SouthWestern Ontario Telehealth Network

Health and the Information Highway Division, Health Canada
March 2003

Table of Contents

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

1.0 Introduction

The final report was written to provide a general overview of Videocare: Southwestern Ontario Telehealth Network. As one of 29 initiatives that received a financial contribution from Health Canada, the planning and implementation of Videocare share many similarities of the approaches used by other telehealth networks.

Southwestern Ontario has a long and rich history of working together to ensure that the right patient receives the right care, at the right time and place. When the initial planning for the proposal to CHIPP was undertaken in the Spring of 2000, the southwest region of Ontario was facing some significant challenges in healthcare delivery. Consistent with other regions of Ontario, the recruitment and retention of physicians and healthcare specialists was not occurring at a sufficient rate to meet the need of our residents. As well, significant gaps in network connectivity were present across the region that reduced our ability to share idormation in a timely and secure manner. The application to CHIPP sought to resolve some of these challenges by building a network infrastructure that would connect the acute care hospitals and regional cancer centers together. Telehealth was seen as a communication application would enhance the coordination of health services and reduce the sense of isolation for healthcare providers working in rural under-serviced communities. The use of ICTs to span multiple jurisdictions in Southwestern Ontario meant that regardless of the location of the patient, or the physician, healthcare delivery could be complimented through telehealth.

Through the contribution of resources by Health Canada and the matching "in kind" resources provided by the healthcare partners in Southwestern Ontario, a 43-site Telehealth network was planned and implemented over an 18-month timeline. Best practices and lessons learned from the development of other large, provincial IP-based telehealth networks were realized through the use of Telehealth Consultants. Significant energies and attention were paid to understanding the unique workflow processes associated with the delivery of clinical care in order to identify opportunities that lent themselves to telehealth.

This report showcases many of the successes and challenges associated with building a telehealth network and integrating the technology into healthcare delivery. Although significant successes associated with the utilization of telehealth for patient care have been realized, significant work remains to be undertaken both provincially and federally around physician remuneration, physician credentialing, and also patient privacy,

2.0 Project Description

Today, many communities in the Southwest region of Ontario are critically underserviced with respect to access to healthcare resources. While the region's demographic mix is both rural and urban, healthcare facilities in the rural communities of this vast region are fewer and farther apart than the urban centres. Travel distances to and from such facilities for the 1.5 million residents of the region, especially during the winter months, often makes round-the- clock access to healthcare, and emergency services in particular, extremely difficult.

Videocare, the Southwestern Ontario Telehealth Network (SWOT-N) project funded by Health Canada and healthcare partners in Southwestern Ontario, saw the deployment of a 43-site videoconferencing-based network across the southwestern region. It was designed to extend existing and proposed clinical programs across the entire region through teleconsultation, while enabling tele-education and administrative opportunities. The clinical programs participating in Videocare (SWOT-N) include Regional Geriatrics, Renal Dialysis, Oncology, Paediatrics, Stroke, Radiology and Ophthalmology.

The major tasks undertaken through the Videocare (SWOT-N) initiative include:

• Implementation of a scaleable and flexible technical telehealth solution providing high quality and secure, internet-based videoconferencing to support patient care delivery as well as educational and administrative applications.
• Integration of existing hospital/partner networks and infrastructure to deliver videoconferencing applications using Internet Protocol (IP) technology.
• Design and implementation of clinical workflow and change management processes necessary to integrate telehealth programs and technology in the seamless delivery of healthcare services across southwestern Ontario, through the use of best practices gained from other Canadian and international telehealth networks, while respecting existing patient referral patterns.
• Implementation of a program management structure to manage the Network, provide strategic leadership and ensure evolution and long-term sustainability.

The Videocare (SWOT-N) initiative will result in the development of a regionally managed and sustainable network that will enable physicians and consultants to case conference through a private, secure system. The Network will also allow allied health professionals such as nurses, dieticians and social workers to build and support relationships with their peers through case management activities as well as through distance learning opportunities.

A thorough evaluation strategy of the Videocare (SWOT-N) initiative has been developed and implemented. This evaluation will examine five areas, including improvement to healthcare delivery, integration of health services, cost-effectiveness, lessons learned and technology performance. The results of this evaluation will be shared with all participants in this initiative.

The London Health Sciences Centre is the Lead Recipient in this initiative. The Principal Partners include the hospitals in the counties of Essex, Chatham-Kent, Lambton, Middlesex, Oxford, Elgin, Huron, Perth, Grey, Bruce, as well as the Brantford General Hospital, the Louise Marshall Hospital (Palmerston) ,the London Regional Cancer Centre and the Windsor Regional Cancer Centre, the Heart and Stroke Foundation of Ontario and the Faculty of Medicine of the University of Western Ontario.

3.0 Achievements

3.1 Goals Reached

The elements presented in the approved workplan (Appendix 1) have been implemented during the term of this initiative. As originally presented, the plan consisted of eleven (11) major tasks, each having a multitude of sub-tasks. These tasks include:

• Project Planning
• Evaluation (Prep work)
• Develop plan for network interoperability
• Develop plan for videoconferencing installation
• Telehealth Service Planning
• Communications Plan
• Network Installation
• Videoconferencing Installation
• Education and Staff Training
• Implement and Deliver Programs
• Project and Program Evaluation

The key contributing factors to the successful implementation of these elements can be directly linked to the formation of a Regional Steering Committee, and the development of a Regional Technical Task Team as well as a Regional Clinical Advisory Group.

The Steering Committee, with senior leadership representation from the partner organizations, was actively engaged in setting the strategy associated with the development of the project implementation team, the allocation of resources (financial, and otherwise) as well as setting the governance structure for the project. The identification and allocation of "in kind" contributions, such as site coordinators and technical assistance (as required by Health Canada), was determined by each of the Steering Committee members for their respective organization. The availability of "in kind" resources to the implementation team remains one of the significant key success factors that enabled the planning and implementation of the elehealth network.

The Regional Technical Task Team was instrumental in working withSmart Systems to jointly design the network architecture that integrated community based networks and complimented existing WANs across the Southwest region. The recommendation to proceed with the Smart Systems network was made by the Technical Team following significantdue diligence of alternate solutions and the development of contingency plans. The recommendation was then forwarded to the Steering Committee for their review and ultimate endorsement. The Regional Clinical Advisory Team emerged during the rollout of the clinical telehealth applications. Videocare's Clinical Managers, in conjunction with each of the clinical programs, undertook the creation of Service Design Manuals. Based on best practices acquired through Telehealth Consultants, the Service Design Manual was a tool that documented the specific clinical applications of telehealth within each regional clinical program. Unlike many telehealth networks that were implemented on a point-by-point basis, Videocare seized an opportunity to leverage existing regional relationships that existed within clinical programs. Consequently, clinical planning associated with the integration of videoconferencing into these programs was undertaken on a regional level as opposed to a site-by-site basis. This approach not only respected the relationships between care providers in these programs, but also was an important process in maintaining referral patterns and in creating region-wide momentum for telehealth as regional clinical groups 'came online' together.

All of the elements described above are responsible for the rapid adoption of telehealth in the southwest region. As shown in the accompanying utilization report, the initial seven (7) months of the implementation of Videocare saw exponential growth as each of the 43 sites became operational. Healthcare providers were trained and engaged in using videoconferencing as a viable way to enhance the delivery of patient care across the vast region. The utilization levels achieved in January 2003 have been sustained pending a potential announcement of provincial sustainability fbnding and a strategy for physician remuneration. Once these elements have been addressed, Videocare expects that the exponential growth rate seen over the initial start-up period, will resume over the subsequent months as new programs come on-line and physicians are appropriately compensated.

3.2 Additional Successes

Three significant elements achieved were outside the scope of the original workplan. These include the purchase and installation of a videoconferencing bridge that facilitates multi-site videoconferences, the installation of a web-based scheduling server and finally, the ability of hospitals in Southwestern Ontario to communicate with the 19 hospitals in Eastern Ontario.

The contributing factors that enabled Videocare to acquire and operationalize the multipoint bridge and web-based scheduling were the relationship developed with a private sector company, and the availability of financial resources. During the WP process for videoconferencing end-points, on-site demonstrations were set up so that each potential vendor could show the technical and clinical committees the quality of their products by connecting through the hospitals IP network to an external site. During these demonstrations, one of the vendors demonstrated the ability of doing multi-point videoconferencing (i.e., the ability to simultaneously connect one site to many). The same vendor also demonstrated the ability to remotely schedule and to manage videoconferences through a new web-based system that was simple to use and password protected. During the demonstration period, the clinical providers liked the ability of the scheduling software to coordinate the conferences and to self-initiate the call on the appropriate dayhime. These two elements have contributed to the significant expansion in user uptake because of its' ability to extend point-to-point calls to multi-point while changing scheduling from an uncoordinated system to one that is highly-orchestrated, sits on the end user's desktop and is easy to use.

Smart Systems for Health enabled the care providers in Southwestern Ontario to connect with the hospitals in Eastern Ontario. While the network infrastructure has enhanced the communication among care providers across the province, it has also facilitated the sharing of other resources. For example, the 19 hospitals in Eastern Ontario access the multi-point bridge in Southwestern Ontario so that they are also able to expand from point-to-point to multipoint case conferencing. The ability of the two telehealth networks to share resources and to provide patient care remains highly aligned with Health Canada's vision of a Pan-Canadian Telehealth Network.

3.3 Unreached Goals

The goals identified in the originally approved work plan were either met or exceeded during the implementation of Videocare (SWOT-N).

3.4 Documents or Products Generated

Document /Product Name	Available in Paper and/or Electronic	Licence Fee Required for use (Yes /No)	Previously Provided to Health Canada (Yes /No)	Appended to this Report (Yes /No). If yes, please provide Appendix Name /Number
Template(s) for vendor RFP	Yes	No	No	Yes Appendix 2
Template(s) for vendor contract(s)	No
User Guide(s) and/or Training Manuals	Yes	No	Yes
Template(s) for equipment testing	No
Policy and Procedure Manual(s)	Under development
Job description	Yes	No	Yes
Software Aplication(s), includes: EHR application Security /access alert software Telehealth scheduling cosftware Other		Yes, scheduling sofware purchased through First Virtual Corp.
Standards, includes: Data (includes minimal data sets) Image Messaging Other	No
Clinical Training Protocols	No
Clinical Program Protocol(s)	Yes - service design manual	No	Yes
Video Conference Protocols and Etiquette Guide	Yes - service design manual	No	Yes
Quality Assurance Procedures	No
Confidentiality and Privacy documents	Yes	No	Yes
Sustainability Plan	Yes	No	Yes

In order to understand the impact that Videocare (SWOT-N) is having on the southwestern Ontario community (inclusive of patients, healthcare provider and partners), an independent evaluation of the clinical, technical and administrative activities associated with this telehealth network was undertaken and will be reported under a separate report.

4.0 Main Impact

4.1 Human Resources Impact

Staff and healthcare providers have developed the skills necessary to effectively utilize videoconferencing to deliver healthcare services. These skills including scheduling multi-point and point-to-point calls as well as using the videoconferencing hardware and peripheral devices (such as a document camera for the transmission of paper/film based information). These skills can be readily transferred to others.

New positions have been developed as a result of this initiative. For many of the 43 sites participating in Videocare (SWOT-N), their in-kind contribution has taken the form of a .2 FTE telehealth site coordinator -a new role for nearly all of the sites. The role of the Site Coordinator varies among organizations based on the availability of resources available to schedule videoconferences, room bookings, to perform routine testing of the telemedicine camera, and to undertake the room-set up for care providers. Since the videoconferencing units deployed in Southwestern Ontario are on mobile platforms, the Site Coordinator is also responsible for ensuring that the unit is in the right room at the right time and that it is connected to the network.

An assessment of job satisfaction and productivity levels were more appropriately assessed through the evaluation processes undertaken by Videocare. These will be reported in the Videocare Evaluation Report; however, it is anticipated that the enhanced levels of communication among regional care providers will reduce the sense of isolation and increase the sharing of information between sites.

4.2 Privacy and Protection of Information

Videocare (SWOT-N) participated in the CHIPP Privacy and Security Survey that was conducted in August of 2002. The project does not collect or store patient information. Consequently, privacy-related issues (e.g., access controls) would fall under the responsibility of the individual sites. The Videocare network has completed a threat and risk assessment (TRA). The network utilizes the infrastructure of SSH. The project team, in collaboration with the Lead Partner's Risk Management department, has developed a regionally endorsed patient consent form for the participation in a telehealth session (including policies for telehealth) as well as consents for photography. The security and confidentiality of patient information during videoconferencing sessions remains of paramount concern to the Videocare team. Videocare will continue to undertake Privacy Impact Assessments in consultation with the regional healthcare partners and in conjunction with the other telehealth initiatives in Ontario. It remains unclear whether Videocare has had an impact on Ontario's privacy policy or process development; however, as telehealth continues to become mainstream and more widely adopted by patients and healthcare providers, the need for a provincial privacy policy for both telehealth and electronic health record initiatives will require timely action by the province.

4.3 Policy and Research Implications

Major Finding #1: Technical requirements -Telehealth equipment
As Videocare (SWOT-N) undertook an RFP process to identify and select the preferred vendor for the telehealth equipment, it was clear to the project team that there were many product offerings using different platforms (from PC-based to codec based). While each of the products were based on Open Standards, namely, compliance with H.323, the ability of equipment to be inter-operable between suppliers proved to be a significant challenge. Based on Videocare's experience, the recommendation around telehealth equipment is the need for defined national standards for telehealth equipment, instead of relying on manufacturers' open standards.

Major Finding#2: Patient Consent
Videocare (SWOT-N) developed a patient consent process for its' partners that included both a patient information sheet and the consent form. Based on feedback from telehealth initiatives across Canada and from Telehealth Consultants that were retained to assist with the implementation of Videocare, a national process around patient consent remains elusive. While some networks require patient consent prior to a clinical telehealth session, others do not. The recommendation is that a national consensus be reached on the need for patient consent.

Major Finding #3: Definition of Telehealth
As a network based in Ontario, significant confusion around the word 'telehealth' has occurred resulting from the provincial launch of a telephone-based nursing triage program that has been widely marketed as Ontario Telehealth (with a 1-800 number). As well, the term 'telehealth' has also been used to describe broader activities than videoconferencing-based healthcare, such as the electronic health record, and conversely, narrowly defined around clinical subspecialties like teleradiology and telesurgery . Because of the conhsion around the word telehealth, SWOT-N opted to change its name to Videocare (SWOT-N) to further distinguish this project from tele-triage. The recommendation is that a consensus be reached around the term used to describe videoconferencing-based healthcare delivery that will mitigate the public's confusion between phone-based services and others.

5.0 The Future

Videocare (SWOT-N) undertook a proactive approach to ensure the ongoing sustainability of telehealth through the development of a regionally endorsed Sustainability Plan (Appendix 3). The plan addresses the technical infrastructure requirements of the region as well as the ongoing clinical coordination and centralized support roles provided during the implementation phase of the initiative.

6.0 Communications

Methods or Tools	Date	Targeted Audience	Documents or Presentations Produced
Conference	Oct '02 Nov '02 Nov '02	CST Conference OHA participants Rural healthcare providers	presentation Poster presentation
Media Events	August 20, 2002 December 11, 2002 (34-site media launch)	Woodstock, ON Southwestern ON	Media kit Media kits/posters /brochures
Publications
Open House
Marketing /Advertis-sement	December 2002	Partners, healthcare providers and general public	Newsletters and brichure (Appendix 4), notepads and magnets
Website (please provide the Website address)	December 2002	General public and healthcare partners	www. videocare.ca
Branding	November 2002	Logo launched to healthcare providers and to general public

7.0 Other

Through the implementation of a 43-site videoconferencing network, several key learnings resulted that would be of interest to someone intended to undertake a similar initiative. The primary learnings associated with the introduction of new technologies are that the time required to complete the project is longer than you estimated, and the financial cost will be greater than anticipated. The number of operational, technical and clinical tasks is incredible and extremely difficult to track without using project management software/tools.

The identification of telehealth 'best practices' developed by others at an early stage in the development of a telehealth network will mitigate future challenges associated with organizational governance and structure, clinical process design and implementation and technical standards. Videocare adopted the best practices from several provincial/state-wide telehealth networks through the use of Consultants. The role of consultants in the implementation of new technologies should also be carefully considered. While consultants bring significant knowledge and expertise to the table, their involvement must be balanced with the need to gain local buy-in and support for the initiative.

Having a champion is key to success. Having more than one champion is ideal. Having motivated and knowledgeable 'local' people promote the benefits of telehealth is crucial to the successful integration of telehealth into healthcare. Videocare recruited two nurse managers and three part-time physician consultants to meet with stakeholder groups and present the vision of telehealth while facilitating group discussion around potential cIinical applications for telehealth at their hospital/organization.

The commitment of partner organizations is also critical to the success of a telehealth network. The identification of "in kind" contributions through Health Canada's Contribution Agreement brought dedicated resources from the partner organizations to Videocare. For example, each site was required to identify and provide a .2 FTE Site Coordinator responsible for scheduling and setting-up the videoconferencing unit prior to a clinical session. Senior leaders from the partner organizations also participated on the Steering Committee that provided strategic oversight to the initiative.

Finally, Health Canada's active participation in the deployment of Videocare by the Program Analyst - from planning through to implementation and evaluation - enabled all members of Videocare to learn what other national/provincial networks were doing, while also providing a source of contact for the team back to Health Canada who understood exactly what was occurring in the project. The open relationship between Health Canada's Program Analyst, the Project and Task teams and the Steering Committee was a significant benefit to Videocare.