IIU Network Nunavut Telehealth Project

Health and the Information Highway Division, Health Canada
October 2003

Table of Contents

• 1.0 Introduction
• 2.0 Project Description
• 3.0 Achievements
  • 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

1.0 Introduction

This report has been created as both a final requirement to the partnership agreement between Health Canada and the Government of Nunavut under the Canadian Health Infostructure Partnership Program (CHIPP) and an information tool to assist other organizations embarking on similar projects.

The IIU Network Telehealth project was planned and executed by a strong and diverse project team whose various backgrounds included expertise in medicine, nursing, technology, training, the law, management and finance. That team was supported throughout the life of the project by government officials in Nunavut and resources within many departments including but not limited to Health and Social Services and Public Works and Services, as well as resources from the Office of Health and the Information Highway managing the CHIPP initiative.

Lastly, and of utmost importance, was the support and enthusiasm the team encountered at the community level from the health centre nurses, social workers and support staff as well as community members.

2.0 Project Description

The Government of Nunavut recognizes that telehealth will play a potential role in delivering a wide range of health care, social programs and services to Canadians living in remote and isolated communities. A series of pilot projects were implemented including a videoconferencing project connecting Iqaluit to Cape Dorset and Pond Inlet. Pilot activities have included telepsychiatry, teleradiology, dermatology, mental health counseling, education, and a visitation program. The IIU Network project will extend these services to additional Nunavut communities with links outside the territory. To achieve this objective, installing a parallel network will expand the existing infrastructure and all equipment will be verified to ensure compatibility. The IIU plans to use bandwidth from the Anik-F1 satellite to support the expansion. The IIU Network will improve the access to health care by the people of Nunavut beyond the "basics" to include health, social services, public health, education and administration. The project will also significantly impact the existing infrastructure and provide greater access to information for professionals working in Northern remote communities. The continuing education and contact with other health care providers will provide much-needed support to health care workers -- potentially improving health care resource shortages by encouraging the recruitment and retention of medical professionals.

3.0 Achievements

The IIU Network has not been in place long enough to achieve all of our objectives, but the overall feeling is that we will, given time. The Department of Health and Social Services is committed to ongoing evaluation of the program and to producing a report at the end of the fiscal year.

This section will highlight goals within the project plan that were reached, some that have not been achieved as of this writing, as well as documents and product that are available as a result of the project.

It is important for the reader to understand the environment surrounding the implementation of such projects in Nunavut. Some of the challenges present during this project include:

• Territory is vast, 1/5^th the size of Canada
• 27,000 inhabitants spread over 26 communities
• Communities only accessible by air or sea
• Substantial difficulty in recruitment and retention of clinical and technical professionals
• Unique infrastructure in the North, on a community to community basis and from north to south; communication based on a hybrid network of frame relay and satellite technology.
• Reliance on referral services from providers in jurisdictions in other provinces and territories.

A more complete picture of the challenges presented can be found in the IIU Telehealth Project Document in Appendix A.

3.1 Goals Reached

This section will detail some of the goals the IIU Network Telehealth project reached throughout the course of the project.

An Advisory Committee (AC) was developed at the onset of the project. This committee was tasked as the oversight for the project and included membership from the existing Steering Committee as well as a Health Canada rep and project team members. This committee evolved throughout the course of the project to the Telehealth Steering Committee in place today. This committee vets all telehealth issues and makes recommendations directly to H&SS executive committee. A partner's forum was developed but not struck as the AC felt this group would be well represented in the individual Telehealth Working Groups. These working groups were developed to assist in the cross-jurisdictional referral agreements. Each region has its own working group, which reports its progress to the Steering Committee (nee Advisory Committee). The Steering Committee is comprised of the following members:

• ADM, Corporate Services - Chair
• Manager, Telehealth Services - Secretary
• Executive Director, Baffin - Member
• Executive Director, Baffin Regional Hospital - Member
• Executive Director, Kivalliq - Member
• Executive Director, Kitikmeot - Member
• Director Social Programs - Member
• Health Centre Representative - Member
• Director Medical Affairs - Member

Each Working Group (WG) is tasked with developing telehealth programs in their region in cooperation with their referral partners.

The WG is comprised of:

• Manager, Telehealth Services - Chair
• Executive Director/Designate - Member
• Director Medical Affairs - Member
• Manager Health Programs - Member
• Manager Social Programs - Member
• Nurse-in-Charge, Telehealth Community - Member
• Nurse-in-Charge, Non-telehealth Community - Member
• Southern Provider - Member
• 2nd Southern Provider - Member
• Patient Case Management - Member
• Telehealth Coordinator - Secretary

A total of 15 sites were installed within Nunavut, 5 upgrades and 10 new installations.

• The project received positive feedback from the project evaluators around planning and implementation phases.
• The project produced an easy to use training manual and other training tools
• The project selected reliable and easy to use systems

A needs based approach was used when surveying the needs of each community as well as configuring the telehealth stations. This approach was decidedly different that what was used in the past in Nunavut, as well as other telehealth programs across the country. Nunavut communities, practitioners, clients and their families have expressed the feeling of improved access to health care services including health, social services, public health, education and administration.

Throughout this project, the Department of Health and Social Services as well as the Government of Nunavut have supported the ongoing investment in telehealth by expanding the infrastructure, services and telehealth programs to 15 communities. The project assisted the Department in supporting staff that provide services in remote locations through continuing education, enhanced problem solving and greater participation in patient care plans and delivery The team, as well as the Department of Health and Social Services, used Telehealth as a community development tool providing communication between communities and regions supporting broader population health determinants.

The ongoing support of telehealth within H&SS executive, finance, PW&S and GN as a whole has increased over the term of this project. As a result, PW&S are working with H&SS to create a videoconferencing strategy for the entire government. As a demonstration of their ongoing support of telehealth, the Department has created a Telehealth Services Division within Corporate Services. The organizational structure has been revised to include the telehealth positions both centralized and decentralized to the communities. These positions are indeterminate positions.

At the onset of the project, H&SS did not have a strategic plan for telehealth. The project team developed a strategic document over the course of the project that reviews our program to date as well as provides direction for the future. This strategic plan has since been forwarded to the H&SS Telehealth Steering Committee for approval. This document is intended to be a living document the GN will update as required.

In the early stages of the project, the program forwarded a needs assessment questionnaire to all Nunavut communities. Based on the demonstrated needs of the communities, the Department of Health and Social Services attempted to either grow those programs internally (physiotherapy via telehealth) or receive those programs from a southern provider (expand dermatology services to all connected communities in Baffin). The program also examined the needs of specific patients and attempted to meet those needs (ongoing pediatric neurology services to specific clients in a specific community). As the telehealth program continues to evolve, the program list will expand based on the needs of the communities, health centres and/or client needs in the communities. The configured telehealth stations would be capable of providing services in the following areas:

• Dermatology,
• ENT,
• General consultations
• OBS/Gyne
• Pediatrics
• Pre and Post Surgical consults
• Consultations between Northern Physicians and the outlying communities
• Discharge Planning
• Physiotherapy
• OT
• Speech therapy
• Wound Care
• Psychiatry services
• Counseling:
  • Enhanced mental health counseling,
  • Suicide prevention and counseling
  • Psychology services
  • Behavioral Therapy
  • Addictions/Substance Abuse counseling
  • Family counseling
  • Physical and Sexual Abuse counseling
  • Counseling and Adoptions assessment
  • Spiritual Counseling
• Case conferencing with colleagues
• Court related issues
• Investigative Interviews
• Social Work training, consultation and supervision
• Family Visitation
• Poison control and disease reporting
• Prenatal classes

Nunavut is developing a wide range of services from our southern providers. During the course of the project the communities demonstrated that some of their needs would be better met with northern based programs. As our philosophy includes delivering services closer to home; in a culturally appropriate environment; wherever possible Nunavut looked to its own providers (allied health) to grow their programs in their communities or region and deliver them with Nunavut flair. For example, STD CE sessions delivered by a Nunavut source, addressing a unique territorial need.

The territory invested in an enhanced telecommunications network as well as our own MCU bridge. This enabled the territory to access the south for medical, social and continuing educational needs. This investment also allows communication between multiple Nunavut communities as well.

The project developed internal policies and procedures around clinical use, maintenance, educational and scheduling.

The project was able to recruit site technicians from existing staff at the health centres that were local residents. This is extremely important as it builds capacity in our remote communities, as well as assists us in the retention of our local employees. The recruitment of local staff is also one of the requirements of the Bathurst Mandate. The project created new positions in the communities, such as the Senior Telehealth Technician. This position provides dedicated technical support for telehealth and was decentralized to Cambridge Bay. The Regional Telehealth Coordinators were tasked with providing continuous support and training throughout the project. They continue to provide this function today.

The project was completed within mutually agreed upon timelines and budget.

3.2 Additional Successes

Based on the amount of CME provided to our practitioners during the project, it is expected that TH will become an excellent recruitment and retention tool. Of the 167 CE participants, 95% saw this as a beneficial tool to reduce the isolationism of our practitioners.

The Bathurst Mandate is one of Nunavut's founding documents. Its principles are:

• Health Communities
• Simplicity and Unity
• Self Reliance
• Continued Learning

The adoption of telehealth in 15 of our communities will enable us to meet some of the principles outlined in the Bathurst Mandate. We are putting people first as well as providing a care option that reinforces the family, community and culture of our clients. This tool allows us to train our practitioners in the areas of violence and substance abuse as well as connect families in times of forced separation. It enables Nunavut to build on the existing skills at the community level and invest in our local staff. We have trained 30 local Inuit staff at the health centre level and are committed to working with the Nursing Program at Arctic College to provide continuing education and additional training to the nursing students.

The project implemented a videoconferencing system across the territory and we were tasked with forwarding complicated information in a simple and easy to understand way. The team developed a training manual, student handbook, trainer's handbook and quick reference guides that were easy to understand, included simple instructions and were translatable. This enabled us to train local staff and build capacity in the communities. The training was tailored to the needs of the individual student and constant reinforcement via continued training utilizing the videoconferencing network is still provided today.

Today Nunavut is one of the leaders in implementing a videoconferencing network in a remote, rural, isolated and aboriginal environment. We offer services in 4 languages, Inuktituk, Innuinaqtun, French and English. The Quebec government has contacted us to assist them in developing a similar network and program in Nunavik.

3.3 Unreached Goals

The area of cost effectiveness has not been met due to the short time the project has been operational, March31st 2003.

Cost Avoidance through timely treatment, diagnosis and treatment of health problems on a timelier basis. Although the project saw increased access to services the program has only been operational since March 2003, therefore this goal yet to be met.

Reduction in travel costs, again this goal has not been met; however, our evaluation shows that in the 3 short months (June to August 2003) the program provided clinical consultations, 31 professionals, patients and/or escorts avoided travel, at a savings of $56,000. This is an encouraging indication of potential future savings.

The transmission of X-rays from Nunavut communities to a southern source is a demonstrated need, addressed in our original application as well as our needs assessment. Unfortunately in the course of the project, although due diligence was made to address this issue, Nunavut is unable to meet this need. Our current allocation of bandwidth, our existing infrastructure in each of our communities and the capital cost of upgrading our existing radiology equipment are challenges that could not be addressed in this project. This would also represent a change in our current health care delivery system in that, according to the analysis undertaken by this team, the territory would have to change the way our x-rays are reviewed in the south as well as the process undertaken in the north to refer them. Nunavut is committed to continue to review this need, is committed to addressing the issues around this need.

A goal of the project was to develop or amend the services agreement with our southern providers. GN stipulated that these agreements would respect our existing referral patterns. GN has not been able to amend or develop all of their services agreements at this time. This incomplete task remains a high priority within the Department of Health and Social Services. The Department has created 3 working groups which report to the Telehealth Steering Committee. These working groups primary task is to develop or amend the existing service agreements. To date Manitoba has amended their existing service agreement and a new agreement with MB Telehealth was developed by the Kivalliq Working Group.

At the writing of this report, the Department of Health and Social Services has had to make a difficult decision regarding one of our service providers. The Department has chosen to bypass the existing NWT link with the Kitikmeot and receive their telehealth services directly from Capital Health in Alberta. The Kitikmeot Working Group is scheduled to meet in November 2003 and begin their negotiations with Capital Health. The Department of Health and Social Services hopes that in the future they will revisit this decision and augment the services received from Capital Health with services from NWT.

As the southern provider contracts have not been amended, the GN based physicians have not fully bought into telehealth as a delivery mechanism. The Deputy Minister of Health and Social Services has appointed the Director of Medical Affairs to the position of Telehealth Champion. The Director of Medical Affairs has a seat on each of the working groups as well as the steering committee and at the time of this writing, an increase of southern providers as well as northern provider use of the program is being seen.

Due to the delays in the project implementation, the evaluation period (March 31st for CE and June 30th for clinical) was determined to be to short for conclusive evaluation of the impact of the project. The Department of Health and Social Services is committed to showing the positive impacts of telehealth on our remote communities and will continue to evaluate the effectiveness of the program.

The project chooses not to implement a Partners Forum. The project partners, particularly our southern providers were given seats on the working groups. These working groups are represented on the steering committee by the regional directors.

Although our current technical resource is not a part of the GN help desk, the GN is forging a partnership with PW&S. The goal of this partnership is to move all technical components of the telehealth program to PW&S.

Due to the reduced award from CHIPP, the training program through Arctic College and the Website were excluded from the project. The end user and tech training, which was complete and easy to follow, was delivered by the Regional Telehealth Coordinator and Senior Telehealth Technician resources.

Nunavut is divided into 3 regions each with different referral patterns to medical centres in NWT and southern Canada. The project was mandated to respect these existing referral patterns in establishing telehealth programming. This increased the number of individuals and organizations with whom negotiations for telehealth programs were conducted. The procedures and business processes in each region are significantly different. From a telehealth perspective this means that Nunavut communities potentially require connection with several different health centres/organizations. In additional each region had a different view of how telehealth programming would be implemented and managed with that region. The team attempted to standardize telehealth programs/processes to the greatest possible extent across all regions. Technology tests were conducted with all referral centres to ensure no technology barriers were present. The project team initiated dialogue with the senior H&SS regional management in conjunction with the referral centre telehealth programs. In at least one instance Nunavut was forced to review it's existing referral pattern and change that pattern for telehealth programming. In some cases the clinical activity requested by Nunavut was either not available via telehealth or not a mature telehealth program. This reflects the current Canadian telehealth environment where educational sessions comprised the major volume of telehealth activity. However as this project is completed these is a trend developing that shows increased levels clinical service compared to educational service delivery via telehealth. It is expected that the clinical service delivery options to Nunavut will increase to original project expectations levels in the near future.

Medical staff within Nunavut has taken a go-slow approach to clinical telehealth sessions. It is reasonable to expect that with some early successes that their "buy-in" will accelerate the demand for clinical telehealth sessions. Nunavut has chosen to grow their own clinical programs to address this issue. The physicians in Baffin & Kivalliq are required to provide telehealth community visits to the connected telehealth communities. These began as case conferencing sessions and are expanding to include clinical interaction between practitioners and patients. The fear the physicians have expressed is that telehealth will replace their in-person services that they deliver today. The program has not decreased the in-person visits but rather use them to increase the access to their community physician. It will take time to ally this fear. This has not been implemented in the Kitikmeot, as they do not have a regular physician at this time.

3.4 Documents or Products Generated

Document/Product Name	Available in Paper and/or Electronic Form	License Fee Required for use (Yes/No)	Previously Provided to Health Canada(Yes/No)	Appendix Name/Number
RFP Template(s) for: Project Management Equipment Evaluation	Both	No	No	G H I
Proof of Concept Testing Criteria	Both	No	No	J
Template(s) for vendor contract(s)	N/A
User Guide(s) and/or Training Manual(s)	Both	No	No	K
Policy and Procedure Manual(s)	Both	No	No	D
Job Descriptions and/or recruitment material	Both	No	No	L
Software Application(s), includes: - EHR application - Security/access alert software - Telehealth scheduling software - Other	No
Standards, includes: Data (includes minimal data sets) Image Messaging Other	No	No
Clinical Training Protocols	Included in policies	No	No	D
Clinical Program Protocol(s)	Included in policies	No	No	D
Video Conference Protocols and Etiquette Guide	Included in training and policies	No	No	K
Quality Assurance Procedures	Included in policies	No	No	D
Confidentiality and Privacy documents	Included in policies	No	No	D
Consent Forms	Included in policies	No	No	D
Sustainability Plan	Included in Strategic Plan and budget	No	No	B
Strategic Plan	Both	No	No	B
Project Plan	Both	No	No	E
Project Document	Both	No	No	A
Needs Assessment	Both	No	No	C
Risk Management Matrix	Both	No	No	F
Communications Plan	See project document	No	No	A

4.0 Main Impact

The main impact of telehealth in Nunavut is the increase in access to primary health care. Although the program has been operational for a brief 6 months, and clinical activity began 3 months ago the benefits are already apparent at this early stage. Our evaluation shows that 33-provider/patient/escort travels were avoided in three brief months (June to August 2003). These trips would have cost the government of Nunavut $56,000 dollars. Although this figure is small in comparison to the amount of money the GN spends on travel, it does highlight the possibilities of avoiding travel costs while reinforcing our mandate of receiving services closer to home. Of the patients surveyed, not one of them declined to use telehealth.

This project has provided a much need link between our northern providers and the outside world. Our providers were given the opportunity to access relevant educational opportunities in the South. These sessions were southern based in that Nunavut has little input in the content and or frequency of the sessions. They are offered in a variety of formats and time zones. The evaluation clearly demonstrates that although Nunavut is not the driver in this program, Nunavut service providers see this program as beneficial and it reduces the feeling of isolationism in our communities.

This feeling of isolationism can be attributed to the high turnover rate in Nunavut. These CE sessions also empower our northern providers, as they would not have any other way of accessing these sessions other than via telehealth. Our northern providers see this as such a benefit, in that they are not compensated for their time when attending these sessions which can occur in the evenings, during lunch and on the weekends. Some staff in the Kitikmeot actually attended these sessions at 7 am in the morning as they are on Mountain Time and would otherwise not be able at attend these sessions.

These sessions to date are offered to Nunavut free of charge by our partners in Alberta and Saskatchewan. Although Saskatchewan is not a referring partner they see this as a contribution to our northern sites and are not compensated for this service.

The only issue our northern providers have with this service is that we are not able to record these sessions. We are committed to tackling and resolving this issue as these sessions could assist us in developing a video library for our northern practitioners.

Although our program to date is Health and Social Services specific the advent of videoconferencing in 15 Nunavut communities enables other agencies, such as the departments of Justice, Education and the R.C.M.P. to utilize the links H&SS has forged. This will enable them to move forward with programs in their specific program areas and enhance the service they provide to Nunavummiut.

The IIU Network in partnership with the CHIP program enabled Nunavut to meet one of its mandates, outlined in the Bathurst Mandate.

Continued Learning, is one of the principles outlined in the Bathurst Mandate. The government will support training and learning for a Nunavut-based workforce as well as increase opportunities in Nunavut for post-secondary learning and put into place strategies to develop Nunavummuit in every profession as part of a resident workforce.

The training of our local Inuit staff at the health centre level enabled the Department of Health and Social Services to invest in our most stable workforce. The training occurred in their home communities, and in an Inuit way. The trainers provided an overview of the system and the Inuit staff was then given an opportunity to train in their own language and at their own pace. The trainer's role changed to that of a support vs. a training role. The training was tailored to the individual's skills and abilities and although an estimate of a week was designated for training, if required the trainers stayed in the community or returned to the community if needed. A total of 30 Inuit staff were trained in this fashion.

4.1 Human Resources Impact

The Project team developed a training plan that targeted 3 groups:

• Health and Social Services Care Providers
• Regional Telehealth Coordinators
• Site Technicians

The Care Providers at the community level were trained during the first initial training that occurred in September 2003. The care providers were trained to operate the peripheral equipment but this work force is very unstable. The turnover rate for our Care Providers is about 40%.

The Site Technicians and Regional Telehealth Coordinators provide ongoing training to the term and indeterminate nursing and social service staff; however, Health and Social Services executive does not encourage the training of agency nurses or transient social services staff. This decision was made, as these workers are in the north for a very short period of time (at times a few short weeks) and are an expensive resource. The Site Technicians and Regional Coordinators are tasked with continued ongoing training of the staff at the health centres and at the community level. The Regional Telehealth Coordinator or the Telehealth Manager reviews training provided during site visits that are scheduled annually. The Manager is required to visit the 3 regional centres and the Regional Telehealth Coordinators visit their telehealth communities on an annual basis.

The Regional Telehealth Coordinators meet on a monthly basis to discuss issues at the community level with their sites as well as the training needs in their communities. The Regional Telehealth Coordinators provide a monthly progress report to the Manager of Telehealth Services as well as an activity log. They also provide a monthly activity schedule showing all activity in their region. A summary of these logs and schedules as well as the written reports are forwarded to the Assistant Deputy Minister of Corporate Services and finally to the Deputy Minister and Minister detailing activity on a monthly basis. A sample of these reports can be found in Appendix N.

The Northern Care Providers were able to attend continuing educational sessions during the last phase of the telehealth project. These providers are in remote communities and often unable to access outside training as they would have to leave the community to receive it. This can be costly to the Health Centre as they must replace the nurse receiving education, pay for continuing education as well as fly in a replacement and house them. Therefore, continuing education is not offered to our outpost staff unless they participate on their own time, at their own expense and often they do not have the means to do so. The IIU Network offered continuing educations to our physicians, nurses, social workers, mental health care providers and allied health workers for 6 months. The network facilitated over 150 sessions from March to August 2003.

Although the program was not driven by the needs of our providers, as Nunavut does not have a continuing education program, these sessions were an overwhelming success.

The Territory did produce some pan-territorial sessions, SARS, STD and TB that were delivered to all telehealth sites. Non-telehealth sites participated via audio conference.

The CE that was provided to Nunavut was from a variety of sources, most notably from Alberta Mental Health Board and Saskatchewan Telehealth. These programs are notable as they provided relevant education to Nunavut in medical, social and public health areas. These programs although provider driven were delivered to Nunavut at no charge. The participants completed evaluation forms and 95% of the participants saw the education as beneficial and it reduced their feeling of isolationism. Half of those surveyed felt that this component of our program could be used as a retention component for our northern providers. By providing these sessions we have also increased the knowledge base of our northern providers and therefore providing better care in the north.

The Regional Telehealth Coordinator positions are both new (Kivalliq) and existing (Baffin and Kitikmeot) positions in GN. These positions are indeterminate. Although the Baffin and Kitikmeot positions were existed in our organization, they were not filled for nearly 2 years. Each of the job descriptions were re-written to reflect the telehealth project goals as well as the future program requirements. A sample of these job descriptions can be found in Appendix L.

Each of the Regional Telehealth Coordinators was trained by the project team and has intimate knowledge of the telehealth technology, and the design and implementation of the Site Technician training program. The Regional Telehealth Coordinators were exposed to all aspects of the project, including policy development and negotiations with the southern referral partners. The Regional Telehealth Coordinator also functions as a conduit between the region and headquarters. The incumbents have a variety of backgrounds and this enabled them to experience all aspects of coordinating the activities of a multifaceted program.

The Regional Telehealth Coordinators are responsible for:

• evaluation,
• program assessment,
• scheduling,
• maintaining videoconferencing equipment and
• on-going training.

They were also at the forefront of all negotiations with the referral partners. Nunavut has a representative in the Telehealth Coordinator Special Interest Group and is a participant in the Canadian Society of Telehealth.

The position of Senior Telehealth Technician is one that was created during the course of the project. A sample of this job description can be found in Appendix L. This position serves as the IT resource for 15 telehealth sites. The Senior Telehealth Technician is a dedicated resource and is responsible for the repair and maintenance of all of our videoconferencing systems. The Senior Telehealth Technician was trained and certified by our vendor to perform these functions.

The Senior Telehealth Technician files monthly activity reports and logs all trouble tickets submitted by the Regional Telehealth Coordinator and Site Technician. The Senior Telehealth Technician must then work with our telecommunication and/or our equipment provider to solve the issue(s).

As noted in the evaluation, technical problems occurred nearly 50% of the time. A certified IT technician fills this position and although the position is separate from Public Works and Services, Health and Social Services is working to integrate this position into our Help Desk organization.

The Senior Telehealth Technician is not an indeterminate position but a temporary position created for the project. Health and Social Services is seeking approval to permanently add this position to its organizational structure.

The Site Technician position is a new position within the organization. They are located at the health centres and report directly to the Nurse-in-Charge. A sample job description is in Appendix L.

These positions were in most cases filled by staff already employed in the health centre. The added responsibilities of the Site Technician required the health centre to review the distribution of workload within the health centre and in some cases enabled them to add staff and/or reorganize the duties shared by the Inuit staff. In some cases new staff was recruited to fill the void left by those who were now Site Technicians.

The Site Technicians were empowered by the added responsibilities and training. Although some resistance was encountered on the part of the Nurse- in-Charge who was required to reorganize their local workforce, most were pleased at the improved skills and abilities of the Site Technicians.

Many of the Site Technicians have a lower level of education and may not have had computer experience at the beginning of this project. Typically English is a second language. The training received was tailored to meet the individual Site Technicians needs and ability and was provided at a pace that they were comfortable. The key to this training was to develop local Inuit at the community. The Site Technician skills they acquired enabled them to be more competitive in the workplace as they learned how to operate a computer and complex video equipment. The Site Technicians train nurses and social workers, as well as others, how to operate the video conferencing equipment as well as the Telehealth protocols the project developed during the course of this project. This builds self-confidence in the Site Technician.

The Site Technician is also responsible for training other Inuit staff and/or providing assessments to the RTC regarding training needed. When a Site Technician trains other Inuit, they usually do so in their own language.

4.2 Privacy and Protection of Information

The objective of the Telehealth project was not to introduce a new health delivery system in the North, but to add another tool for the practitioners to use while delivering that care. Health professionals and staff will continue to adhere to the currently used procedures to ensure protection of personal health information and address privacy and confidentiality issues.

Appendix D contains the current recommended policies and procedures that were created through the project to begin to address issues around using Telehealth, including a patient consent form. It is expected that, after GN reviews them, they will be implemented and added to over time.

To date there have been no instances where patients refused to complete a consent form for Telehealth use. The current use has been in a videoconference mode with no patient data being transferred during the sessions. As Telehealth progresses and patient information transfer becomes a part of those encounters, GN will conduct Privacy Assessments and implement policy to safeguard that information.

4.3 Policy and Research Implications

The IIU Telehealth Project is unique in that it involves clinical referral patters that extend to a number of Canadian jurisdictions. These include the Provinces of Alberta, Manitoba, Ontario, as well as the NWT & #38; Nunavut itself. Out of necessity, this project has integrated many of the necessary areas which would be included within a "Pan-Canadian approach," as suggested by several leading organizations including: Canada Health Infoway, Health Canada, and National Initiative for Telehealth Guidelines (NIFTE) and the Canadian Society of Telehealth. The lessons learned by the IIU Telehealth Project should be examined closely by such organizations.

There are several reasons for telehealth policy to be developed. Obviously, any organization requires some degree of standardization to deliver a measured service to its clients, but even more importantly is the area of liability that is assumed by any organization conducting a telehealth session. Telehealth organizations require policies that stand the test of reasonableness. Such policies must be integrated immediately into the organizations operational structure. Unfortunately, many health care organizations utilizing telehealth have not undertaken such policy development. This may constitute a threat to the sustainability of their telehealth program.

The primary contractor of the IIU Telehealth Project has developed over 200 pages of policy recommendations. A review of this information may be beneficial to others, when considering policies addressing the clinical, educational, technical and operational aspects of telehealth delivery.

Although the IIU Telehealth Project funded by the Health Canada CHIPP program was a tremendous success in many ways; more work needs to be undertaken towards the creation of a cross-jurisdictional network. Several stakeholders from across Canada share in this requirement. If a Pan-Canadian vision is to be undertaken stakeholders need to come together in one forum to share lessons learned and move forward. The IIU Telehealth Project could be one such contributor.

5.0 The Future

The future direction for telehealth in Nunavut is well laid out from both a planning and budgetary standpoint in the attached strategic plan and budget in Appendix B. We recommend a thorough reading of this plan to understand our future direction as of this writing.

The IIU Network project has made the transition from project to program. The Department of Health and Social Services and the GN as a whole are committed to the continued growth of the telehealth program.

The Advisory Committee is transitioning to a Steering Committee, which is reviewing the mission, objectives and vision of the program. The goal of the telehealth program is to integrate all telehealth activities with mainstream primary health care in all Nunavut communities.

• Mission:
  • To improve the access to and delivery of health social services and health education in Nunavut using electronic networks and to integrate these tools into the health and social services delivery system.
• Vision:
  • To implement Telehealth in all Nunavut communities with appropriate intra-territory and out of connections.
• Objectives:
  • To improve access to health care services including health social services, public health, education and administration
  • To support the ongoing investment into Telehealth, by expanding the infrastructure, services and Telehealth programs
  • To support staff providing services in remote locations through continuing education, enhanced problem solving and greater participation inpatient care plans and delivery
  • To deliver tools to support the integration of telehealth into health and social services delivery system, including health information and access to other specialists/professional opinions
  • To us telehealth as a community development tool providing communication between communities and regions, in support of broader population health determinants.

Health and Social Services has shown commitment to the telehealth program by committing funding from their existing budget the operation of the telehealth network. Health and Social Services will be forwarding a proposal to our Financial Management Board (FMB) for an increase in our funding base to accommodate the telehealth program.

The Department of Health and Social Services has applied for funding under the Primary Health Care Transitional Fund, Aboriginal Envelope. Our proposal has been approved and the IIU Network will be expanding to an additional 7 communities. This funding will enable the team to continue the next phase of the program which includes adding additional communities to our telehealth network, expanding our existing telehealth program in the new communities and adding new programs to all sites.

The Department of Health and Social Services in partnership with Public Works and Services will be re-instituting the GN Videoconferencing Steering Committee. This committee will be chaired by Public Works and Services Director of Operations (DIO) and as the anchor tenant of the network; Health and Social Services will act as the Secretariat. Membership on this committee will include the departments of Justice, Education, Sustainable Development, Arctic College, Human Resources and the R.C.M.P. Each of these departments recognizes the need for integrating this service into their service delivery. Each of these departments faces the same issues that Health and Social Services encounter; extreme distances, costly travel, recruitment and retention issues. If the network was expanded to meet the needs of all departments within the GN, the costs of the telecommunications could be shared and would become affordable. Health and Social Services is committed to this goal and will be working closely with Public Works and Services to develop a videoconferencing strategy for Nunavut.

As stated earlier in this report, the geographic issues and extreme conditions in the north make investing in innovative projects a requirement. Today if an X-ray is taken in a community, it can take almost 4 weeks for the film to be reviewed, diagnosis made, a report written and returned to the health centre. Although the practitioners in the north are the most diverse in Canada and work under the most extreme conditions, our health indicators show us that compared to the national average we have:

• 2 times the infant mortality rate
• 3 times the teenage pregnancy rate
• 8 times the TB infection rate
• 26 times the solvent abuse rate
• 10 times the suicide rate
• 13 to 20 times the STD rate
• 5 times the violent crime rate
• 7 time the sexual assault rate
• 50% of the population is less than 25 years of age
• 60%+ of the adult population are smokers
• 42% of our residents > 15 years have less than a grade 9 education
• 26-40% of Nunavut's population is unemployed

The access to basic services in the north is well below the standard most Canadians take for granted. If an investment in improving access to services is the vision then a considerable investment in the infostructure or lack of infostructure in Nunavut must be made. Most Nunavut communities share the same amount of bandwidth that you have in your home in Southern Canada.

The needs assessment clearly shows the need for an integrated health information system as well as a teleradiology system is required. The two very necessary pieces of the infostructure puzzle would move Nunavut into the telecommunication age and level the playing field not only in primary health care but also in the service delivery of education, justice, etc.

6.0 Communications

Methods or Tools	Date	Targeted Audience	Documents or Presentations Produced	Appendix Name/Number
Conference	Various	CST, B.C. Telehealth, Telematics Unit, University of Calgary	Various	M
Media Events	Various	Multiple CBS interviews, selected communities	Free format
Publications	H&SS Newsletter, Newspaper articles, Community Information Tear Sheet, Posters	Community at large	Various	N
Open House	Various	All Telehealth sites	Free format
Marketing / Advertisement	See Publications
Website (please provide the Website address)	N/A
Internal GN Communications	Various	Minister Statements and Deputy Minister Briefing Notes	Briefing note, progress reports and minister statement	N/A

7.0 Other

Patient safety issues were not an issue for this project. The targeted use of this technology was scheduled interaction between a practitioner and client. Having stated that, all policies and procedures/guidelines used in face-to-face interactions between practitioner and client were adopted for this project/program.

Although this program did provide, due to extreme location and weather conditions, some emergent/urgent care, telehealth was not the only option for our clients. During these types of sessions, a physician was at either end and in some cases a 3-way connection was made to advise/assist in the care of our clients.

This project was planned from a clinical environment to use non-invasive peripherals and patient/client encounters are envisioned to be non-emergent or non-urgent.