NORTH Network Program

Health and the Information Highway Division, Health Canada
June, 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
  • 7.1 Lessons Learned
  • 7.2 Next Steps

1.0 Introduction

The NORTH ¹ Network is a telemedicine program, which has been providing patient consultations and continuing professional education to northern and rural communities in Ontario via two-way television, electronic medical devices and other advanced technologies since 1998. CHIPP funding (April 1/01 - March 31/03) enabled NORTH Network and its partner, Keewaytinook Okimakanak Telehealth, in collaboration with 75 member and funder organizations, to expand telehealth services from 14 to 78 sites, to deploy advanced technologies, to further develop and refine the service framework and to build significant capacity to deliver services. (Please refer to Appendices A and B for a map and list of sites, respectively).

During the past two years, NORTH has grown to become one of the busiest telemedicine networks in Canada - managing almost 500 patient consultations per month, approximately 60 educational and administrative events monthly and providing access to 48 unique specialties.

Organized into five functional regions based on existing referral patterns (Northeast, Northwest, Sioux Lookout Zone, Central, Greater Toronto Area), this structure supports existing health care providers and multidisciplinary health care teams and provides a framework for regional leadership. (Please see Appendix C - Referral Patterns). The NORTH Network program emphasizes the integration of telemedicine into everyday practice by making the technology easy to use, providing telemedicine and telemedicine technology expertise for all of its partners, interfacing with government and regulatory bodies and increasing awareness among health providers and the public of the benefits of telemedicine.

The NORTH Network has invested significant resources to facilitate and support change management. Key features of the change management strategy to encourage physicians and other health professionals to adopt telemedicine in their practices include:

• Local leadership at every site
• Enhanced regional communication
• Adaptation to First Nations communities
• Maintenance of existing referral patterns
• Communication and promotion
• Payment for fee-for-service practitioners
• Training
• Turnkey technology management

A business approach was adopted to ensure future sustainability. In response to increasing referrals for consultation and follow-up, CHIPP funding has been used to create a scaleable, comprehensive infrastructure and initiatives. Local resources have been recruited, trained and supported to ensure efficient and effective delivery of telemedicine, membership in the project has grown, new partners have been identified, existing referral patterns have been maintained, and new projects in specialty areas are being piloted and evaluated (teleophthalmology, teleradiology, telepsychiatry, teleburn, telestroke, teleprison).

The NORTH Network has optimized its support from Health Canada by identifying a broad range of partners and funders including both provincial (Ministry of Health and Long-Term Care, Northern Development and Mines, Public Security and Safety) and federal governments (Health Canada, FedNor), corporate partners (Cisco Systems Canada, Hydro One, Placer Dome, Weyerhauser, Workers Safety Insurance Board, Cancer Care Ontario, Provincial Air Ambulance program), education partners (NOMEC, NOMP, NOMS) and Research Programs (Canadian Stroke Network, HEALnet). Numerous hospital members are also considered an integral part of the partnership model. An expanded partnership base improves the project's capacity to develop and expand its services. It is noteworthy that the partnership comprises multiple levels of government, private industry and community-based organizations all with a key stake in the success of the project.

The NORTH Network is collaborating with other provincial telemedicine projects (SWOT-N and EOTN) to create a 'network of networks' and to jointly explore further initiatives for telemedicine. The NORTH Network also continues to work closely and collaboratively with the MBTelehealth Program in Manitoba.

In addition, throughout the CHIPP Project, NORTH Network has worked in partnership with Keewaytinook Okimakanak (KO) to improve access to integrated health services for First Nations in the Sioux Lookout Health Zone.

The NORTH Network began working with Keewaytinook Okimakanak in July 2000. Since then, KO Telehealth has worked closely with NORTH Network staff, sharing many administrative protocols and service models. Similarly, NORTH has taken lessons learned from KO and applied them to its operations and management. These experiences have strengthened the partnership. Moreover, KO has demonstrated its capacity to achieve clearly defined goals, influence and manage systemic changes to the regional health system and foster unprecedented regional support for First Nations access to telehealth services.

The KO Telehealth/NORTH Network partnership grew following the successful submission to the Canadian Health Infostructure Partnership Program. Between April 2001 and March 2003, KO Telehealth successfully modeled and migrated an integrated and scaleable telehealth service for the Sioux Lookout Zone. Similarly, the Kuh-ke-nah Network of SMART First Nations (K-Net) managed the network delivery and technology support services for the five KO First Nations, the Balmertown Telehealth Hub and the Menoyawin Health Centre in Sioux Lookout.

A detailed evaluation of the NORTH Network Project during the CHIPP funded period (April 2001 - March 2003) has been completed and is available under separate cover. The evaluation report documented that telemedicine provided improved access to healthcare services, reduced out-of-pocket expenses for patients and consistently produced high patient and provider satisfaction. Initial estimates indicate that savings to programs like the Northern Health Travel Grant Program will likely be substantial and the potential for future savings is promising.

In April 2003, the Ontario region of Health Canada's First Nation Inuit Health Branch recognized the value of KO Telehealth's contribution by continuing to fund the First Nations project after CHIPP pilot funding had expired. Similarly, NORTH Network has received confirmation from the Ministry of Health and Long Term Care of ongoing base funding. This support will enable further integration of telehealth services into the health care delivery system of the province.

2.0 Project Description

The following is the original project description used by the CHIPP program in 2001. It remains as an accurate description of the objectives of the project.

G3-6F-DY3/0083
NORTH Network (Northern Ontario Remote Telecommunications Health Network)
The NORTH Network is a telemedicine program administered through Sunnybrook and Women's College Health Sciences Centre.

The NORTH Network is a telemedicine project which has been providing medical consultations, continuing professional education and patient education via two-way television to rural communities in Ontario since March 1998.

By using videoconferencing technologies and medical instruments such as digital stethoscopes and patient examination cameras, a health professional in a distant city can examine a patient as if the patient were in his or her own office, thus eliminating distance as a barrier to care.

In Phase II of the NORTH Network Project, the objective was to create a comprehensive telemedicine program to extend across Ontario and beyond its borders. It was to be designed to serve a vast rural and remote area, ranging from the remote First Nation community of Fort Severn on Hudson's Bay, to rural communities across Northern Ontario, to Northern referral centres like Thunder Bay and Sudbury and to academic health science centres in Southern Ontario and Winnipeg, Manitoba.

The vision was for it to be one of the most advanced telemedicine programs of its kind - one with the capability, sustainability and program infrastructure to deliver high quality patient consultations from any type of medical specialist or other health professional, and with the ability to provide a full range of education services for rural health providers. The Network was to dramatically enhance rural citizens' access to health care and reduce professional isolation of rural care providers.

With the NORTH Network's program organization and its proven ability to motivate health care professionals to use the technology, the success of the Network provided an important building block for the rest of the country. It propelled the technology to the next level of utility - the seamless integration of telemedicine into the everyday delivery of health care for rural citizens.

Objectives for this Phase included the following:

1. Maintain and augment the health services delivery and continuing education among the existing 14 NORTH Network sites in Northeastern and Southern Ontario.
2. Continue to build partnerships with hospitals and other organizations to use the telemedicine network to meet their own objectives and to contribute towards its sustainability.
3. Build a comprehensive telemedicine program that is sustainable in the long-term as well as a technological infrastructure that is modern and interoperable with networks in the local community and across the country.

Specific objectives for Phase II included the following:

1. Provide patient consultations in a wide variety of medical specialties and other health disciplines, according to the needs of rural users. More than 4,000 patient consultations were expected during the 2 year CHIPP funded period, reaching a maximum of 420 patient consultations per month by the end of Phase II.
2. Provide education for health professionals, community health representatives and students in the communities involved in the project, reaching at least 14 hours per month per site of educational activity by the end of the project.
3. Establish secure, standards-based Internet Protocol (IP) network at all Northern Ontario sites with appropriate bandwidth and guaranteed quality of service (QoS) for telemedicine videoconferencing and data applications.

This project was to enable the installation and operation of telemedicine technologies in twenty-six rural hospitals across Northern Ontario, in community health stations in five remote First Nations communities in Northwestern Ontario, in one rural clinic and to link with two Winnipeg referral hospitals. These sites would benefit from the existing NORTH Network program, which at the beginning of Phase II, operated fourteen telemedicine sites in hospitals in Northeastern and Southern Ontario. The project provided the technical infrastructure and program organization which enabled these independent centres to work together to use the technology effectively to improve the delivery of health care and health knowledge in the communities to be served.

The major eligible project activities included:

• 1. Patient telemedicine consultations and patient education.
• Health professional continuing education and training courses.
• Creation of a practical telemedicine delivery framework for First Nations and deployment of a local integration strategy to meet specific needs of remote Indigenous communities and deliver world-class healthcare to these communities.
• Rural health professional student and medical resident training program support.
• Tele-radiology and store-forward applications.
• Development of a strategy to spread the lessons and successes of the model to other First Nations communities across Canada when they are ready to migrate to telemedicine.
• Creation of an open architecture, IP (standards-based), virtual private telemedicine network.
• Program evaluation and investigator-driven research activities.
• Distribution of telemedicine applications within two referral centres and at a rural clinic.
• Implementation of technologies which support the business operations of telemedicine service delivery and enable the integration of telemedicine into the delivery of everyday health care.
• Maintain and augment the health services delivery and continuing education among the pre-existing 14 NORTH Network sites in Northeastern and Southern Ontario.
• Continue to build partnerships with hospitals and other organizations to use the telemedicine network to meet their own objectives and to contribute towards its sustainability.
  Build a comprehensive telemedicine program that is sustainable in the long-term as well as a technological infrastructure that is modern and interoperable with networks in the local community and across the country.

3.0 Achievements

3.1 Goals Reached

Over the course of the CHIPP project, all of the tasks and milestones outlined in NORTH Network's CHIPP business plan were accomplished (see table below).

Table 1

CHIPP Tasks	% Completed
1. Install and operate network	100%
2. Procure, install and manage telemedicine workstations and technologies	100%
3. Install and operate tele-radiology and image archiving	90% *
4. Project Management	100%
5. Recruit clinical staff and train users	100%
6. Security management	100%
7. Telemedicine health care services delivery	100%
8. Operate health professional and student education	100%
9. Manage user requests and scheduling	100%
10. Initiate governance committees and Telehealth Professional Advisory Committee (TPAC)	100%
11. Develop plans and implement communications, promotion and telemedicine education	100%
12. Implement program evaluation and research activities	100%
13. Plan and implement strategy to assist other First Nations communities to build telemedicine capacity	100%
14. Maintenance and development of staff skills	100%

* The Tele-radiology Project deployment was 100% completed June 17, 2003

The following are the key accomplishments achieved in collaboration with partners and members:

• Design, deploy and manage an advanced, secure IP network using bandwidth provided by Smart Systems for Health and the Kuh-Ke-Nah Network.
• Design, deploy and manage IP videoconferencing infrastructure including gateways, gatekeepers and bridging technologies.
• Design and implement a "Point-of-Presence" architecture for all hospitals using the Smart Systems for Health.
• Procure, roll-out and manage telemedicine workstations at 78 sites.
• Develop training programs and training materials. Train over 150 health professionals in spring 2002 and provide ongoing training for new technology roll-outs, staff turnover and new site roll-outs.
• Specific training program developed and delivered for First Nations Community Telehealth Coordinators who were not health professionals.
• Source, configure, clinically trial and then roll-out digital stethoscopes and PCs to all sites.
• Model business process for referral and scheduling management, leading to development and deployment of an automated scheduling system - "Telehealth Service Manager."
• Design, deploy and operate a 24x7 formal Help Desk with complete suite of monitoring, tracking and management tools.
• Growth from 3.5 FTE at project start to more than 30 FTE at project completion, leading to development of new management approach and organizational structure.
• Development and implementation of a framework to support telemedicine for First Nations communities.
• Validation of the framework and regional capacity building at a workshop held in October 2002 with support from all First Nations in the Sioux Lookout Zone region.
• Implementation and operation of a structure of steering committees, regional Telehealth Professional Advisory Committees and the Clinical Operations Committee.
• Development of 12 policies and procedures reviewed and approved through a committee structure with broad regional representation.
• Procurement and implementation of PACs system for Northwestern Ontario, including 14 hospitals and two First Nations communities, half of which will be filmless. (deployment completed June 17, 2003).
• Development of a regional governance structure for the NW PACs network and hand-off of governance to the region.
• Develop, deploy and manage the tele-stroke initiative, NORTH Network's first emergency service.
• Pilot of screening program to detect diabetic retinopathy in First Nation's communities.
• Pilot of Store-forward technology at two sites.
• Continued growth in patient consultations, continuing professional development and administrative uses, including mentoring of medical residents.
• Continued attention to privacy and confidentiality as well as state-of-the-art network security infrastructure.
• Continued support of member organizations, all of whom renewed their membership commitment.
• Communications program, including biweekly broadcast e-mails, web site, patient and provider materials, multiple community press launches and annual report.
• New program development including an emergency electrical burn management program funded through Hydro One Inc, rural nurse practitioner fellowship to explore uses for telehealth and a tele-corrections initiative funded through the Ontario Ministry of Public Security and Safety.
• Collaboration with Eastern and Southwestern Ontario Telehealth Networks.
• Ongoing sustainability funding through the Ontario Ministry of Health and Long-Term Care.

For a full description of the core components of the NORTH Network, including the service framework, health care delivery and continuing professional development, please refer to Appendix G.

As indicated in Table 1: CHIPP Tasks, all tasks and milestones set out in the CHIPP statement of work were successfully achieved. In addition, the project's evaluation objectives were to assess the following: improvements to health services (i.e. quality, access, utilization); integration of health services, health and health care system-outcomes; cost-effectiveness; and technology performance (i.e. effectiveness, ease of use, training, maintenance and support). Relevant metrics identified through the evaluation process are provided in Appendix I.

Contributing Factors

A number of key contributing factors helped NORTH Network to reach its goals. Of course, the overarching reason for success is the core reason for undertaking the project - the needs in rural Ontario. An acute shortage of health professionals, particularly in Northern Ontario drove utilization and maintained a high level of ongoing support for the project.

The previous experience of NORTH Network was also a key contributing factor. This helped to guide the project toward appropriate and proven approaches. As well, because of NORTH Network's experience, a relatively comprehensive business plan was developed which fully defined the program framework as well as the technical infrastructure. This enabled the project to hit the ground running and to provide very clear direction to vendors and partners. This level of focus, as well as an experienced and highly committed staff, enabled this relatively large project to roll out efficiently.

Another key contributing factor was the availability of bandwidth. The decision by Smart Systems for Health (SSH) to provide bandwidth to NORTH's member hospitals, as well as the SMART Communities grant acquired by K-Net which enabled development of the network infrastructure to communities in the First Nations Zone provided most of the required bandwidth for the project. The availability of SSH bandwidth during the project required a redesign of the network architecture, but overall enabled the project to reallocate resources to other uses in the development of the service framework.

Challenges

A number of challenges were faced along the way. The earliest challenge was achieving adequate funding to match the scope of the project. NORTH Network requested $11 million and received a grant of $8.5 million from Health Canada. This was mitigated through acquisition of an additional $1 million funding from Industry Canada through the FedNor Program as well as some savings through use of SSH bandwidth.

Another challenge related to the rapid growth and scaling of the project. At onset, there were 3.5 FTE staff. By the end of the project there were over 30 FTE's. This required a great deal of energy to be spent hiring staff and usually meant that the resource levels consistently trailed the workload. It also required changes in management approach and development of a new organizational structure in order to support people in these new roles.

Through all of this, utilization continued to grow and it became imperative to create a scheduling and referral system to match expected utilization. This was definitely a key challenge. Inability to provide seamless and efficient scheduling would have very quickly resulted in a loss of confidence in the project. Early on, NORTH Network recognized a requirement to automate the scheduling process because of the huge workload that would be generated.

An analysis was done to find appropriate scheduling software. A parallel activity was the analysis of the business processes around scheduling leading to detailed documentation of the process. Unfortunately none of the products that could be purchased could accommodate the business process required by NORTH Network. A deal was struck with one company to modify its existing product to meet NORTH's needs, however ultimately, the company was unable to accommodate the scope of the requirements. Hence, more than halfway through the project, NORTH Network decided to develop its own scheduling software. This was done quite successfully on time and on budget, but was launched somewhat late in the project. The extreme dedication and long hours of NORTH's Central Scheduling Office staff in Timmins kept the project afloat during this trying period.

Ultimately, NORTH Network has created a unique scheduling system, called "Telehealth Service Manager". It has an industry standards-based, scaleable, secure architecture which should serve the program well into the future.

The availability of Smart Systems for Health (SSH) bandwidth provided great benefits but also yielded some significant challenges. NORTH Network was the first user of Smart Systems for Health's network and the roll-out was significantly delayed as the vendors figured out how to do what they said they were going to do. This meant that bandwidth did not start to become available until January 2002. Once bandwidth became available, NORTH Network rolled out network equipment, followed by telehealth workstations through the winter and telehealth services finally went live over the new network at the end of April 2002 - fully one year into the project.

As well, while SSH provided bandwidth, there was no provincial network architecture standard for hospitals to follow. This led NORTH Network to design a standard point-of-presence architecture which has been promoted as a standard for all hospitals in Ontario. Finally, another set of issues arose around network services including lack of quality of service (QoS) on Smart Systems for Health and the inability for SSH vendor's to deliver promised encryption across the network. This latter issue was mitigated by Smart Systems for Health providing NORTH Network with its own closed user group which, while effective for security purposes, cut off NORTH Network hospitals from other hospitals on the SSH network. This situation was finally remedied towards the end of the CHIPP project through the development of a "meet-me" point which enabled encrypted traffic between the two closed user groups.

Another challenge during the project was presented by the NORTH Network bridge, which failed during multipoint events on five occasions. Despite escalation to the vendors, the instability could not be fixed. After the fourth crash, a new Accord bridge was installed for testing and after the fifth crash, the new bridge was purchased. The new Accord bridge is considered the gold standard in bridging. Since it was installed in January 2003 there have been no substantial bridge failures.

3.2 Additional Successes

• NORTH Network was very pleased to see rapid uptake of its services across many sites driving utilization faster than was expected. Following the regional roll out meetings, communications campaign and training at each site, it appears that many sites were simply ready to go. One small rural hospital site adopted telemedicine so quickly that installation of a second videoconferencing platform was required in order to increase capacity to do both clinical work and education at the same time.
• Additionally, NORTH Network has created a number of processes that are scaleable, reliable and business-like in nature which will enable the network to continue to grow successfully in the future. The ever-increasing utilization rates and continual growth in membership and special projects, attests to the validation of the model and success of the project.
• A number of items which appeared as a single line in the business plan became much larger and successful projects in their own right. This includes the automation of the scheduling desk as noted above and the development of the robust automated 24 by 7 Help Desk.
• NORTH Network also acquired additional members and partners during the course of the CHIPP grant and initiated several new projects, including an emergency electrical burn project sponsored by Hydro One Inc. and a correctional tele-prison project funded by the Ontario Ministry of Public Security and Safety. These projects are briefly described in Appendix K.
• Finally, NORTH Network is pleased to have received base funding from the Ontario Ministry of Health and Long-term Care as a vote of confidence in our operational success.

3.3 Unreached Goals

There are still a number of items that are a work in progress. Not all communities were rapid adopters. Some of these slower-uptake communities are still making progress marching along the adoption/diffusion process, albeit at a slower rate than some of their peers. However a few have local issues which may impede their progress forward.

As well, a critical problem has been identified which may impede future growth in telemedicine. In many communities, the assigned Telehealth Coordinator is an already over-burdened nursing professional who may have very little capacity to expand the telemedicine service. In spite of great enthusiasm, the telemedicine program simply cannot expand without an active Telehealth Coordinator. This capacity issue may stall future telemedicine growth unless a way is found to address this human resource shortfall.

The Toronto academic centres have not yet fully embraced telemedicine. While they are active in delivering this service, it is currently more a collection of individual specialists delivering services, rather than any kind of organized or integrated activity. Our ultimate goal is to make sure that telehealth becomes part of these institutions' strategic plans and hence become an integral part of their business processes.

Another unreached goal, not unexpectedly, is our lack of ability to demonstrate health systems or health outcomes evaluation data. While these evaluation goals are known to require longer term strategies, it is apparent that the yardsticks have not advanced as well as hoped for over the past two years. A concerted effort made on a national level is required to move this forward in a significant way.

Finally, while NORTH Network is working with a number of partners in the telehealth area to increase interoperability across telemedicine networks, there is still no master plan for national interoperability. Now that provincial interoperability is proceeding, it is our hope that national interoperability standards can be achieved in the next year.

Each of these unreached goals has been integrated into NORTH Network's future plans as part of the document entitled"NORTH Network's Roadmap - 2003/04" (available in Appendix H).

3.4 Documents or Products Generated

Document/Product Name	Available in Paper and/or Electronic Form Both for all items	Licence Fee Required for use (Yes/No)	Previously Provided to Health Canada (Yes/No)	Appendix Name/Number Products on CD
Template(s) for Vendor RFP Request for Information Evaluation Sheet; Request for Information Scoring Evaluation Spreadsheet; Request for Information Package; Tele-radiology: Request for Proposal, Oct./01 Cost Summary Form; Site Hardware Needs Form; Summary Evaluation Chart; NORTH Network Teleradiology Final Report - May/03
Template(s) for vendor contract(s) Knet Service Level Agreement, Oct./02; Stethoscope Rollout Project;
User Guide(s) and/or Training Manual(s) ABC Manual Patient Examination Camera - Guidelines/Use; Smartsteth User's Guide; Smartsteth Quick Reference Card for Patients/Physicians; Smartsteth TopCon Retinal Camera Documentation Guide; Connecting to laptops: to Polycom HCs; to Polycom View Station; to Tandberg 6000; to Tandberg HSCIII;

Document/Product Name	Available in Paper and/or Electronic Form Both for all items	Licence Fee Required for use (Yes/No)	Previously Provided to Health Canada (Yes/No)	Appendix Name/Number Products on CD
Global Address Book: Frequently Asked Questions; NORTH Network Global Address Book Entries; Protocol for Videotransmission Requirements for Telehealth Consultations on the Tandberg Telemedicine Workstation; Polycom Telemedicine Workstation Training Manual; Tandberg Workstation Training Manual; Keewaytinook Okimakanak (KO) Training Manual for Telehealth Coordinators; Telehealth Coordinator Training Package; Regional Telehealth Coordinators Training Plan; Tele-stroke: Telehealth Coordinator Training Package Forms Patient Information Brochure (English/French) Neurologist Information Package Northern Physician Information Package Self-Directed Learning Package Medical Peripheral Training Material Non-Medical Peripheral Training Material Framework KO Training Workbook for CTC/Backups
Policy and Procedure Manual(s) NORTH Network Policy/Procedure/Guideline Tool Kit; NORTH Network Policies & Procedures Manual: Documentation for Tele-consultations; Out-of-Province Tele-consultation; Consents for Tele-consultations; Physician Remuneration; Elective Patient Referrals; In-Kind Contributions; Faxing Prescriptions; InterpretersClinical Guidelines: Credentialing of Consultants Participating in Telehealth Consultations; Scheduling Consultations with Manitoba Specialists;Committee Terms of Reference

Document/Product Name	Available in Paper and/or Electronic Form Both for all items	Licence Fee Required for use (Yes/No)	Previously Provided to Health Canada (Yes/No)	Appendix Name/Number Products on CD
Job Descriptions and/or recruitment material
Software Application(s), includes: EHR application Security/access alert software Telehealth scheduling software Other Health Canada Medical Device Licensing: Device System Requirements; Healthcare System Certification Statement
Standards, includes: Data (includes minimal data sets) Image Messaging Other NORTH Network Point of Presence Proposal - Feb./03 NN Integration Sites Infrastructure SSH "Meet Me Point" Infrastructure Teleradiology Sites
Clinical Training Protocols KO Training Workbook for CTC/Backups

Document/Product Name	Available in Paper and/or Electronic Form Both for all items	Licence Fee Required for use (Yes/No)	Previously Provided to Health Canada (Yes/No)	Appendix Name/Number Products on CD
Clinical Program Protocol(s)
Video Conference Protocols and Etiquette Guide
Quality Assurance Procedures
Confidentiality and Privacy documents
Consent Forms Consent form for Photographs & Videotaping Tele-consultations (English/French); Consent to Videotape/Stream

Document/Product Name	Available in Paper and/or Electronic Form Both for all items	Licence Fee Required for use (Yes/No)	Previously Provided to Health Canada (Yes/No)	Appendix Name/Number Products on CD
Sustainability Master Work Plan - New Business; Business Process Flow for North Management Team; Impact Analysis June 27/03; Steps to Implement New Requests Final Strategic Planning Document - Jan./03 NORTH Network Strategic Planning Session Follow-up April 11/03 New Business Process Business Process Flow Considerations for Interview Impact Analysis June/03 Master Work Plan Membership Application Request Form Steps to Implement New Business Report on First Nations Telehealth Workshop - Oct./02 KO Proposal for Expansion Patient Questionnaire; KO Store Forward Report; KO Telepsychiatry Report, 2002

4.0 Main Impact

Evaluation of the NORTH Network project demonstrated that the project had an impact on healthcare service delivery as well as the healthcare stakeholders perceptions of telemedicine across the regions served. There is little doubt that the project has brought telemedicine into the fabric of healthcare delivery in many communities across northern and rural Ontario. The project is viewed positively and is well supported by stakeholders.

The evaluation demonstrated improved access to healthcare for patients. For many people living in rural and remote communities, there are few, if any, physicians and virtually no specialists. Telemedicine dramatically improves access to physicians and allied health care professionals. In addition, First Nations groups felt that more attention is being paid to their community with respect to delivery of healthcare. Telemedicine provides these communities with access to care as well as to education related to their condition (diabetes education sessions). Patients also commented favourably on the reduced waiting times for telehealth appointments as compared to traditional face-to-face appointments.

Reduction in travel costs was demonstrated for both patients and the Ontario provincial government. As well, physicians and allied health professionals reported increased access and a high degree of satisfaction with the continuing professional development and education opportunities made available through the NORTH Network. The technology was widely used for education and administrative activities, reaching 60 multi-point events per month (each event with an average 8 or 10 sites). Increasingly, the network is being seen as a routine way for health professionals to interact across the region. Although not quantified, there was undoubtedly an avoidance in travel for education and administrative purposes and hence, a reduction in costs for organizations and individuals in the north.

Improvements in quality of care were also noted. The most obvious of these can be found in the tele-stroke project which is NORTH Network's first emergency application. This project provides potentially lifesaving treatment which simply would not be available in the communities in northern Ontario without this technology. Similarily, diabetic retinal screening would not be available in First Nations communities without telemedicine and the Teleopthalmology pilot project.

Surveys and key informant interviews demonstrated buy-in from the stakeholders and a realization of the value of telemedicine. There was also a (healthy) concern about the sustainability of the program. The NORTH Network has stimulated many public sector organizations to think about how they can use telemedicine to improve their services and in fact some have initiated projects with NORTH Network. Additional members have also come to the Network over the CHIPP project period. The process of engaging in the CHIPP grant introduced this collaborative approach and encouraged the development of durable partnerships and the ability to maximize resources and avoid duplication.

Another exciting aspect of the technology was its use beyond the physician/medical model utilizing many other health professionals, and its use for case conferences, mental health worker and diabetic education in First Nations communities, televisitation, nurse practitioner support and telementoring applications. By improving access to other professionals, it further supports the multi-disciplinary team approach to care.

The NORTH Network project stimulated the first deployment of Smart Systems for Health in Ontario. This allowed NORTH Network to reallocate resources to service delivery while aligning with the province's vision. Overall, NORTH Network has been able to bring telemedicine infrastructure, support services and telemedicine program organization to a new level of excellence as good or better than any achieved in telemedicine in Canada to date. This infrastructure includes turnkey technology management, monitoring, proactive maintenance and the development of standard processes for referrals and scheduling as well as a comprehensive support and training program for telehealth staff . As well, the NORTH Network has provided a best practice approach to change management which has served to sustain support levels in the communities throughout the project.

The NORTH Network has also played a stimulating factor in bringing diverse groups together. One of the best examples of this is NORTH Network's activities in bringing fourteen hospitals and two First Nations communities from across northwestern Ontario together to develop a tele-radiology network for their region. NORTH Network worked with the region to develop a governance structure for the tele-radiology program by the stakeholders. Ultimately, success in projects that involve many organizations can only be achieved by collaboration and good working relationships.

4.1 Human Resources Impact

As part of their membership in the NORTH Network program, rural hospitals were asked to provide a half-time health professional, usually a nurse, to serve as the community's Telehealth Coordinator. This is in addition to a part-time Medical Director at each site. Each First Nations community hired a Community Telehealth Coordinator who was a layperson in the community. NORTH Network developed a training program for the Telehealth Coordinators and the Medical Directors and Keewaytinook Okimakanak developed an extended training program for the Community Telehealth Coordinators. Many of the hospitals reassigned a current nurse to fill the Telehealth Coordinator position and others hired a new resource. Each of the Community Telehealth Coordinator positions in the First Nations communities was a new job.

A specific customized training approach was developed by the First Nation's communities for their Community Telehealth Coordinators (CTC) in recognition that they do not have clinical backgrounds. The in-depth training program included topics such as computer skills, health care skills, basic first aid and vital signs, physical assessment, medical terminology and technical and equipment training. A minimum of 40 hours of training was augmented with customized training and support as required.

NORTH Network's regional centres and academic centres each have (at least) a full-time Telehealth Coordinator resource.

One of the critical ongoing problems as we reach the end of the CHIPP project is the workload placed upon the Telehealth Coordinators at the hospital sites. These coordinators who are usually halftime nurses, typically fulfill other roles in their institution. As telehealth becomes increasingly popular, they are often unable to keep up with the workload. Telehealth Coordinators are very excited and satisfied with their position and the telemedicine service, but are quite concerned with their ability to maintain the workload.

NORTH Network is developing a strategy to assist Telehealth Coordinators and is also advocating for specific funding to be directed to the hospitals to support these positions. It is hoped that eventually all hospital staff will be able to participate in managing telehealth in their community, much as everybody knows how to use a telephone today. However, for the next several years dedicated positions are required in order to ensure the survival of the telemedicine program.

NORTH Network core staff increased from 3.5 fulltime equivalents at the onset of the CHIPP grant to over 30 equivalents at the end of CHIPP. This included about 19 staff in Toronto, 1.5 in Barrie, approximately 6 in Timmins, 3.5 in Thunder Bay and 1 in Sudbury. In addition, Keewaytinkook Okimakanak (KO) had 2.5 FTEs in Balmertown and 5 half-time Community Telehealth Coordinators in various First Nations communities. Additional human resources include over 40 Medical Directors who receive an honoraria and a 0.5 FTE Telehealth Coordinator in every rural member hospital. Future staffing will focus on increased hiring in the northern and rural areas.

4.2 Privacy and Protection of Information

Most focus group participants expressed very little concern about privacy issues. They described the telemedicine conference as being very similar to an in-person appointment.

In addition, NORTH Network has developed a state of the art secure technology including a closed user group and a virtual private network architecture. Patients engaging in videoconferencing are fully informed and are required to read, understand and sign a consent form prior to the teleconsultation.

All paper and electronic patient data are handled according to the confidentiality policies of each host hospital. Community Telehealth Coordinators in First Nation communities were required to sign a privacy and security agreement as they operate outside of a hospital environment. NORTH Network participated in a CHIPP privacy and security survey which was conducted in August of 2002. Since then NORTH Network has commissioned an external consultant to conduct a detailed Privacy Impact Assessment (PIA) and help develop overarching policies and procedures regarding privacy, security, and confidentiality. The assessment report and initial policies are expected by the end of June 2003 and will be forwarded to Health Canada.

Based on the CHIPP privacy impact and initial feedback from the current review, the NORTH Network is comfortable that appropriate privacy and protection of information are being maintained. New internal policies will serve to support the development of new applications which will involve storage of increasing amounts of personal information. Constant vigilance in this domain is required.

4.3 Policy and Research Implications

1. Evaluation - Clearly there is a limit to the depth of evaluation that a telemedicine program can be expected to do. In order to fully assess the impact of telehealth on health services utilization and on health outcomes, research programs in telehealth have to be initiated. NORTH Network hopes to be able to catalyze some of this research through supporting external researchers, but a national effort is required to come up with appropriate indicators and research directions.
2. Mainstreaming Telemedicine - Telemedicine is simply a tool to achieve health or program objectives. We propose that all government and public sector organizations who are planning to deliver healthcare programs consider whether telehealth should be part of their business plan. It is our hope that this would be considered much in the same way that all business planners would consider whether they need a computer or network in their plan. If even a moment's thought around telemedicine's utility can be incorporated into the business planning process, huge opportunities to leverage the telemedicine infrastructure which already exists may be realized.
3. Training and Academia - There are currently no formal training or academic programs which provide appropriate instruction or provide standards for telemedicine. This is urgently needed particularly for nursing and medical professionals. It also should be required learning for health administrators and planners.
4. Persistent Barriers to Telehealth - While the NORTH Network program has managed to overcome many of the barriers to telemedicine, several of the traditional barriers still remain. These include:
   • Physician remuneration
   • Credentialing of physicians
   • Interprovincial licensure
   • Hospital charting and MIS guidelines.

   It would be most helpful to the telehealth community if the appropriate organizations dealing with these issues would proceed with recommendations and policies.

   Meanwhile, the NORTH Network has created policies, procedures or guidelines to assist member hospitals to navigate issues related to the above issues.

5. New Applications - There are many applications in telemedicine that have not yet been deployed in Ontario. Some of these are of exceeding value and should be initiated as pilot projects or programs. In our opinion, this includes remote support for rural nurse practitioners and the development of virtual intensive care unit environments. There also needs to be continued development of emergency applications. As well, the recent Severe Acute Respiratory Syndrome (SARS) crisis has highlighted the vulnerability of our healthcare system. It is clear that telemedicine may provide a number of very important strategic benefits which can reduce the impact of the next crisis. Telemedicine should be aggressively positioned to play a role in emergency preparedness. NORTH Network is currently developing a White Paper on the application of telemedicine in relation to infectious disease outbreaks and emergency preparedness.

5.0 The Future

Along with the two other CHIPP funded telehealth initiatives in Ontario, the Eastern Ontario Telehealth Network and the Southwestern Ontario Telehealth Network, NORTH Network has been provided with ongoing base funding by the Ontario Ministry of Health and Long-Term Care. The level of funding did not allow for growth in new areas, but will sustain the existing infrastructure and the capacity that has been developed.

In addition, the three CHIPP funded initiatives in Ontario have begun collaborating more extensively. The projects have already joined together to launch a single web portal called "Telemedicine Networks of Ontario" to represent all three programs. Work continues towards creating a single telemedicine initiative for the province which will retain regional autonomy. Interoperability among many sites on the three networks has already occurred and more are in progress.

The NORTH Network is currently developing a document called "NORTH Network Roadmap for 2003-2004" which will serve as the core of the NORTH Network business plan for the next two years. (Please see Appendix H). The plan contains metrics which will serve as goals to be reached over this period, new staff required/vacancies to be filled to achieve this and the focus for the year to come. As part of the plan, four major projects have been identified that will be initiated this year. The first includes the distribution and de-centralization of our automated scheduling system. The second is enhanced support for Telehealth Coordinators, the third is the development of academic centre support strategy and the fourth, enhancing our educational services.

In addition to these large projects, a number of new applications and special projects will be undertaken based on user needs as well as based on some of the health system priorities which have emerged as a result of the SARS situation in Canada. Other important initiatives include enhancing NORTH Network's role in stimulating research, collaboration with the two other telehealth networks in Ontario, continued work on network and network inter-operability (particularly pan-Canadian interoperability), improved opportunities for training and the revitalization of our web portal as a customer service centre.

The NORTH Network is currently working with a consulting group to develop plans for future governance and accountability frameworks. As noted above, a balance between centralized infrastructure and regional leadership must be developed in Ontario. NORTH Network is also looking to work closely with its First Nations partners to ensure ongoing commitment and support to telehealth development in First Nations communities.

NORTH Network also hopes to continue its practice of leveraging existing funding through strategic partnerships with groups like the Northern Ontario Medical School and ministry program areas. NORTH Network will continue to look for additional funding in order to embark on strategic initiatives.

Finally, a large part of the Network's plans over the next two years include taking the steps that will make telehealth a mainstream part of the Canadian healthcare system. All of the proposed major projects noted above will increase the capacity for telemedicine as well as the integration of telemedicine into everyday healthcare.

6.0 Communications

The NORTH Network has embraced a comprehensive communication strategy using a number of interactive, multimedia approaches to facilitate communication with members, stakeholders and patients, and to maximize promotional opportunities and improve overall accessibility.

Methods or Tools	Date	Targeted Audience	Documents or Presentations Produced	Appendix Name/Number
Conferences	2001-03	Various audiences	Multiple	Appendix N
Media Events	Fall/02- Winter/03 Dec./01 Sept./02 June/03	19 communities Ministry of Northern Development & Mines Tele-stroke launch, North Bay	media press kits for community launches news releases media press kits	Appendix O Appendices L & M
Patient Information Brochures NORTH Network Site Map News in a Nutshell	May/02 May/02 Ongoing	Patients/Families General Public NORTH Network members/partners & staff	Brochure Map Bi-weekly Newsletter	Available on CD # 1 Appendix A Available on CD # 1
Open Houses	Ongoing	Ministry representatives	Presentations	Available on CD # 2
Marketing / Advertisement Report to Our Communities	April/03	General public, members and funders	Annual Report	Available on CD # 1
Website www.northnetwork.ca	Nov/02	Members, partners, staff and general public	NORTH Network Website Information Package	Available on CD # 1

Communication is an essential component of any change management initiative. The following activities and mechanisms were utilized to support and promote the NORTH Network and telemedicine: the recruitment of local champions, regional roll-out meetings (Sault Ste. Marie, Sudbury, Thunder Bay), the hiring of a Communications Officer, the development and dissemination of the ABC Training Manual, the development of a health professional brochure and press kit, multiple media and community launches and showcasing the NORTH Network to a number of Ministry representatives, strategic planning sessions, Quarterly e-Newsletter, biweekly"News in a Nutshell", and the publication"Report to Our Communities". In addition, posters are currently in production and scheduled for distribution in July, 2003.

A website was developed in November, 2002 (www.northnetwork.ca). The website includes a"members only" section and new security measures. An innovative feature of the website is a password-protected, Tele-Stroke on-call schedule for neurologists. This functionality has broader applicability as the Network continues to expand its services. In addition, enhancements have been made to the Continuing Professional Development areas of the website as well as increased access for NORTH Network members to information (e.g., new or changed policies and manuals, newsletters and events).

Currently the NORTH Network is providing leadership on a joint web portal project with the SWOT-N and EOTN to enable communication and collaboration within this newly formed "Telemedicine Networks of Ontario".

7.0 Other

7.1 Lessons Learned

Service Framework Lessons Learned

• To facilitate adoption, implementation and endorsement, telemedicine programs must be driven by the needs identified by the communities themselves.
• Telemedicine is much more than the introduction of new technology. It requires efficient and effective change management strategies that are sensitive to local needs, cultures and resources.
• Scheduling a telemedicine appointment for the referring health professional must be as easy as scheduling a face-to-face consultation - otherwise it will not be used.
• The referral process must be automated to be efficient for scheduling and for monitoring program performance.
• To facilitate the integration of telemedicine into every-day practice, the technology must be accessible and available to the end-user.
• Technical support must be available 24/7 to be responsive and proactively anticipate and resolve problems.
• Locally-based resources need to be identified and supported in order to promote and facilitate telemedicine utilization.
• Full-time Telehealth Coordinators are required at the local level in response to increased consultation volumes and organizational demands.
• Physicians must be appropriately reimbursed.
• Physicians must be credentialed by appropriate licensing bodies to deliver telemedicine services.
• A flexible membership model provides an opportunity for broad representation, increased participation and ongoing sustainability.
• Multiple communication strategies and mechanisms are required, both internally and externally, to facilitate decision-making, information-sharing, promotion and accountability.
• Coordinated, customized training must be provided on an ongoing basis to facilitate the implementation of new technologies and processes, and to maintain and enhance staff skills.
• Need to establish a methodology to facilitate roll-outs of new sites that accounts for the needs and resources of local communities and incorporates lessons learned and change management strategies.

Health Care Delivery Lessons Learned:

• Telemedicine can be broadly applied, regardless of specialty.
• Telemedicine must respect existing referral patterns.
• Integration through partnerships with other telemedicine service providers, provincially, nationally and internationally, is essential to ensure broad access to health care services.
• Need for more promotion of the telemedicine program to family physicians, specialists and the community
• Telemedicine programs can actively participate in research and special projects to identify opportunities to expand the scope of services provided (e.g., emergency services).

Continuing Professional Development Lessons Learned:

• Telemedicine can be used effectively to deliver a broad range of continuing professional education activities.
• Program evaluation is essential to continuous quality improvement and accountability to funders and stakeholders.
• Regional leadership on the development of content for continuing professional development activities is essential to ensure that it is relevant to and meets the needs of local health care professionals.

7.2 Next Steps

The NORTH Network will continue to integrate the lessons learned, further build capacities and nurture partnerships as the project moves into the next phase of growth and development. The document entitled,"NORTH Network Road Map 2003/04", will serve as the core of the NORTH Network's business plan for the next two years (please see Appendix H).

¹ The acronym NORTH in NORTH Network refers to Northern Ontario Remote Telecommunication Health Network