Impact Assessment? Did you participate in the CHIPP Privacy and Security Survey conducted in August 2002.

• No.

Did you receive any patient views/concerns/compliments on the handling and use of their personal information?

• Confidentiality of information was more of an issue for providers than for patients.

Did any of your privacy/confidentiality rules/guidelines help or hinder your health care providers (all staff) to provide patient service?

• No.

Was patient privacy raised as an issue in any way during the trial?

• No.
• Standard operating procedures regarding patient confidentiality were applied to telehealth consultations.

What tools were used for obtaining and managing patient consent? (electronic/paper/combination)

• TH patient consent forms were developed at most of the sites.

Were there instances where patients refused consent and, if yes, what were the reasons given?

• No.
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Will you be conducting regular Privacy Impact Assessments?

• No.

Have you participated in discussions with representatives of provincial health infostructure networks on privacy and protection of personal health information?

• Yes.
• Discussions are on-going.

Do you feel your project has influenced privacy policy and process development in your jurisdiction?

• No.

4.3 Policy and Research Implications

What results do you feel can be used to influence key groups, based on the knowledge and experience gained by your project? Consider stakeholders such as government policy makers at the federal, provincial, and territorial levels; health planners; health administrators; and health, health care, and technology development researchers. Please include your recommendations for next steps based on these major findings.

The Project Manager was appointed to the Ontario Advisory Committee on Telemedicine (ONACT) which was established by the Minister of Health to review provincial policy and sustainability of TH in Ontario. Representatives from the three main provincial networks (EOTN, SWOT-N, NorthNet) have joined forces in a provincial initiative called the Telemedicine Networks of Ontario (TNO) to ensure a smooth transition to full interoperability in the province. Technical standards and infrastructure integration will be coordinated among the three networks.

Major findings	Policy Implications	Applied Research Implications	Recommendations for next steps
Central office function required to manage regional network	Administrative structure to be confirmed; on-going funding required past March 31, 2003 to sustain the EOTN		Discussions with MOHLTC
Physician credentialing and reimbursement process needs to be clarified			Coordination of credentialing process among partners; Discussions with OMA-OHIP Tariff Cttee
Physician referral patterns need to be studied further; need more buy-in at both referring and consulting sites		Study the impact of TH on physician referral patterns
Costs savings perceived by patients, physicians and other staff		A more in-depth analysis of the costs and cost-savings achieved through TH
Patient Consent process should be consistent across Ontario			Discussions with other networks and MOHTLC
Provincial standards required for network infrastructure and interoperability	Technical standards required		Discussions with SSH, technical leads from each network
Physician payment	Provincial funding formula required		OHIP-OMA Tariff Committee need to agree on a set fee schedule

5.0 The Future

What are your plans for maintaining or developing your project once CHIPP funding ends? If you have already prepared a sustainability plan, please attach it as an appendix.

Refer to the EOTN Sustainability Plan.

In addition, we would be interested in your views on areas where additional pilot projects are needed.

One area of interest would be to study the effect of telehealth on current medical referral patterns. Secondly, the use of telehealth by nursing and other allied health professionals to treat/educate patients is the next logical step to be studied and evaluated.

The EOTN seems to be well on its way to becoming a viable, sustainable network providing the MOHLTC follows through on their funding plan. The next step is expansion to include the other Ottawa area hospitals as well as those hospitals in the South Eastern region up to, and including, Trenton. Discussions have begun with these sites but there are no immediate funds available to include them systematically as we expand. A third pilot project could be the expansion of the EOTN. Fourthly, some of our partner sites are interested in investigating opportunities to deliver home care via telehealth.

6.0 Communications

What methods or tools did you use to communicate with your stakeholders? Please provide a copy of the documents you will list below as appendices.

The Eastern Ontario Telehealth Network developed a comprehensive Communications Strategy at the beginning of the project. Refer to Appendix 1a.

Brainstorm Communications led the communications effort, providing leadership to partners and taking a primary role in developing the collateral materials, media stories and communications pieces. The partner hospitals provided a key role in providing input and in disseminating EOTN materials across the region.

Proactive, two-way communications, with ongoing dialogue between sites, ensured that the aims and objectives of EOTN were clearly articulated and shared with our communities.

The following chart summarizes some of the key communications materials produced during the implementation project:

Methods or Tools	Date	Targeted Audience	Documents or presentations produced	Appendix Number
EOTN Launch Workshop	Oct 2, 2001	Partner hospitals; government officials; media	Workshop provided an opportunity to present details about the new partnerships and demonstrate the capabilities	Media release (Appendix 1b)
Media Events	Various	Partner hospitals staff, physicians, volunteers and board members; local community members and health care partners; local media; local politicians	In addition to the launch workshop, several small events were held at individual hospitals resulting in local media stories	Various clippings (see samples in previous quarterly reports)
Media Events	Apr 4, 2003 (postponed)	Partner hospitals and staff; local, provincial and municipal politicians, Health Canada and MOHLTC repre-sentatives; media	A major media event planned for April 4 was cancelled due to SARS outbreak; it will be rescheduled at a future date
Media Coverage	Various	All partner communities, City of Ottawa, provincial coverage		Sample media summary (Appendix 1c)
Presentations	2001-2003	To partner sites, Health Canada, MOHLTC, CST conference	Project manager	Appendix 1l
Publications	EOTN Fact Sheets	See above	Three fact sheets developed: overview, history and technology	Attached (Appendix 1d - 1f)
Publications	EOTN Articles	See above	Five articles produced during project to provide updates - partner hospitals were encouraged to use these materials for newsletters, board presentations, local media updates, etc.	Attached (Appendix 1g - 1k)
Publications	EOTN Poster	Posted in prominent location at each site	48X30" laminated poster	Small version attached
Publications	EOTN Brochure	See above	Bilingual brochure produced and widely distributed
Publications	EOTN Powerpoint Presentation	See above	Generic presentation developed for presentations to: boards, community groups, staff, etc.	Available upon request
Open House	Partner hospitals staff, physicians, volunteers and board members Several partner hospitals held an Open House to provide tours of the new TH room, demonstrate equipment	Collateral materials produced for partner hospitals (see above)
Website www. eotn.ca	Launched April 2002	Partner sites including clinicians Health care community General public Media

Refer to Appendix 2 for a complete list of EOTN contacts (administration, clinical, technical and communication) at each site.

7.0 Other

7.1 Major Tasks and Risk Management Plan

Table 1 refers to the list of Major Tasks that were completed in the final quarter of the project between January 1 and March 31, 2003. All tasks were completed by the project end date. See below.

Table 2 provides a summary of all risk management activities that have been resolved during the course of the project. Risk management activities were reviewed weekly by the Management Team, monthly by the Steering Committee and quarterly by the Advisory Council. See below.

Are there other thoughts or information you feel Health Canada and other possible readers should be aware of, such as, patient safety issues?

Implementing telehealth in multiple sites is more complex and time-consuming than imagined as it represents major organizational change. It took almost two-thirds of the 18 month project to deploy the equipment, train the staff, develop clinical protocols and processes, and then, begin conducting telehealth activity. This left very little time to generate extensive clinical and educational sessions for evaluation purposes.

Patients living relatively long distances from Ottawa embraced the use of telehealth through the EOTN. There remains much work to do to achieve higher levels of buy-in from physicians and other providers in both the referral and consulting sites.

Confidentiality of information was more of an issue for providers than for patients. Policies were followed as if they were in traditional settings. The overall benefits of TH appear to favour patients more than other parts of the health care system at this point in time.

Access to educational sessions through the EOTN, appears to have increased considerably at little or no additional cost to participants and their organizations. It is important to have dedicated site coordinators who could lead education efforts and act as champions for the system.

Permanent funding is required to cover on-going operating and maintenance costs of the EOTN. Support from the MOHLTC has been very favourable, however, on-going negotiations are required. The EOTN needs to become part of a larger regional network including all hospitals in the South Eastern and Champlain District Health Council regions. Finally, the EOTN needs to continue working collaboratively with the MOHLTC and the other telehealth networks in Ontario to improve access to health care via telehealth in the province of Ontario.