Project: MBTelehealth Network

Canada Health Infostructure Partnerships Program

Synopsis

The centrally administered MBTelehealth Network uses broadband information and telecommunications technology, such as Internet-based (IP) video-conferencing, to bring and 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 the 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.

Outsomes

Improving Manitobans' access to care was 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. In 92% of patient care sessions, travel was 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; and
• 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 included 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; and
• 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.

Telehealth has also had positive impact on linkages between 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; and
• Stronger professional linkages throughout the Province contributing to improved managerial decision-making, increased stakeholder participation, and greater support for improved practice.

Policy Implications

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

• Telehealth specific administrative data - 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. 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. Administrative databases are used extensively by the Manitoba Centre for Health Policy to evaluate health services delivery and shape provincial health policy; and
• Supporting Clinical Services - 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.

Research Implications

As above, the following have been noted as having possible research implications:

• Centralized management structure - 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;
• Expanding Capacity to Support Client Centered Care - 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; and
• Surgical Mentoring - Demonstrating the value of telehealth for mentoring, peer-support and competency analysis supporting earlier surgeon placement in the remote sites.

Lessons Learned

The MB Telehealth Project reported multiple lessons learned; an excerpt follows.

• Efficiency gains are most likely to result from administrative uses of the system - this is likely to increase pressure for administrative use; additional incentives and disincentives may need to be built into the system to encourage clinical usage;
• Patient information management mirrors almost exactly the systems in place for regular consultations; and
• The decision to coordinate the network centrally with MBTelehealth site coordinators situated in the Regional Health Authorities has had more advantages than disadvantages

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 2004-04, Manitoba Health has approved the addition of five rural and northern telehealth sites and also supports two additional Winnipeg sites.

The most significant area of growth will be the additional Winnipeg sites. The needs assessment and business plan have been completed, with a high need for educational activities identified.

Further, the network has discussed with First Nations and Inuit Health Branch (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 arrangement.

The network has already launched projects in website-based diabetes management and shared psychiatric services with rural Region Health Authority (RHA) partners, as a way to expand the services offered to patients in the first case and to support health care professionals manage the most difficult mental health patients in the second case.

Appendix A: Documents or Products Generated

Template for RFP/ Contract:

• WRHA RFP

User Guide/Training Manual:

• Site Manual

Template for Equipment Testing:

• Site Manual

Policy & Procedure Manual:

• Site Manual

Job Descriptions & Recruitment Material:

• Job Descriptions
• Site Coordinator Orientation
• Site Backup Orientation
• Site Coordinator Annual Workshop

Software Applications:

• Telehealth scheduling software
  • VCWizard/ Magicsoft

Standards:

• Site Manual
  (re: minimum 512 kb)
• Network Diagrams (four)
• Tandberg / Adcom Equipment Implementation Schedule
• Evergreen Program
• Computerized Radiography
• Deliverables for Norway House

Clinical Training Protocols:

• Site Manual

Clinical Program Protocol(s):

• Site Manual
• Clinical Specialties
• Process Clinical

Education Program Protocols:

• Pamphlets:
  Fall-03-04, Fall-02, Spring-02
• Vision/Mission Feb-02
• Facilitator Learning Sep-02
• CME Feb-03, Apr-02-03
• CNE May-03

Video Conference Protocols & Etiquette Guide:

• Site Manual

Quality Assurance Procedures:

• Site Manual
• Balance Scorecard Backgrounder

Confidentiality & Privacy:

• Site Manual

Consent Forms:

• Site Manual

Sustainability Plan:

• Budget 03/04

External Evaluation:

• Evaluation of the MBTelehealth

Research and Evaluation:

• Research and Evaluation

Governance:

• Advisory Board Terms of Reference
• Governance Model
• Organization Chart

Conference:

• Presentations

Media Events:

• Binder

Open House:

• Strategic Plan

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

Publications :

• Map
• Vision & Mission
• Brochure
• Newsletters: Sep-01, Dec-01
• Report to Partners

Website:
 www.mbtelehealth.ca

Other:

• Aggregated Needs Assessment
• NORTH Network Map
• Nunavut Map

For more information, please contact:

Dr. Sarah Muttitt at smuttitt@ms.umanitoba.ca or at (204) 975-7755