MB Telehealth

Health and the Information Highway Division, Health Canada
October 2003

Table of Contents

• 1. Project Description
• 2. Achievements
  • 2.1 Goals Reached
    • Contributing Key Factors
  • 2.2 Obstacles and Challenges
  • 2.3 Additional Successes
    • Contributing Key Factors
  • 2.4 Unmet Goals
• 3. Main Impact
  • 3.1 Human Resources
  • 3.2 Privacy & Protection of Information
  • 3.3 Policy and Research Implications
  • 3.4 Centralized Management Structure
  • 3.5 Telehealth Specific Administrative Data
  • 3.6 Expanding Capacity to Support Client Centered Care
  • 3.7 Supporting Clinical Services
  • 3.8 Administration and Education Uses
  • 3.9 Just in Time Telehealth in the Neonatal Intensive Care Unit
• 4. The Future
• 5. Documents Generated

1. Project Description

The Winnipeg Regional Health Authority and a consortium of partners worked on an ambitious project to deliver specialist telehealth services and distance medical learning to nearly 30 rural and remote sites in Manitoba and Northwestern Ontario.

The centrally administered MBTelehealth Network uses broadband information and telecommunications technology, such as Internet-based (IP) video-conferencing, to improve health services closer to home for rural Manitobans. Currently, some 30 percent of residents in the province must travel to Winnipeg for specialized care.

The network initially focused on identified medical priorities, including Fetal Alcohol Syndrome and pediatric care, diabetic self-management, dermatology, rehabilitation, mental health, diagnostic imaging, and continuing medical education for rural and northern health care practitioners. These services were also offered to Northwestern Ontario and Nunavut communities on a cost-recovery basis.

In addition, the project provided continuous telehealth services from a Neonatal Intensive Care Unit, Health Sciences Centre, Winnipeg to Thompson General Hospital, in northern Manitoba. This service will allow project leaders to determine if other services can be provided 24 hours a day, seven days a week.

To ensure the network's long-term sustainability, the community-based services of MBTelehealth will continue to integrate into the normal flow of health care delivery, through protocols based on proven best practices. The MBTelehealth network is a telemedicine centre of excellence through its development of policy guidelines, clinical and technical training programs, and ongoing balance scorecard evaluation.

With funding from CHIPP and Manitoba Health, through the Winnipeg Regional Health Authority, MBTelehealth developed the network in partnership with the Regional Health Authorities of Manitoba; Assiniboine (formerly Marquette and South Westman), Brandon, Burntwood, Central, Churchill, Interlake, NOR-MAN, North Eastman, Parkland, and South Eastman; with the Selkirk Mental Health Centre, CancerCare Manitoba, the University of Manitoba, Health Canada's First Nations and Inuit Health Branch, the CHIPP-funded Northern Ontario Remote Telecommunications Health (NORTH), Nunavut IIU telehealth network, and several First Nations communities.

Project Management: Winnipeg Regional Health Authority

Contact: Dr. Sarah C. Muttitt, Director Telephone: (204) 975-7755

2. Achievements

Goals Reached

All elements in the final approved work plan were achieved. MBTelehealth surpassed expected volumes of clinical work and educational activities, from an anticipated 21 clinical specialties to 54 clinical specialties offering services over the network.

There were two revisions to the work plan: the use of hand-held devices by clinicians was discontinued very early in the initial review of the project deliverables. Dr. Amin Kabani, Health Sciences Centre, was involved in the development of this concept and unfortunately was no longer available to provide leadership due to delays in CHIPP funding and due to changes in local staff at IBM Winnipeg. Secondly, the development of a joint-teaching facility for diagnostic imaging with the University of Manitoba, was not successfully pursued. It was determined that such training was readily available through vendors. Resources were thus applied to clinical service delivery and the teaching of clinical instructors on how to effectively use videoconferencing for teaching.

In addition to the partnerships listed in the project description (above) MBTelehealth developed partnerships with major telehealth vendors and provider companies, including; Engineering Consultants EB Systems, Manitoba Telecom Services (MTS), Tandberg, Adcom, AMD, and Cisco.

Contributing Key Factors

1. Strong financial and collaborative support from Manitoba Health, which included access to the Provincial Government Data Network (PDN). The PDN expanded midway through the life of the project to a broadband network with a minimum of 2-megabit/second service to most of the hospital-based telehealth locations.
2. Direct ongoing communication with Chief Executive Officers and key administrative staff of all participating regional health authorities. This helped resolve problems at early stages and to develop a consensus around an objective Needs Assessment process that was inclusive of most stakeholders.
3. Extensive Program and Staff Development. Local Site Coordinators were recruited from a variety of backgrounds including experienced nurses, technical and allied health staff. Coordinators received their initial and ongoing training together as a group beginning with the first Site Coordinator Workshop in October of 2001. In addition to telehealth skills, Site Coordinator received ongoing training to support their involvement in local marketing and promotion and other local activities. Rural and Northern staff were also supported by a full-time Site Supervisor to encourage and facilitate their input. A comprehensive Site Manual was developed to include policies, procedures and guidelines that would be consistently followed by all sites; a centralized scheduling desk was established; the position of Winnipeg Site Coordinator was created to work with clinical provider teams to integrate telehealth into work activities. The position of Network Researcher was created to facilitate research and project development to involve clinicians in testing of new technology and procedures, to solve emerging clinical problems and to explore emerging clinical opportunities, as well as maintain records of network activities.
4. Use of a project management approach that kept staff focused on milestone activities and achievements. This maintained morale and built confidence as a "green" staff achieved new learning.
5. Careful and detailed accounting and bookkeeping activities and procedures which kept the project moving in concert with available resources. The Winnipeg RHA through the Health Sciences Centre had the ability to advance funding so that delays in receiving federal funds did not create stalls in meeting project deadlines.

Obstacles and Challenges

1. The network's technology partners did not have prior successful experience in video over I.P. The engineering consultants, hired by the network, along with MBTelehealth administration, conducted research, met with vendors, etc., to formulate plans. This was done in concert with Manitoba Health network architect staff, MTS, Cisco, and local hospital's I.T. staff. The collaboration lead to selection of standard switches and routers for the network (with a few problematic legacy issues), consistent programming of switches, a series of "low stress" trials, and adherence to an implementation schedule that all parties supported. Finally, without having achieved consistent success, MBTelehealth found it necessary to bring all parties together to experience end user problems, such as frequent video freezing. This lead to a "break through" solution - of turning all switches to the same settings as used by the video terminal equipment. This success provided the groundwork for ongoing high rates of satisfaction with the technical effectiveness, reliability and ease of use of the network (as indicated in MBTelehealth Evaluation: Final Report, Volume I: Evaluation Methods and Findings, April 15, 2003).
2. Satellite sites came on later and did not have the same high reliability as the land-based network. This involved three northern sites: Churchill, Leaf Rapids, and Lynn Lake. The fourth northern satellite site, Berens River, continued to use separate legacy satellite equipment, and was reliable for most of the duration of the CHIPP project. The satellite reliability issue was particularly difficult in Leaf Rapids and Lynn Lake, two smaller communities with limited human and technical infrastructure. In addition, the satellite vendor was contracted through Government Services, a separate department of the Manitoba Government, and it was difficult and time consuming to establish a successful working relationship. Further, the engineering consultants for MBTelehealth experienced difficulties defining the technical solutions with the satellite vendor company, specifically around the network's needs for 512-kb/second video quality. Technical failures of both satellite equipment and video conferencing equipment at Lynn Lake, led to unacceptable amounts of downtime. The Site Coordinator from this community relocated and it was not possible to recruit another nurse for this position. Two lightning strikes at Leaf Rapids knocked out receiver equipment and during the project, the Leaf Rapids mine shutdown reducing the community size by two-thirds. The Site Coordinator from this community also relocated and it took some time to find and train a replacement.

   MBTelehealth's response to these challenges was to hold weekly progress meetings with Government Services and the satellite provider company. Technical issues were resolved, MBTelehealth relinquished on its request for multi-point service, and procedures were put in place with the vendor to assure staff that scheduled events would take place. Site Assistants were successfully recruited and trained for both Leaf Rapids and Lynn Lake.

3. Network scheduling software, necessary to accommodate the quick growth in utilization, proved difficult to implement. At the time MBTelehealth was looking for centralized network scheduling software, the tragedy in New York City occurred, which incapacitated one of the potential suppliers located there. The Request for Proposals (RFP) elicited a response from Magicsoft of the United States. There was difficulty working through technical support issues, given the network and provincial government's security needs, since much of the company's approach was to provide live troubleshooting directly into the network. Four network staff attended software operation training in the United States. Training was complex and given delays in implementation, learning retention rate was decreased. Staff changes within MBTelehealth further delayed implementation. The network's solution was to continue to work with the company, to pare back expectations as to the breadth of activities the software would achieve, recruit for an I.T. specialist to help with implementation and to contract a local software development company to modify the software to respond to the networks needs more appropriately. The network is still in the process of implementing this strategy, however the software is currently being used and will become more useful, it is hoped, by the end of October 2003.
4. The network experienced resistance to participate in telehealth from some clinicians, but more so from the clinic support staff. Tele-dermatology is an important and high demand activity over telehealth; however, a lack of clinic staff time and delays in obtaining good images from digital cameras for the dermatologists during the sessions, led to frustrating backlogs and delays in service. As a solution, MBTelehealth agreed to pay overtime for the clinic's clerical staff to prepare patient charts and notify patients, which led to immediate improvement. One dermatologist agreed to provide extra hours over telehealth to help reduce the backlog of patients. This lead to long sessions where as many as 21 patients would be scheduled throughout numerous sites for access to the doctor through the network's "virtual waiting room." To speed work at the local end, digital cameras were replaced with AMD patient cameras. These more expensive cameras proved more efficient for staff to use and more effective overall. MBTelehealth staff teamed with the dermatologist to keep the workflow moving quickly throughout the sessions, and the telehealth-dermatology clinics have reduced the patient waiting list to virtually zero. This is a tribute to the hard work and perseverance of Irene Paré, Winnipeg Site Coordinator, Winnipeg Site Assistants, and the participating dermatologist, Dr. Lorne Hurst.
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5. Greater than anticipated use of the network was identified in the first two years of development. MBTelehealth has achieved a higher volume of out-of-province links then was anticipated. These include weekly case conferencing links to Stollery Children's Hospital in Edmonton, links to NORTH Network and to Nunavut sites, and occasional links to Europe for surgical training (funded outside of the CHIPP project). Response to these demands has been to add ISDN-IP interconnectivity over Polycom and Tandberg terminal video conferencing equipment, to increase central office staff and to seek outside funding sources.
6. A Needs Assessment and Business Plan has been completed at the request of the Winnipeg Regional Health Authority on behalf of the Winnipeg hospitals for potential future deployment. The success of the network generated requests from the Winnipeg hospitals to join the network. It was determined this would help maintain sustainability of the network by making it more inclusive, lay the groundwork for the development of telehealth in an urban environment, plus expand the range of services to northern and rural sites to include education and services for rehabilitation, gerontology, chronic care and other services available at other Winnipeg sites.

Additional Successes

Elements achieved beyond the original approved work plan include:

1. Regular clinical services are provided to the Kivaliq Region of Nunavut. This required a written service agreement, technical testing and operational scheduling.
2. Regular clinical and occasional educational services to eleven sites in Northwestern Ontario through an agreement with NORTH Network and (since CHIPP ended), use of CANet 4 to connect to NORTH Network.
3. The original project description referred to twenty-one clinical specialty areas. The network greatly surpassed that with fifty-four clinical specialties. Further, the level of clinical activity called for half-time Site Coordinators at each site. Greater than anticipated volumes of activity (approximately 300 per month) have required additional staff at key busy sites. MBTelehealth has budgeted for a increase in staff time for 2004-2005, and has trained a number of backup staff at most sites.
4. MBTelehealth established multi-point connections (throughout North America) for additional purposes using a variety of techniques, gateway and the Multi-point Control Unit (MCU). The network increased video capacity and ISDN lines have been added to handle the load.
5. The network expanded beyond the twenty-two sites identified in the original work plan, specifically Steinbach was included in the spring of 2002 at the request of the CEO for the South-East Health Authority, and CancerCare Manitoba requested inclusion in the Network, which was accomplished through a service provision agreement to establish CancerCare as the twenty-fourth site.

Contributing Key Factors

1. Nunavut - Manitoba Health formed a committee which met regularly to discuss ways in which services (including telehealth) could be provided to this Northern area. This kept communication open from the time when Nunavut had its technology in place to link to MBTelehealth. Direct meetings, facilitated by the Northern Medical Unit of the University of Manitoba helped work through issues.
2. NORTH Network contacts were achieved at the Director level, the Medical Director level, the clinical coordinator and scheduling levels throughout the development of services with NORTH Network. In addition, the network established a direct relationship with the Keewaytinook Okimakanak Northern Chiefs Council, a partner of NORTH Network, which has helped in the provision of services. Further visits to NORTH Network in Toronto and participation in conference call meetings helped create a climate for cooperation.
3. Clinical "buy-in" exceeded expectations due to the excellent work of Dr. Ray Postuma, Medical Director. MBTelehealth Winnipeg Site Coordinators, Linda Johnson and later Irene Paré, aggressively sought out clinical support staff and encouraged them to develop plans to integrate telehealth into clinical activities. In addition, the network continually expanded its capacity to use equipment in as many clinical areas as possible, by adding local area network (LAN) drops capable of handling video over IP. The work continues and has proved to be an important way to obtain clinical "buy-in" since telehealth is visible and available to service providers where they work.
4. As clinical activity and buy-in rose, the demand to access educational video activities throughout North America and beyond has grown. The addition of a second I.T. staff position has enabled the network to respond to requests consistently.
5. Network expansion occurred because of frequent presentations by the Director, Medical Director, Network Researcher, Site Supervisor and Winnipeg Site Coordinator, at meetings, conferences, and group presentations. Consistently positive network media coverage, with Dr. Postuma acting as network spokesperson, proved effective in generating interest.

Unmet Goals

All elements from the approved work plan were achieved, and in most cases surpassed. In all cases the elements have been sustained, with the two exceptions mentioned above.

The network was slow to implement diagnostic imaging activities due to heavy workloads on staff in other areas of network development. The delay in implementing diagnostic imaging related to two circumstances:

1. A growing realization among diagnostic imaging managers in key regions that computerized radiology had advantages over digitization of film x-rays, and
2. The network felt it was important for long-term success and integration to work with diagnostic imaging managers to make joint decisions that would be consistent with an overall provincial plan for diagnostic imaging.

CHIPP project staff agreed to an extension of the project term by six months to accommodate all the diagnostic imaging projects. These included computerized radiology to Russell (Assiniboine RHA), Dauphin (Parkland RHA), and Pine Falls (North East Health Authority); digital ultrasound to Flin Flon and The Pas (Nor-Man RHA); and digitizing of x-rays to Churchill (Churchill RHA), and Norway House (Norway House Cree First Nation, First Nation and Inuit Health Branch).

To put this approach into perspective it is important to note that when the original CHIPP proposal was prepared in the summer of 2000, a number of MBTelehealth partners expressed interest in being able to send x-ray images to distant radiologists. Through preliminary exploration of available technology, and the Director's experience in a pilot project between the Winnipeg Children's Hospital at Health Sciences Centre with Thompson General Hospital, a limited number of x-ray digitizers and physician view stations were envisioned to respond to needs for six to eight sites. Follow-up meetings with diagnostic imaging managers in four key rural and northern regional health authorities revealed new information which provided guidance to an action plan for integrating tele-radiology into a broader provincial plan for moving forward with improved diagnostic imaging. Specifically, the information included:

• A provincial PAC system was being funded by the province, thus any equipment put into place needed to be consistent with this plan, and would need to be able to send and receive images from this province-wide system of picture archiving (PACs).
• For sustainability purposes, it would be necessary to have equipment registered with the province for renewal, and this could best be done through each partner regional health authority.
• Computerized radiology systems had important advantages for some of the larger partner sites. These included the ability to reduce the number of x-rays required to complete a patient study; reduction in costs for film x-ray processing; the ability to send digital images to distant radiology, while maintaining a copy at the home site.
• The costs of computerized radiology systems had dropped significantly from the time the original CHIPP proposal was written and that regional health authorities were willing and able to contribute to some costs for installation, training, and facility readiness to accommodate this new equipment.
• New CT scanners had been allocated in several telehealth sites, including The Pas, Dauphin and Thompson, and there were staff at these locations who were receiving related training in working with digital diagnostic equipment.
• The community of Flin Flon was about to lose its part-time radiologist, who interpreted ultrasound, and that the community wished to link to Health Sciences Centre to receive enhanced support from ultrasound experts there.
• The Norway House Cree Nation, in partnership with the Winnipeg RHA Diagnostic Imaging program, had successfully applied for funding to digitize and send x-rays from Norway House to Winnipeg but additional funds would be required to provide equipment for Churchill to send images and for the Health Sciences Centre and St. Boniface General Hospital to receive x-rays for interpretation. MBTelehealth worked with the Winnipeg RHA, Norway House, and Churchill, to contribute an amount equivalent to one installation of one x-ray digitizer ($63,805) to develop connectivity between Churchill and Health Sciences Centre/St. Boniface General Hospital.
• Computerized radiology was new for smaller telehealth sites, and the network's diagnostic imaging consultant, Dr. Martin Reed, encouraged discussion with medical physicist, Dr. Jacqueline Gallet, to determine what issues might arise. Subsequently, MBTelehealth hired Dr. Gallet to prepare a paper on the subject (see Computed Radiography). This paper was distributed to diagnostic imaging managers and discussed with them and the head of radiology for the Winnipeg RHA, Dr. Blake McClarty, in a process to determine a decision on how to proceed with this equipment approach.
• In addition, the Director of MBTelehealth met with diagnostic imaging managers and toured two sites where existing computerized radiology equipment was installed by two different vendors. The regional health authorities then prepared requests for proposals (vetted by MBTelehealth) for equipment installation and staff training. Agreements with regional partners required them to provide reports, as requested, on usage of the equipment. These agreements have led to the development of protocols for the sharing of CT scans with neurosurgeons at Health Sciences Centre on a 7/24 basis for head trauma patients. This project is still in the pre-implementation stage and does not have shareable documentation at this time.
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3. Main Impact

Improving Manitobans' access to care is a key driver of the MBTelehealth program. The evaluation process carefully examined the impact of the system on access to care, with the following key findings:

• The MBTelehealth system is being used to address a wide variety of health issues with more than 50 subspecialties utilizing the network at this time.
• Telehealth has been integrated into the continuum of patient care.
• Patients are highly satisfied with the telehealth experience.
• For patients and their families, telehealth has facilitated access to health care by making it more convenient and less costly with 92% of patient care sessions resulting in travel avoided.
• Timeliness of access to care through telehealth is good in most specialty areas.
• Telehealth may reduce barriers to patient compliance with appointments and recommendations.
• In some cases, telehealth has permitted rural and remote Manitobans to access services previously unavailable.
• Telehealth facilitates family involvement in patient care.
• Telehealth has the potential to play a larger role in promoting population health in Manitoba particularly in areas such as diabetes and mental health.

Because of the MBTelehealth Network focus on clinical activity, the impact on health professionals is critical to telehealth uptake and utilization in the province. Findings in this area include the following:

• Many physicians are interested in using telehealth but find it difficult to integrate into their practices. Careful attention must be paid to work flow analysis and the development of strategies to promote seamless integration into existing service delivery.
• Continuing Education via telehealth is well-received and has four main impacts:
  
  
  • Access to information previously unavailable in rural communities
  • Reduced necessity to travel
  • Development of closer ties among practitioners, increasing sense of community and support
  • Improvements in the quality of care delivered to patients
• Telehealth contributes to work satisfaction for professionals and may contribute to recruitment and retention in rural and remote communities.
• The workload impact of telehealth, although universally positive in educational and administrative applications, is often seen as greater in the clinical setting where telehealth consultations may take longer or the care provider must change 'venue' for a telehealth encounter. Additional training and support, workflow redesign, and increased ease of access are necessary considerations to improve the perceived impact of telehealth for clinical encounters.

Telehealth has also had positive impact on linkages among health care settings. Examples include:

• Strengthened relationships between local practitioners and specialist providers and educators - this has increased support to and reduced isolation of local practitioners
• Stronger professional linkages throughout the Province contributing to improved managerial decision-making, increased stakeholder participation and greater support for improved practice.

Finally, telehealth in Manitoba has the potential of large cost savings associated with travel avoidance, and indirectly, through improved patient outcomes. Much of the direct savings is accrued directly to the health care system for travel avoided by health care professionals and administrators. Similarly, patients realize significant travel cost savings when seen over the MBTelehealth Network (an average of $568 per session) and in many cases note other measurable savings related to the avoidance of childcare costs and lost work time.

For a detailed review of the impacts of the MBTelehealth program, please refer to MBTelehealth Evaluation: Final Report, Volume I: Evaluation Methods and Findings, April 15, 2003.

Human Resources Impact

Over the course of the past two years the Site Coordinators, all of whom had no previous experience in telehealth, have developed, or enhanced, existing skills in the following areas:

• technical (telehealth equipment, IP technology and peripherals), computer programs (MSWord, PowerPoint, Outlook),
• communication and public speaking (effective written and verbal skills)
• providing education and training (to back-up staff, clinician and patient users),
• analytical thinking (problem solving/trouble shooting),
• marketing (developing site specific plans for promotion of the telehealth program utilizing a variety of marketing tools),
• operation of audio visual equipment (LCD projector, document handler), and,
• program management, group facilitation, and evaluation process skills (balanced scorecard indicators, quality improvement process).

These are skills and knowledge that can be applied in a variety of work situations in and outside of telehealth.

Several new positions have been created with the development of the telehealth network including; the Network Director, Rural and Northern Site Supervisor, Network Researcher, Telehealth Site Coordinator/Assistant, Network Scheduler, IT Analyst and Technical Resource Coordinator.

There has been an increased demand on multiple service providers necessitating strong partnership and alliances. These partnerships include Manitoba Telecom System, local hospital Information Technology departments and staff, vendors, local physicians, specialists and other health care professionals. There has also been an impact on the educational institutions in Manitoba such as the University of Manitoba and also Manitoba Health for delivery of programs over this media. Strategies to alleviate increased demands have included the sharing of information and expertise on this new technology through involving MBTelehealth' Engineering Consultants, EB Systems, to assist with the development of the network and consulting with local I.T. personnel in local sites and Manitoba Telecom System. A number of strategies have been used to alleviate increased demands on clinicians including:

• placement of additional drops accessible to clinicians within existing client care areas such as dialysis to improve integration with usual clinical routines,
• keeping clinicians and technical supports informed of requirements in timely manner so they can develop a work plan,
• providing clinicians with current information about the technology and any existing relevant clinical research, as well as licensure, liability and remuneration information.

All partners have been provided with regular information regarding the benefits seen for patients and regions through the use of the network as it was felt that buy-in to the extra demands would be facilitated if providers could see the short and long term benefits to their efforts.

Site Coordinators have seen telehealth as being a very positive addition to the health care process. Following are some of their observations on the positive attributes of their new roles:

• doing something worthwhile,
• providing a needed service to clients in their regions - seen as providing access to care that was difficult for clients in the past,
• professional satisfaction in bringing about positive change in health care, learning new skills,
• self-direction and autonomy,
• being involved in the cutting edge of technology and a new way of delivering health care,
• a positive change from past positions which may have become routine,
• the ability to work with a multidisciplinary team that is motivated and energized,
• continuing to provide patient care.

Some of the negative things reported were:

• feelings of isolation due to the uniqueness of their position with no other staff in their community doing similar work,
• increasing network activity demands create conflict with other part-time schedules for staff working in two positions,
• physician buy-in can be difficult in local sites, and
• frustration with delays and limitations imposed by jurisdictional restraints such as requests for provision of service from or to Saskatchewan or Nunavut without having licensure agreements in place.

Considerable support given has been given to Site Coordinators to assist in alleviating some of the negative impact including:

• frequent communication between Site Supervisor and Site Coordinators by phone, email, and fax,
• monthly small group meetings using the telehealth network,
• regular site visits,
• ad-hoc meetings and educational opportunities,
• regular quarterly meetings between regional health authority contacts and Site Coordinators, the Site Supervisor and the Director to provide updates on program progress, new initiatives and to hear and respond to health authority concerns and questions
• responsive technical support for network and equipment problems and this continues to evolve as an "Evergreen" process is being put into place to keep extra equipment at strategic locations for rapid deployment to adjacent sites in cases of equipment failure to reduce the impact on service delivery.
• distribution of a newsletter was used initially and is again being developed as another means to circulate information.

All new MBTelehealth staff receive a general orientation which includes, mission and vision, operational processes and policies, ongoing educational opportunities, basic and peripheral equipment (terminal equipment, stethoscope, digital camera, patient camera), specialized clinic requirements, privacy orientation, and evaluation processes. In addition, an annual Site Coordinator workshop continues to offer the staff an opportunity to learn and review topics of interest, training for new equipment, review of existing equipment, and to provide an update on clinical deliverables. This time also provides the opportunity to have guest speakers and facilitate team building and peer support groups. Orientation of local staff who function as back-up support for the local Site Coordinators has and will continue to be offered and the Site Supervisor will continue to meet with them during local site visits to provide continuing educational sessions and updates. Staff also participate in meetings with the regions when appropriate. This has helped to develop regional contacts and affiliations as well as being useful in promotion of the telehealth program within that region.

There has been a great increase in productivity and provision of clinical and non-clinical services since the beginning of MBTelehealth in 2001. Increases in the number of clinical providers have been noted in all specialties and the volume of clinical activity has risen in relation to the increase of providers and increase in awareness of the program. Other health care professionals such as dietitians, speech language pathologists, occupational therapists, nurses and other care providers have begun to use telehealth to provide client assessment, support and educational opportunities to both client and provider. Specialist clinics are also being developed within the regions (Thompson, Dauphin and Brandon) to provide consultative services to clients from those centres. Educational opportunities exist for physicians, nursing and other allied health care providers as well as for clients and families in the regions. There have been some instances for tele-visitation and promotional posters are being developed to increase this type of service in obstetrics. Administrative usage has increased in all regions with regional staff requesting telehealth for a variety of activities including management meetings, accreditation process, interviews and peer support.

Site Coordinators, as well as other MBTelehealth staff, have found the increase of activity to be exciting but also demanding on current staffing levels. Many of the Site Coordinators work less than full time and the increased activity has also created some scheduling challenges. It is rewarding however, to see the increased usage of telehealth and the positive responses from participants who have utilized the system and who are now looking for ways to incorporate this process into their current practice.

There has been little resistance to change in the MBTelehealth staff group. Site Coordinators have been eager to learn new skills and to receive new peripherals to enable them to provide increased services to clients in the region. New forms and processes have been initiated on a regular basis to respond to network growth and most have been received and incorporated in a timely manner. With the increase of activity in the network, and with the maturing of the network itself, it will be interesting to see if change from current practice is as easy as it was to introduce in the first place.

There has been a noted resistance to change in some of the providers of services and MBTelehealth staff have utilized many techniques to try to overcome this resistance. Key areas of resistance seem to be:

• unfamiliarity with process,
• providers who feel current process works for them,
• the perception that more time is required to access telehealth,
• occasional limited access at some times preferred by clinicians to match their usual clinic schedule,
• uncertainty regarding legal implications,
• fear of technology, and
• perception all care will be given over this media with no face-to-face consultation.

The strongest area of resistance however, has been with provider's clerical/reception staff who express feelings of increased workload to them to set up provider clinics.

MBTelehealth staff have utilized several techniques to overcome these barriers and concerns including:

• basic informational sessions to health care providers, clients, community groups, allied health providers,
• clear instructions that access to telehealth for consultation follows a similar process as in-person consultation,
• meetings with provider's support staff to develop mutually agreeable processes,
• increased accessibility to telehealth stations with drops right in some busy clinic areas so health care practitioners and client have easy access,
• virtual waiting rooms so clinical sessions can move rapidly from one site to another reducing waiting times for physicians,
• encouraging use of current referral patterns,
• circulation of regularly updated listings of providers using telehealth to referring physicians,
• increasing the visibility of the program in regions through; posters, informational bulletins circulated, and web site development, and
• access to educational offerings such as interactive continuing medical and nursing education, grand rounds and other timely topics such as SARS have increased the familiarly with the equipment.

Privacy and Protection of Information

The Manitoba Personal Health Information Act (PHIA) predated the implementation of the MBTelehealth Network therefore all privacy protocols and standards were developed in compliance with this act. The MBTelehealth Network adopted all existing PHIA policies in place through the Winnipeg Regional Health Authority and developed separate policies related to network security. As all health professionals in Manitoba were already expected to be in compliance with PHIA, there have been no changes in their behaviour with respect to privacy with the possible exception of transmission of patient information such as digital images via e-mail where contact with MBTelehealth may have indirectly enhanced their understanding of their obligations to ensure secure e-mail transfer.

Our external evaluation found that patients generally felt comfortable with their privacy on the network. Part of their first orientation to the network includes information about mechanisms in place to ensure privacy. The network does not maintain patient records and/or personal health information past the date of the telehealth consult. At the time of the consult, all information about the nature of the consult, services provided, diagnoses are documented in the existing paper-based patient record at the clinician site. A note is added to the patient record at the patient site noting the date of the telehealth consult, the remote site, and the clinician name. Consent to participate in telehealth is obtained at the first contact with the network and stored on file within the paper-based patient record at the patient site. No patients refused consent. Our external evaluation indicated that clinicians and regional health board members were more likely than patients to raise concerns regarding privacy. In our experience, these concerns were addressed effectively through the sharing of privacy policies and discussions with individual clinicians regarding safeguards in place.

MBTelehealth did participate in the CHIPP Privacy and Security Survey conducted in August 2002, however there were no recommendations received back in response to this participation. An in-house privacy impact assessment was the mechanism used initially to guide policy development related to privacy issues so the survey did not raise any additional policy changes. Privacy Impact Assessments will be completed on an as-needed basis in response to changes in operations, network structure or legislative requirements. The network has been involved in the development of privacy (and security) policy at both the provincial and regional level.

Policy and Research Implications

MBTelehealth has demonstrated its commitment to the development of a telehealth centre of excellence through promoting high standards, improving health care services through appropriate use of telehealth, and to promoting a learning and evolving organization through a number of special projects which have expanded and supported the network's development. There have been several noteworthy key findings during the first year and a half of operations.

Centralized Management Structure

The MBTelehealth Network was developed as a provincial network with a centralized management structure. This structure allowed for several benefits including: province wide access to new telehealth clinicians, reduced duplication in effort recruiting clinicians and developing policies, consistent standards and training across sites within the province particularly in the areas of privacy and security, reduction in interoperability issues, quick deployment of new and developing applications, and consistent communication. Potential pitfalls of this approach have been avoided through regular meetings with regional representatives, rural and central staff involvement in development of policies and procedures, and support from partners (such as provincial funders) for the centralized model. The success of this supports the current model for new telehealth initiatives within Manitoba which requires integration with the existing MBTelehealth structure and operations as a part of this network. MBTelehealth has been particularly successful at developing clinical applications. Future research could explore correlations between the centralized structure and ease of integrating new clinicians. Manitoba is also somewhat unique, as the majority of tertiary health services are only available in one southern location. Future research comparing the effectiveness of the centralized model in Manitoba with other provinces where tertiary services are more readily available would assist in determining if this model would be as successful in an alternate setting.

Telehealth Specific Administrative Data

There is little administrative data available within the Management Information Systems at Manitoba Health to track the impact of telehealth on physician billings and access to services. Manitoba Health provides reimbursement for physicians using telehealth at the same rate of compensation as in-person visits, which has been critical to clinician acceptance of telehealth. Physicians are provided with information regarding billing codes for telehealth as part of the information they receive about using telehealth. However, the volume of physicians billing for services using the telehealth tariff codes within the existing MIS database is not consistent with the actual volume services provided, suggesting that physicians are not using the telehealth tariff codes. This may be due to a lack of interest on their part in changing billing processes given that their compensation is the same regardless of which billing code is used. A slightly higher compensation rate for telehealth consultation (which would acknowledge the additional time involved with most telehealth consultations) would act as an incentive for physicians to use the appropriate billing codes and would ensure more accurate telehealth representation in administrative databases. The lack of accurate administrative data related to telehealth utilization has considerable implications as administrative databases are used extensively by the Manitoba Centre for Health Policy to evaluate health services delivery and shape provincial health policy. These administrative databases are also an excellent resource for exploring long-term impacts on health and referral patterns as service delivery episodes can be linked to individual patient identifiers, much needed research in the telehealth sector.

Expanding Capacity to Support Client Centered Care

Access to telehealth has expanded the outreach capacities of the health centers providing care. In particular, the external report found that telehealth facilitated family involvement in patient care. While clinicians and families indicated this was a benefit to patients and the quality of patient care, clinicians indicated that this added complexity and time to the scheduling of patient contacts, which was seen as a negative impact. The network has been used for several related purposes such as family conferences, case conferencing for families and local supports such as education, health, social work for children with FAS/FAE, and tele-visitations, which included family and local health staff, who provided initial care. The value of interdisciplinary care for complex clients is generally recognized however; there are few incentives for individual health care providers to use this approach, particularly those who are compensated on a salaried basis. Clinicians who work within a salaried arrangement and who already carry a heavy workload may have difficulty integrating the outreach capacity offered by telehealth into their practice without additional administrative or clinical supports and resources. Research that demonstrates the value of the use of telehealth for family conferencing, discharge planning may be useful for supporting additional or alternate funding mechanisms, which encourage alternative care models.

Supporting Clinical Services

MBTelehealth was successful in establishing and maintaining a high proportion of clinical use (currently averaging greater than 60% of network usage). This has not been the consistent with the experiences of many other networks. There are several potential reasons for this including a stated priority for clinical bookings, a centralized management structure which maximized use of new clinicians, strong local champions, and the concentration of specialists within two tertiary centers within Winnipeg. Despite this growth there are still many clinicians who indicated that they will not use telehealth to see clients, in some cases, regardless of patient requests for this service and success stories from their colleagues in similar specialties. Clinicians have expressed strong preference for drops located within their ambulatory clinic environments, some indicating this is a prerequisite to participation, to allows them to integrate telehealth into their existing practice patterns. These have been successfully implemented in a number of settings. However, managing multiple drops with mobile equipment adds complexity from the perspective of the telehealth program and requires additional resources to manage mobile equipment, complex scheduling, and compensate for the telehealth assistant's time in moving equipment from location to location. Maintenance of clinical services requires ongoing development through recruitment of new clinicians, integration of new technologies such as digital stethoscopes and continued efforts to integrate the telehealth mode of contact into existing clinical structures. Clinicians working in disciplines that are conducive to telehealth activity require additional incentives to offer this alternative to rural and remote clients.

Several sub-projects have also been undertaken to support and develop clinical services on the telehealth network:

Digital Stethoscopes - Digital stethoscopes (AMD SmartSteth) were tested with five physicians from both adult and pediatric cardiology and respirology specialties for clinical acceptability and their willingness to utilize over telehealth. In addition to transmission over IP, clinicians were given an opportunity to try the units in their in-person patient care settings and compare the quality of the sound with the sounds they currently receive with acoustic stethoscopes. Clinicians indicated a high level of acceptance for the stethoscopes and a willingness to utilize in practice. Stethoscopes were implemented in 7 sites in January 2003 and as of October 2003 they are in use in 12 sites and will be deployed in 18 sites before the new year as equipment and training are deployed. Clinicians on the network have integrated these into their sessions willingly and have expressed appreciation for the additional assessment capacity.

Patient Examination Cameras - At the initial deployment of the MBTelehealth sites, all sites were equipped with a digital camera to support clinical activities requiring detailed images such as dermatology. Despite considerable efforts invested in training and upgrading site coordinator skills with the digital cameras, the quality of images during clinical sessions was not consistent and the cameras did not allow for easy transitions when clinicians requested additional, real-time images during the session. Hand-held patient cameras from AMD Telemedicine were tested with the dermatologists using the network and compared with images from a hand-held video camera and images from a digital camera. Clinicians expressed preference for the hand-held patient camera as did site coordinators who found the device easy to use. They have since been deployed to all sites.

Doppler Assessment - Vascular surgeons using the network expressed a need for Doppler studies at the patient sites for vascular assessment of Ankle Brachial Index (ABI) and Photoplethysomography (PPG). A review of current literature and available equipment found that while this was not a telehealth application specifically, it could be a very useful tool in the rural sites both for supporting vascular assessments and for screening clients with diabetes who are at increased risk of vascular compromise. A trial is underway to demonstrate the value of this model in Manitoba. One site coordinator, who also works as a community health nurse in a neighboring First Nations community, has received two days of hands-on training in use of the Doppler at the vascular lab in St. Boniface General Hospital. Beginning in October, 2003, with the support of both MBTelehealth and the First Nations Community involved, the Doppler will be utilized for screening as part of a comprehensive diabetes screening and complications prevention program as well as available to support clinical referrals to the vascular surgeons in Winnipeg.

Occupational Therapy - MBTelehealth has partnered with the department of Occupational Therapy at Health Sciences Centre on a telehealth component of a project looking at Enhancement of Seating Assessment Resources in Manitoba. Access to specialized wheelchair seating services is limited in rural and remote parts of Manitoba. Appropriate seating choices can be critical for prevention of pressure ulcers and maximizing mobility. This multi-faceted project looks at the need for specialized seating services within HSC, has developed a resource manual of best-practices in seating assessment and also examined the use of telehealth to provide or supplement seating assessment services. Education sessions have also been delivered to rehabilitation staff in 18 MBTelehealth sites to increase awareness and skills related to seating and positioning. Approximately $25,000 in funding for this initiative was received from the Health Sciences Centre Innovations and Opportunities Fund.

Surgical Mentoring - As assessment of competence becomes increasing important in the Canadian Health care environment, information communication technologies can assist with the assessment of surgeons in both rural and urban institutions. Currently in Manitoba, assessment and mentoring of foreign graduate surgeons is a process that is undertaken at the two tertiary hospitals in Winnipeg under the direct observation of a University of Manitoba surgeon. This often delays the start of the surgeon's practice in the remote area in while they will be employed. The new surgeons also develop their social networks in Winnipeg making the transition to the new community more difficult, affecting retention once the surgeon begins practice. This demonstration project provided an IP connection, linking a surgeon in Winnipeg (the assessor) to the operating room in Thompson General Hospital allowing the surgeon to see operating room images as well as laprascopic images in real-time in order to assess skills and provide expertise. The initial demonstration linked two fully registered Manitoba surgeons and was very successful in demonstrating the value of telehealth for mentoring, peer-support and competency analysis supporting earlier surgeon placement in the remote sites.

Administration and Educational Uses

In addition to demand for clinical services, regional partners found considerable savings through their use of the network for administrative and educational uses. The value of administrative meetings was most evident for regions with more than one telehealth site as they were able to use the network for internal meetings. In regions without Northern Patient Transportation Program costs, a reduction in administrative travel shows greater fiscal benefit than a reduction in patient travel costs, as these are the responsibility of the patient or private insurers in these regions. Continuing education activities also reduced the need for staff travel, developed closer ties among practitioners through the use of communities of learning for CME activities, and improvements to the quality of care delivered to patients were reported. Continuing education was found to have particular benefits for non-physicians and physicians in rural Manitoba versus those in Northern Manitoba who often have continuing education access arranged as part of their contract. All uses have continued to increase throughout the duration of the MBTelehealth start-up phase and it is anticipated there will be growing pressure on the network for expansion to accommodate increased demands for service. In order to continue to meet demands for service the MBTelehealth network will need to expand with additional sites, equipment, and human resource capacity. Regions that currently have only one site may see considerable value in the addition of a second or third site within their region. The network will be monitoring demands for service and tracking events, which could not occur due to staffing or equipment unavailability as a result of conflicting bookings. MBTelehealth is already working with interested regions to submit requests for additional sites that will become part of the MBTelehealth Network.

Just in time Telehealth in the Neonatal Intensive Care Unit

MBTelehealth was able to support the development of a sub-project linking the Neonatal Intensive Care Unit at Children's Hospital of Winnipeg with the newborn nursery in Thompson to support just-in-time urgent and emergent support for sick neonates born in Thompson. This project demonstrated that telehealth can be successfully integrated into a direct patient care area provided that protocols and processes are mutually developed and that additional supports such as staff education are integrated. It also provided an in-house link to the newborn resuscitation area of the Women's Hospital. If this program was expanded, future requirements may include provisions for ongoing staff education (clinical and technical), and mechanisms for 24-hour technical support. Approximately $25,000 in funding for the evaluation and establishment of this project was received from the Health Sciences Centre Innovations and Opportunities Fund. A final report of this project should be completed in November 2003. The NICU provided a relatively controlled environment in which to implement an emergent/urgent application. Information gained in this project and other related CHIPP projects can inform future expansions into emergency department settings. As part of this project, a research study, The S.T.A.B.L.E.^® Program: Comparing In-Person to Videoconferenced Delivery was established. The S.T.A.B.L.E.^® Program is an educational program for pre-transport stabilization of sick neonates. While well established as an in-person course both within the United States and Canada, there was no previous experience with this course using videoconference. With approximately $7,000 in funding from the Children's Hospital Foundation, this study compared in-person delivery with videoconferenced delivery. Through the study, the program was delivered free of charge to 56 health care providers in three different communities and demonstrated that participants showed similar learning between both modalities. Results from this study have been presented in poster format at the 2002 Annual Conference of the Canadian Society of Telehealth, presented orally at the Canadian Pediatric Society Annual Conference in Spring, 2003 and will be published in the Journal of Telemedicine and Telecare in December 2003.

4. The Future

Through discussions with Manitoba Health, the network has secured funding for operating and capital activities based on an expansion of network activities. The network received funding for 2003-04 at the same operational level as 2002-03. For 2004-05, Manitoba Health as approved the addition of five rural and northern telehealth sites in the communities of: Snow Lake (Nor-Man RHA), Ste. Rose (Parkland RHA), Neepawa (Assiniboine RHA), Arbourg and Selkirk (Interlake RHA). Manitoba Health also supports two additional Winnipeg sites (to be determined). All additional site funding are subject to Treasury Board approval.

Further, the network has discussed with FNIHB (Health Canada) and Manitoba Health, the potential for a site in the Island Lakes First Nation group of communities in northeastern Manitoba under a special joint funding arrangements.

Discussions have begun with Saskatchewan telehealth to develop a cooperative support agreement. At present, the MBTelehealth site at Flin Flon, which is located within several hundred feet of the Saskatchewan-Manitoba border, provides approximately 40% of is services to Saskatchewan residents. It would be beneficial to include telehealth to support a broader range of those services. A new Saskatchewan site is being developed in Yorkton, which could provide cooperative services with the Manitoba telehealth site in nearby Russell.

The most significant area of future growth will be the additional sites in Winnipeg. The Needs Assessment and business plan have been completed, with a high need for educational activities identified. Funding by the Winnipeg Regional Health Authority is currently being considered. As stated earlier, this will expand the range of services to rural and northern locations as well as offer services between sites in the Winnipeg region.

Finally, MBTelehealth has begun discussions with Infoway for strategic investment in development of telehealth to more First Nations communities in Manitoba. With positive experiences in Norway House and Berens River, as well as servicing First Nations members through sites in Brandon, Dauphin, Swan River, The Pas, Thompson, Leaf Rapids, Lynn Lake, Churchill, Pine Falls, Ashern, and Portage la Prairie, the network is well positioned to provide national leadership in this important area.

The network has already launched projects in web site based diabetes management and shared care psychiatric services with rural RHA partners, as a way to expand the services offered to patients in the first case and to support local health care professionals manage the most difficult mental health patients in the second case.

A new project to support emergency services on a 7/24 basis utilizing Physician Assistants, employed at Health Sciences Centre, is in the early stages of discussion. It would respond to an unmet need identified in the site Needs Assessments.

5. Documents Generated

Document Name	Paper and/or Electronic Form	Licence Fee (Yes/No)	Previously Provided to Health Canada (Yes/No)	Appendix Name / Number
Template for RFP/ Contract	WRHA RFP	No	No	Appendix 1 Confidential
User Guide/Training Manual	Site Manual	Yes	Yes	Copyright - not for inclusion on OHIH web site
Template for Equipment Testing	Site Manual	Yes	Yes	Copyright
Policy & Procedure	Manual Site	Yes	Yes	Copyright
Job Descriptions & Recruitment Material	Job Descriptions Site Coordinator Orientation Site Backup Orientation Site Coordinator Annual Workshop	No No No No	No No No No	Appendix 2 Appendix 3 Appendix 4 Appendix 5
Software Applications: EHR Security/access alert software Telehealth scheduling Software	N/A N/A VCWizard/ Magicsoft	Yes	No	Vendor Copyright
Standards: Data Image Messaging Other	Site Manual (re: minimum 512 kb) Network Diagrams (four) Tandberg / Adcom Equipment Implementation Schedule Evergreen Program Computerized Radiography Deliverables for Norway House	Yes No No No No No	Yes Yes No No No No	Copyright Appendix 6 - Propriety Appendix 7 Appendix 8 Appendix 9 Appendix 10
Clinical Training Protocols	Site Manual	Yes	Yes	Copyright
Clinical Program Protocol(s)	Site Manual Clinical Specialties Process Clinical	Yes No No	Yes Yes No	Copyright Appendix 11 Appendix 12
Education Program Protocols	Pamphlets: Fall-03-04, Fall-02, Spring-02V ision/Mission Feb-02 Facilitator Learning Sep-02 CME Feb-03, Apr-02-03 CNE May-03	No No No No No	Yes Yes No No No	Appendix 13 Appendix 14 Appendix 15 Appendix 16 Appendix 17
Video Conference Protocols & Etiquette Guide	Site Manual	Yes	Yes	Copyright
Quality Assurance Procedures	Site Manual Balance Scorecard Backgrounder	Yes No	Yes No	Copyright Appendix 18
Confidentiality & Privacy	Site Manual	Yes	Yes	Copyright
Consent Forms	Site Manual	Yes	Yes	Copyright
Sustainability Plan	Budget 03/04	No	Yes	Confidential
External Evaluation	Evaluation of the MBTelehealth	No	Yes	Appendix 19 - document in its entirety prev. submitted
Research and Evaluation	Research and Evaluation	No	No	Appendix 20
Governance	Advisory Board Terms of Reference Governance Model Organization Chart	No No No	Yes Yes Yes	Appendix 21 Appendix 22 Appendix 23
Conference	Presentations	No	Yes	Appendix 24
Media Events Open House	Binder Strategic Plan	No No	No Yes	Appendix 25
Marketing / Advertisement	Marketing Plan (Ashern) Jul-03 Physician Letters: Sep-02 (3), Feb-03 What is Telehealth Telesante MB Jun-03 Patient Poster Fall-03 Tele-Visitation Template	No No No No No	No No Yes No No No	Appendix 26 Appendix 27 Appendix 28 Appendix 29 Appendix 30
Publications	Map Vision & Mission Brochure Newsletters: Sep-01, Dec-01 Report to Partners	No No No No Yes	Yes Yes Yes Yes Yes	Appendix 31 Appendix 32 Appendix 33 Appendix 34 Appendix 35
Website	www.mbtelehealth.ca	No	Yes	Appendix 36
Other	Aggregated Needs Assessment NORTH Network Map Nunavut Map	No No No	Yes Yes Yes	Appendix 37 Appendix 38 Appendix 39
Historical CHIPP Documents	Executive Summary Workflow Communication Plan Risk Management Plan Standards and Interoperability Privacy Diagnostic Tool / Information Privacy Template Mid-Term Report GANNT CHIPP Contract, Costing Memorandum, Amendments	No No No No No No No No No	Yes Yes Yes Yes Yes Yes Yes Yes Yes	Appendix 40 Appendix 41 Appendix 42 Appendix 43 Appendix 44 Appendix 45 Appendix 46 Appendix 47 Appendix 48