Telehealth Saskatchewan

Health and the Information Highway Division, Health Canada
March 29, 2004

Table of Contents

• 1.0 Introduction
  • 1.1 Background
• 2.0 CHIPP Project Description
  • 2.1 CHIPP Project Purpose
  • 2.2 CHIPP Project objectives
• 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

• On February 6th 2004, the last of Telehealth Saskatchewan's (TS) new sites was installed and training was completed.
• On March 11th 2004, the Telehealth Saskatchewan Management Committee held its two and one half hour quarterly meeting using the new IP bridge that is now managed by Saskatchewan Health's Health Information Solutions Center (HISC). Management Committee members in three of the newest sites (Yorkton, Moose Jaw and Swift Current) joined members from a two sites added during the project (Regina and Nipawin) and members from two of the original sites (Saskatoon and Meadow Lake). The committee member from La Ronge joined by telephone also using the new HISC bridge.
• On March 23rd ten Saskatchewan sites (Including four of our new sites and one non TS site) were joined by sites in Nunavut and the Northwest Territories for an education session entitled "Palliative Care in Long Term Care - The Saskatoon Approach". The presentation originated from TS's new St. Paul's site. The session was carried over CommunityNet and used the HISC, Telus and Articom bridges and the HISC gateway to make all ISDN and IP connections.
• On March 24th nine Saskatchewan sites (Including four of our new sites and one non TS site) were joined by seven sites from Nunavut and one from Manitoba to learn about the new COPD guidelines. Again the session was carried over CommunityNet and used the HISC, Telus and Articom bridges and the HISC gateway to make all ISDN and IP connections.
• These activities are example of the results of a concept that started to take shape in 1997 when Saskatchewan Health established a multi disciplinary telehealth steering committee and invited the provinces 33 health district to submit proposals for telehealth applications. This led to two pilot projects involving 10 sites and ultimately to the August 1st 2001 creation of a partnership now known as Telehealth Saskatchewan. Telehealth Saskatchewan now consists of nine of the ten pilot sites and 8 new sites.
• In the interim over 90 individuals made a direct contribution to the establishment and development of Telehealth Saskatchewan. Dozens of others have contributed to the program content by providing consultations, or presenting lectures or education programs. Over 10,000 learners and 600 patients have benefited from telehealth. This does not include patients who remained in their home community while their x-rays or ultrasound scans were transmitted to a consultant in an urban center. Stakeholders include Saskatchewan Health, twelve health regions, HISC (Formerly SHIN), The Saskatchewan Information Technology Office, SaskTel, and Health Canada. Sixteen vendors have supplied equipment and services to TS.

1.1 Background

• Saskatchewan's first telehealth pilot project, the Northern Telehealth Network (NTN). The NTN consisted of sites in eight communities and was established in July 1999 as a 12-month pilot project funded by Saskatchewan Health with supplementary funding from Health Canada's HISP program. Two additional Saskatchewan communities were part of an Alberta based telehealth CANARIE funded project that utilized satellite technology. This project was known as the Satellite Initiative (SI). It operated separately from the NTN and could not effectively participate in many of the programs offered by NTN. The fixed monthly satellite charges are very high and not justified based on the satellite's utilization
• An external evaluator's report identified several issues related to access and the sustainability of the NTN. The evaluation also showed that several sites did not, and will not, fully utilize the capabilities of the costly telehealth workstations. It was determined that the needs of these sites can be met using lower cost video conferencing equipment.
• The evaluators recommended selective expansion of the NTN to allow healthcare workers in more communities to take advantage of the existing services and programming.
• A strategic planning session held in July of 2000 identified several new programs needs in the Network's rural communities. These include specialized children's services; cancer and palliative care case management.
• Discussions were held with representatives from SHIN and SaskTel to determine the feasibility of adding the NTN sites to SHIN's new Community Net WAN.
• Discussions were held with representatives from the SI and Alberta Research Laboratory's Telehealth Interoperability Lab to determine the feasibility of integrating the SI sites with the NTN.
• Discussions took taken place between officials of the SI, SaskTel and Raytheon (Supplier of the SI equipment) to determine the requirements for connecting the SI sites to SaskTel's ISDN lines and ultimately to SHIN's Community Net.
• As part of the strategic planning process, and in response to calls for new program development, members of the NTN Implementation Committee prioritized the programs of greatest benefit to the residents of their districts. After determining the program needs, it was agreed that the NTN would require expansion to three new Saskatoon locations to support these programs. They are the Kinsmen Children's Center, the Saskatoon Cancer Center and St. Paul's Hospital.
• As part of the strategic planning process the NTN Implementation Committee supported the identified need for greater access to specialists practicing in Saskatoon. The most practical and efficient method of meeting these requirements is to provide additional viewing stations in Saskatoon's three emergency departments and to provide the specialists with the ability to access images from their own offices or designated PC's. This was to be accomplished by using web-based applications to provide Saskatoon-based specialists with 24 hour access to viewing of images.
• Discussions took place with representatives from the Kinsmen Children's Center, the Saskatoon Cancer Center and St. Paul's Hospital to discuss program details, program development and equipment needs.
• Discussions took place with representatives from Saskatoon District Health's medical imaging department to identify the equipment needs for new technology and equipment to provide web-based access to radiology reads.
• Discussions took place with CDC, the NTN equipment supplier, to obtain proposals for meeting the IP technology requirements and to purchase video-conferencing equipment.
• Discussions took place with Sharpe's AudioVisual to obtain proposals for meeting the video-conferencing equipment requirements for the Kinsmen Children's Centre and St. Paul's Hospital.
• Discussions took place with officials from the Saskatchewan Cancer agency to confirm the suitability of their existing audiovisual equipment for use with the NTN.

This planning session and the ensuing activities led to what had become known as "The CHIPP Project".

• The CHIPP contribution agreement identifies nine separate tasks that were designed to address several of these issues. While the Contribution Agreement made several references to using Saskatchewan's new CommunityNet as a communications carrier, connecting to CommunityNet was not identified as a separate task. During the early stages of this project, "Connecting to CommunityNet" was identified as Task #10.

2.0 CHIPP Project Description

2.1 CHIPP Project Purpose

The purpose of this project was to develop a permanent provincial telehealth network to be called Telehealth Saskatchewan. The project was to build on the successes and lessons learned from Saskatchewan's first two two-way video conferencing telehealth pilot projects that were launched in 1999.

At the time the CHIPP applications was being prepared, the Saskatchewan government was considering the development of a provincial data WAN known as CommunityNet. CommunityNet would consist of three components; one for executive government, one for education and one for health. The health component would link all health facilities for the purpose of data transmission. The development of the WAN was under the auspices the Saskatchewan Information Technology Office (ITO). SaskTel would provide and install the communication infrastructure following specifications agreed to with the ITO. The health component of the WAN was to be managed by HISC.

Even though CommunityNet was being designed as a data network, officials from HISC, Saskatchewan Health and Telehealth Saskatchewan saw the potential to use CommunityNet for two way video conferencing. This would mean that in addition to carrying data, CommunityNet would be expected to carry audio and video signals. CommunityNet would be come Telehealth Saskatchewan's communications carrier for all programming within Saskatchewan. Project leaders knew that developing this application would mean moving into uncharted waters. However it was felt that a successful outcome could be very beneficial for all parties. CommunityNet was going to use IP technology. This meant that any new telehealth equipment must be IP compatible and all existing equipment must be upgraded to IP standards.

Telehealth Saskatchewan would become a permanent, integrated telehealth network that would provide Saskatchewan residents and health care professionals with access to health care services and education at a distance using innovative telecommunications, computing and information systems technology.

Some of the core components deemed necessary to attain this goal were already in place.

Developments by some of Telehealth Saskatchewan's partners such as SaskTel and SHIN were to facilitate the development of a sustainable telehealth network.

2.2 CHIPP Project objectives

Telehealth Saskatchewan's objective was to continue to develop a sustainable telehealth system that will meet the goals set out in 1997 by the Saskatchewan's Telehealth Steering Committee. These goals were to:

• Improve access to health services and providers for residents of rural and remote areas of the province;
• Enhance rural practice support;
• Improve access to specialists and other health care providers;
• Encourage optimal use of specialist personnel and resources in the province;
• Provide continuing education for health care providers;
• Provide health information and education to patients and the public; and
• Improve patient outcomes through improved (faster) access to health services in urgent or emergent cases.

In early 2002 as a follow up to discussions at a November 2001 strategic planning session, Saskatchewan Health modified Telehealth Saskatchewan's goals as follows:

• Improve access to health services and providers.
• Enhance rural practice support.
• Encourage optimal use of specialists.
• Provide continuing education and health information and education to patients and the public.
• Support provincial or regional service and education networks.

The specific objectives of the CHIPP project are described below.

Objective #1- Upgrade Existing Telehealth Workstations to IP

• To provide access to IP based data transfer to ensure program sustainability.
• To provide store and forward technology to ensure program sustainability by ensuring physician access via the most flexible data transfer system.
• To enable telehealth to connect to Community Net WAN to reduce program operating costs due to telephone line data transmission and to improve security of electronic health record information.

Objective #2 - Upgrade the Nipawin Site to ISDN/IP

• To link the Satellite Initiative sites (Nipawin and Cumberland House) with specialists using more clinically appropriate technology.
• To provide access to store and forward technology.
• To enable the Satellite Initiative sites to connect to Community Net WAN to reduce program operating costs due to telephone line data transmission and to improve security of electronic health record information.

Objective #3 - Upgrade Dermatology Service To IP

• To ensure access to store and forward technology in order to provide specialists with more flexible data transfer.
• To provide easier access to dermatology services for rural and remote patients by permitting telehealth access throughout the month not just at regularly scheduled telehealth clinics, and to increase the number of dermatologists participating in telehealth services.
• To make more efficient use of dermatologists time, securing at least two dermatologists to participate in telehealth services and expanding clinical patient access.

Objective #4 - Establish a Site at the Kinsmen Children's Center (KCC)

• To increase access to specialized pediatric service consultations, and case conferences for children and their parents, referring health care providers and related care team members.
• To assess the suitability of video conferencing equipment for KCC applications, as compared with the current telehealth workstation equipment. Specifically to assess the need for a site coordinator to operate equipment, the suitability of the visual image, and the cost-effectiveness of the video conferencing equipment contrasted with current telehealth workstation equipment.

Objective #5 - Utilize Existing Equipment at The Saskatoon Cancer Center (SCC)

• To assess the suitability of video conferencing equipment for KCC and SPH applications, as compared with the current telehealth workstation equipment. Specifically, to assess the need for a site coordinator to operate equipment, the suitability of the visual image, and the cost-effectiveness of the video conferencing equipment contrasted with current telehealth workstation equipment.
• To increase access to cancer care consultations and case conferences, including palliative care, for patients and their families, referring health care professionals and other members of the care team including cancer tertiary care specialists.

Objective #6 - Establish a Site at St. Paul's Hospital (SPH)

• To increase access to palliative care, renal care, diabetic care and early discharge consultations and case conferences for patients and their families, referring/receiving care providers, and tertiary care specialists.
• To assess the suitability of video conferencing equipment for KCC applications as compared with the current telehealth workstation equipment. Specifically, to assess the need for a site coordinator to operate equipment, the suitability of the visual image and the cost-effectiveness of the video conferencing equipment contrasted with current telehealth workstation equipment.

Objective # 7 - Upgrade Existing Xray Scanners to IP

• To increase access to specialists for radiological consultations referred physicians and other primary care providers, in particular to increase the timeliness and flexibility of access for urgent and emergent consultation requests.
• To provide store and forward technology to support the increased access, in particular by increasing flexibility of access site and time by consulting specialists.

Objective #8 - Design and Develop Saskatoon's LAN To Support Transmission Of X-rays From Rural Areas to The Medical Imaging and Radiology Departments at Saskatoon's Three Hospitals

• To increase access to specialists for consultations by referring physicians, primary care providers, and other members of the health care team for early discharge patients, patients with rare conditions and/or complex post-discharge care needs, or other complex cases requiring consultation.
• To provide urgent and emergent access to specialists and improve turn-around time on diagnosis and treatment advice for referring physicians, primary care providers, and other members of the health care team.
• To encourage and support specialist physician participation in telehealth by providing specialists with more flexibility in organizing consultations.

Objective #9 - Add Additional Communities To The Network

• To respond to several requests from additional communities for telehealth services.
• To conduct detailed needs assessments in the communities who have requested services.
• To determine the impact of the current medical commission review on Saskatchewan's service delivery model.

Objective #10 - Connect All Telehealth Saskatchewan Sites To CommunityNet

• To determine the technical requirements to support end to end QofS
• To determine the requirements for bridge/gateway services and acquire and operate a suitable gateway/bridge/gatekeeper
• To determine the requirements for scheduling the end point devices and controlling bandwidth
• To evaluate and acquire suitable scheduling hardware/software that will support TS business and technical requirements

Telehealth Saskatchewan's CHIPP Project objectives can be summarized as follows;

• Migration to CommunityNet (Task #10) would reduce telecommunication costs and give TS access to the new IP technology. Three of the project's tasks (Tasks #1, 3, and #7) are to upgrade the existing telehealth equipment to IP technology so that they would be able to function on CommunityNet. Task #2 was to upgrade the existing Satellite Initiative (SI) equipment to IP technology.
• Task # 8 was designed to improve access to Saskatoon based consultants by assisting the Health Region with the development of a LAN that will enable Saskatoon consultants to view images at any of the hospitals' emergency or medical imaging departments.
• New programs and consulting services designed to meet identified needs would be provided from The Kinsmen Children's Center (Task # 4), St. Paul's Hospital (Task # 6) and the Saskatoon Cancer Center (Task #5). This would increase the programming available to the existing and potential new sites.
• New sites (Task #9) will be added to increase the population having access to TS programming.

3.0 Achievements

• During the past two and one half years all the original goals were met to some degree. Some goals were fully met, some were met with difficulty and some were partially met.
• Objectives #1, #4, #6, #7, #8, #9 and #10 were fully met while Objectives #2, #3 and # 5 were only partially met.
• Objectives #1, #7, #8, and #10 proved to be very challenging because of unanticipated obstacles or time required for proof of concept work but were achieved by the end of the project.
• Objective # 9 proved to be a major challenge because implementation of Saskatchewan's Action Plan for Health Care led to a reduction and reorganization in the number of health regions understandably distracted senior administrators attention from new programs such as telehealth, to focusing on loss of employment and regional restructuring.
• Objectives #4 and #6 were delayed because of the maternity leave of one of the key leaders.
• Objective #5 was only partially met because of a major organizational review and reorganization by the Saskatchewan Cancer Agency.

3.1 Goals Reached

Objective #1- Upgrade Existing Telehealth Workstations to IP

• The primary objective was to upgrade the existing telehealth workstations so they would support IP technology. This goal was achieved. However it was not without significant effort.
• The software upgrade designed and installed by the equipment vendor in January 2002 did not meet expectations. Testing showed there were many problems with the software upgrade. The site coordinators carried out testing using a defined protocol and these results were compiled into a report that was presented to the vendor. (See Appendix B for a sample of the report). Over the next five months regular meetings were held with the vendor, the project managed and one of the site coordinators to slowly and methodically resolve the outstanding issues. The vendor was very cooperative but the process did take time.
• The key contributing factor to the completion of this objective was good documentation and the positive team approach that was accepted by the project team including the project manager, the site coordinators and the vendors.
• One of the factors that complicated the testing was TS's limited ability to test the IP capabilities because the IP was service was not available to most of the network at that time. It was not until the fall of 2003 that complete IP testing could be completed on a network wide basis.

Objective #2 - Upgrade the Nipawin Site to ISDN/IP

• Nipawin and Cumberland House were part of an Alberta based initiative that used a satellite for communications. The down link was in Edmonton and all transmission had to run from Nipawin and/or Cumberland House via ISDN lines to Edmonton then out over the satellite. This was very expensive and the image quality was not acceptable.
• The initial obstacle was the relationship with the region's existing senior administration. TS was not instrumental in making the change, however did support it. The cooperative approach taken by the new management and TS staff lead to the successful completion of this task.
• After the management change in the region, the new management team was unable to provide any utilization data for the Cumberland House site. This was consistent with the general feeling of the TS staff. TS reached an agreement with the new district management that the Nipawin site would be upgraded but the Cumberland House site would not. The Nipawin equipment was almost entirely replaced because it was impossible to secure parts for the existing Hughes equipment.
• The Nipawin site has become an active participant in TS activities and there have not been any complaints from the Cumberland House site which seems to validate TS's conclusion that the community did not have sufficient interest to make use of telehealth.

Objective #3 - Upgrade Dermatology Service to IP

• One of the goals was to upgrade the telehealth workstation to support the dermatology application. This was accomplished and the dermatologist is satisfied with the quality of the images received over the network.
• A second objective was to provide the dermatologist with the ability to have images forwarded to his office. The initial plan was to use GDC's Desktop Consultant software. The software was still under development at the time the CHIPP project proposal was developed. When the pricing was finally established, TS felt that the software cost of $1,500 for each consultant's workstation made this application too expensive for widespread use. Eventually the vendor agreed to provide two free copies of the software. A suitable computer was purchased for the dermatologist. Only limited testing took place and the dermatologist has since stated that he prefers to see the patient on telehealth rather than use store and forward.

Note: The order of Objectives #4 and #5 has intentional been reversed to reflect the implementation timetable.

Objective #4 - Establish a Site at the Kinsmen Children's Centre (KCC)

• This task had full support of the center's director and the staff had developed an extensive plan for the use of the equipment for a variety of CE, case conferencing and clinics. Two of the KCC staff had used the telehealth equipment at the Royal University Hospital and were anxious to establish a service at KCC. There was good reason to believe there would be good buy-in by the staff. However there were two differences between the KCC and RUH sites;
  
  
  • The equipment would be basic video conferencing equipment and
  • The site would not have a site coordinator to operate the equipment.

The first part of this task was to assess the suitability of video conferencing equipment for KCC applications. This has met with limited success, partly because the equipment that was selected (A GDC Falcon) did not perform as expected.

In spite of extensive marketing efforts by the rural site coordinators and "Lunch and Learn" sessions by the Network Operations Manger, the uptake on this service has been slow. The site has been used for case conferences and for some CE sessions. The initial delay was the fact that the Network Operations Manager was on maternity leave when the CHIPP project started and her replacement(s) were unable to move the project forward even with support from the project manager. In the long run, the primary obstacle to increased use is the lack of a dedicated staff member to operate the equipment. The health professionals are too busy to operate it themselves and several have stated that if there was money available to hire a site coordinator, they money would be better spent hiring more professional staff.

On the positive side, there is growing interest in the use of the equipment for case conferencing.

The staff uses the system to screen some patient referral before they are booked for traveling clinics. In the past, they often booked children into valuable clinic time only to find that the child did not need their specialized services.

One unintended benefit has been the fact that a Winnipeg based consultant has used the telehealth equipment for patient consults between her regular visits to Saskatoon.

Objective #5 - Utilize Existing Equipment at The Saskatoon Cancer Centre (SCC)

• The first part of this objective was to assess the suitability of basic video conferencing equipment for Kinsmen Children's Center and St. Paul's hospital. Equipment vendors were stating that their equipment was inexpensive and did not require a dedicated site coordinator. The external evaluator was asked to interview staff who were using the SCC equipment and determine if they agreed that the equipment was easy to use. The primary use of the equipment was for administrative meetings with the Regina clinic. The conclusion was that the equipment was easy to use. The only instructions required was a single page instruction sheet that was placed with the equipment. One of the secretaries was designated as the troubleshooter and she stated that she had minimal training in the use of the equipment but very little trouble providing "technical support". She reported that there were no significant technical issues. The first part of the objective was met.
• The second part of this objective was to increase access to cancer care consultations, case conferences, and CE. When viewed from a quantitative perspective, this part of the objective has not been met. The primary obstacle has been the reluctance of the very busy oncologists to take time to use telehealth because as they correctly point out, they can see more patients in their regular clinics than they can with telehealth. There have been two cases where oncologists have participated in case conferences with patients who were too ill to travel to Saskatoon. However these sessions were held in the telehealth suite at the adjacent Royal University Hospital with a site coordinator in attendance. Cancer Center staff have presented two educational sessions.
• A second obstacle has been the fact that the Saskatchewan Cancer Agency underwent an operational review during the time of the project and this meant that non of the Center's staff had time to become involved in and CE sessions. After the review there was significant turnover is staff in the education department.
• Meetings have been held with the Clinic's Medical Director (The senior administrator) who personally supports telehealth but has been unable to use the network and he has not been able to persuade his staff to provide CE or clinics.

Objective #6 - Establish a Site at St. Paul's Hospital

The first part of this task was to access the suitability of video conferencing equipment for SPH applications and to assess the need for a site coordinator to operate equipment. The GDC equipment was not used because of the experience at KCC. Polycom equipment was purchased from a local vendor after an invitational tender to GDC and two local vendors. In one sense, this part of the objective was successful because it helped assess the qualifications of a local vendor. It also demonstrated that there needs to be local champions and dedicated resources, at least initially, to establish the telehealth site.

The second part of this objective was to increase access to palliative care, renal care, diabetic care and early discharge consultations and case conferences for patients and their families, referring/receiving care providers, and tertiary care specialists.

This task had the support of the managers responsible for the programs and there was also a suggestion that funding could be available to support a part time educator to operate the equipment for CE and patient consults. The task was scheduled to commence after the sites at the Saskatoon Cancer Center and the Kinsmen Children's Center were operational so these experiences could assist with the development of the St. Paul's service. It was also planned to use basic video conferencing equipment. Unlike the Saskatoon Cancer Center and the Kinsmen Children's Center, there was no one at St Paul's Hospital with previous telehealth experience and there were no "local champions".

Obstacles included the maternity leave of the Network Operations Manager, the lack of local champions and extensive and frustrating experience with the equipment vendor.

This site has only recently been used for telehealth but the sessions that have been held have generated considerable enthusiasm. The March 23 education session is one example. Other examples include consultations between Saskatoon's adult nephrologists and pediatric nephrologists in Edmonton. Another is some case conferencing between Regina and Saskatoon nephrologists.

Objective # 7 - Upgrade Existing Xray Scanners to IP

• The main task was to upgrade four scanners purchased for the pilot to give them IP capabilities. This task is being completed successfully.
• The main obstacle in completing this objective was the fact that the original vendor of the scanners had set them up with proprietary software. Initially the vendor had agreed to develop software that would support IP technology but after a lengthy delay, they stated that they would require consulting fees of $1,000 a day and could not give a firm delivery date.
• This obstacle was overcome by the recruitment of a Saskatoon Health Region Biomedical engineer with a strong interest in this technology. He agreed to analyze the software requirements and develop a new system. Once he had completed his analysis he had to purchase the parts required to retrofit the scanners and test his new design. This was done in stages. The first was a bench top test, second was a test over the Saskatoon Health region LAN. Next was a test from the biomedical engineers home using a specially designed VPN and finally a test over CommunityNet with staff in La Ronge. This process took considerable time because the work was carried out as additional work on an already busy schedule. There was a considerable sense of accomplishment by the biomedical engineer and the La Ronge telehealth site coordinator who assisted with the final stages of testing. During the process, the biomedical engineer developed a "Project Overview" paper (Appendix C) and Instructions for the use of the redesigned scanner (Appendix D)
• The remaining three scanners have been upgraded and are being set up in their respective regions within the next two three weeks.

Objective #8 - Design and Develop Saskatoon's LAN To Support Transmission Of X-rays From Rural Areas to The Medical Imaging and Radiology Departments at Saskatoon's Three Hospitals

• This concept has been successfully implemented. X-rays have been successfully sent from La Ronge to Saskatoon for interpretation. However there has not been any experience with the other three sites because they only recently or are just receiving their upgraded scanners.
• A unintended benefit of this project is the use of the new system to provide service to the Yorkton hospital when their radiologist was away on business. During the one week absence, 158 ultrasound studies were forwarded to Saskatoon and interpreted by Saskatoon radiologists.
• There was considerable proof of concept work carried out. One of the obstacles was the fact that the IT staff and xray technicians were very satisfied with the performance of the Stentor software. However the radiologists preferred the software that was part of the Siemens equipment. In addition there were jurisdictional issues between radiology and IT. The other obstacle was that the Director of IT who proposed the concept, accepted a promotion within the health region and while he tried to help move the project forward, he did not have the line authority to deal with some of the issues that arose. The solutions to some of the problems had be resolved at a slower pace but were eventually resolved
• The radiology manager took a strong interest in the project and helped move the radiology component forward.

Objective #9 - Add Additional Communities To The Network

• The CHIPP proposal called for the establishment of 5 new communities and by the end of the project, 6 were established.
• In November 2001, Saskatchewan Health was ready to select the 5 new sites. However Saskatchewan's Action Plan for Health Care was in early December. The Action Plan supported telehealth but the implementation of one of the Plan's key recommendations became a major obstacle. The Action Plan called for the consolidation of Saskatchewan's 33 health districts into 13 regions. For a full year after the announcement of the plan, senior administrators and regional boards had no interest in new telehealth sites. It was not until the spring of 2003 that Saskatchewan Health was able to obtain the support of regional CEO's to move ahead with the selection of new sites. Even at this time, most new regions did not consider telehealth as a major priority.
• Drawing on past experience, TS prepared "Self Assessments of Readiness for Telehealth" and asked each region to complete the assessment. TS also prepared a document outlining the steps required to establish a telehealth site in each region. The Project Manager and the Network Operations Manager made two visits to each site providing them with an orientation to TS. Based on theses visits, an RFP (Appendix E) was developed and issued in June 2003. After checking reference (Appendix F) two vendors were selected for demonstrations and instructed to follow a prescribed demonstration format (Appendices G and H).
• The equipment that was selected was a new model that still required CSA approval and this slowed delivery. Training was completed at the last site on February 6th 2004 and the sites coordinators are proving to be very excited about the new programs. Having the equipment on site is greatly facilitating the marketing of the telehealth service.

Objective #10 - Connect All Telehealth Saskatchewan Sites To CommunityNet

• The contribution agreement makes frequent reference to the fact that all sites will be connected to Saskatchewan's CommunityNet but does not describe this as a specific task. During the course of the project this was known as Task #10
• CommunityNet was designed as a data network and was still under development when the contribution agreement was signed in September of 2001. It was not until a May 2002 meeting of multiple stakeholders that TS was able to determine all the implications of migrating the existing network to CommunityNet. It was agreed that TS would need the services of a gateway and bridge. Initially SaskTel agreed to assist by developing an options paper. This turned out to be an obstacle and ultimately SHIN made arrangements to borrow a $200,000 CISCO bridge for three months to conduct proof of concept work. While this testing was underway, the project manager developed a costing model to evaluate TS's options. After considerable testing and costing, it was agreed that TS should acquire their own gateway/bridge. (Appendices I and J). It was estimated that the pay back period for the capital investment would be about 39 months. With CHIPP's approval some of the capital funding and operating costs were redirected from the budget for new sites to the cost of acquiring a gateway and bridge. This task did suffer a 10 month delay when SaskTel subsequently stated that they wanted an opportunity to conduct proof of concept work with their own gateway/bridge/scheduler.
• The proof of concept testing helped identify the design specifications required for each telehealth site' LAN to support QofS. HISC developed a template to be completed by each site (Appendix K). Each site was required to complete the template and HISC provided advice on any network reconfigurations required to support telehealth. TS eventually acquired its own gateway/bridge and is working with Alberta Wellnet to develop a scheduling system the will meet TS's business and technical needs.
• The last requirement of this task is to develop/acquire a scheduler to meet TS's business and technical needs. Scheduler requirements were documented and used to evaluate several schedulers (Including SaskTel's). In November 2003, the Network Design Architect who had led most of the development work left HISC but not before agreement was reached to work with Alberta WellNet and use their scheduler for the front end scheduling. Agreement was also reached that TS would acquire Forgent's "Media Manager" software for controlling the end devices.

3.2 Additional Successes

There were several successes beyond the original workplan

• TS acquired its own gateway/bridge/scheduler that will be supported by HISC. The development and implementation of TS's own gateway/bridge/scheduler is a significant achievement that was not contemplated during the initial planning for the project.
• The network redesign work carried out to support end to end QofS for CommunityNet (Task #10) has resulted in most rural LAN's operating in a much more efficient manner. One regional IT director has estimated that the redesign has provided his network with a 50% increase in capacity.
• The teleradiology component (Task #7) lead to the development of a system that allowed Saskatoon to receive 158 ultrasound images from Yorkton (While Yorkton is a new site, teleradiology was not considered part of the CHIPP project). This application will probably become extremely valuable as more and more radiologists are discontinuing or significantly reducing their trips to smaller communities. This can also be used to provide ultrasound coverage while the solo radiologist in many communities is on vacation.
• Developmental work on Tasks #7 and #8 has been very valuable in assisting Saskatchewan Health in the planning for a provincial RIS/PACS strategy.
• A Winnipeg based consultant who travels to Saskatoon twice a year for special clinics is now using telehealth for urgent consultations between visits.
• A number of out of province sites now participate in TS education seminars.
• Saskatchewan Health care providers are able to participate in many out of province education sessions that are not available in Saskatchewan.
• Staff at the KCC put on traveling clinics in many rural areas. They accept pediatric patients based on written referrals from rural physicians. On a number of occasions they arrive at the clinic only to find that the child is not a suitable candidate for the clinic or they have not brought the resources they require to assess/treat the patient. This results in wasted clinic time that could have been assigned to another patient. They know use telehealth to evaluate some the patients before they book them into the clinics resulting in a more efficient use of resources.
• University of Saskatchewan researchers were interested in doing research on memory loss and were trying to find a cost effective method of evaluating patients from all parts of Saskatchewan. TS staff worked with the research team and the team was successful in obtaining a grant from the CIHR New Emerging Team (NET) program.

3.3 Unreached Goals

TS was successful in either fully or partly achieving all of the CHIPP project goals. The project where the goals were only partly achieved are #2, #3 and #5

Objective #2 - Upgrade the Nipawin Site to ISDN/IP

• The original plan was to upgrade the telehealth equipment at both Nipawin and Cumberland House. However a review of the utilization of the existing equipment did not support the investment of additional funding in this site. These projects were undertaken by a healthy region in isolation and the original staff showed little or no interest in working with the TS team.

Objective #3 - Upgrade Dermatology Service To IP

• There are two factors that contributed to the "unreached goal". First was the fact that the software package that was developed by TS's vendor of record at the time this task was attempted was too expensive and was not considered particularly user friendly by the dermatologist. The second factor was the dermatologist's decision that he would like to continue to see his patients in real time.
• The dermatologist has stated that he would like to continue to experiment with the "desktop" store and forward technology but neither TS nor the dermatologist commixed this a high priority at this time.
• One of the reasons this task was of interest to TS was to enable physicians to receive images at the "desktop" weather it was in their home or in their office. Staff working on Task #7 (Radiology) have been successful in establish the capacity to send x-rays to the consultants office and to their home. This was not a part of the CHIPP project but we now know what is required to support this function.

Objective #5 - Utilize Existing Equipment at The Saskatoon Cancer Centre (SCC)

• There has only been very limited involvement by the oncologists in the use of telehealth to see their patients. One of the contributing factors was the fact that the Cancer Agency undertook an extensive organizational review followed by a major reorganization including a number of staff changes.
• The primary reason for the lack of uptake by the oncologists is they have been severely understaffed (About 50% of the approved staffing) and this ahs only recently improved. The oncologist feel that it is more efficient for them to see patients in their clinics rather than use telehealth are they are probably correct. They have seen two or three patients who were too ill to travel but these were exceptional cases. Ties application will probably not see much user until an oncologist with a strong interest in telehealth is recruited to the clinic.

3.4 Documents or Products Generated

Document /Product Name	Available in Paper and/or Electronic Form	License Fee Required for use (Yes/No)	Previously Provided to Health Canada (Yes/No)	Appendix Name /Number
Policy and Procedure Manual	Paper	No	No	A
Template for software upgrade testing	Paper and Electronic	No	No	B
Proposal for Upgrading x-ray scanners Task #7	Paper and Electronic	No	No	C
User Guide Radiology Scanners Task #7	Paper and Electronic	No	No	D
Template for vendor RFP Task # 9	Paper and Electronic	No	No	E
Template for vendor Reference Checks Task # 9	Paper and Electronic	No	No	F
Template for vendor Presentations Task # 9	Paper and Electronic	No	No	G
Template for vendor Demonstrations Task # 9	Paper and Electronic	No	No	H
Video Conferencing Design Evaluation and Testing Task #10	Paper and Electronic	No	No	I
Requirements and Proof of Concept CommunityNet Task #10	Paper and Electronic	No	No	J
Template for Region's LAN Redesign Task #10	Paper and Electronic	No	No	K
Telehealth Scheduler Requirements Task #10	Paper and Electronic	No	No	L
CommunityNet Security Task #10	Paper and Electronic	No	No	M
New Telehealth Saskatchewan Website content	Paper	No	No	N
Job Description Network Operations Manger	Paper and Electronic	No	No	O
Job Description Site Coordinator	Paper and Electronic	No	No	O
Clinical Training Protocols	Paper	No	No	See Appendix A
Education Training Protocols	Paper	No	No	See Appendix A Section 6.0
Clinical Program Protocol	Paper	No	No	See Appendix A Section 5.0
Video Conference Protocols and Etiquette Guide	Paper	No	No	See Appendix A Items 6e and 6j
Confidentiality and Privacy Policy	Paper	No	No	See Appendix A Items 4d and 4e
Consent Forms	Paper	No	No	See Appendix A Item 5m

4.0 Main Impact

The CHIPP funding has been used to support the migration of TS from SaskTel's ISDN and SW56 lines to CommunityNet in anticipation of significant telecommunication cost savings. Some of the anticipated cost savings will not be realized because of unanticipated SaskTel QofS charges. The switch from ISDN/SW56 to CommunityNet will not take place until the end of April so the exact impact will not be known until then. However based on utilization to the end of December it is estimated that the annual telecommunications cost savings will be about $150,000 and the incremental QofS costs incurred by HISC will be about $70,000. There has been a significant impact on the body of knowledge related to video conferencing over IP. Much of the proof of concept work carried out during the project to support TS, will be 100% transferable to other video conferencing projects to be undertaken by HISC and the College of Medicine.

A second major impact is on the number of sites. The contribution agreement called for the establishment of five new sites. Six new sites were added to TS during the project.

A third major impact was the body of knowledge acquired during the upgrading of existing xray scanners and the Saskatoon Health Region's LAN and RIS to support the transmission of x-rays from rural site to urban centers such as Saskatoon and Regina. While there were comparatively few x-rays sent from rural Saskatchewan to Saskatoon during the pilot, the software that was acquired by Saskatoon was used to interpret about 1,300 x-rays that were transmitted between the three Saskatoon hospitals. In addition, during the week of February 2nd, 158 ultrasound studies were sent from Yorkton to Saskatoon for interpretation because Yorkton's radiologist was out of town on business. The project was also instrumental in establishing IP capacity in the La Ronge ultrasound suite enabling La Ronge's untrasonographer to send studies to Prince Albert for interpretation. While La Ronge will use video tapes (store and foreword) for the majority of the ultrasound cases, this new feature gives the ultrasonographer the capability to immediately obtain a consultation with a radiologist if she encounter's an unusually case. This could avoid delays in diagnosis medical conditions and is a key to maintaining ultrasound services in La Ronge. In Saskatchewan all ultrasound must be carried out under the supervision of a qualified physician and the use of telehealth is recognized as a method of supervision.

There has been an increase in the number of clinical consultations, the number of clinicians participating in the program and in the number of education sessions and participants.

TS had an existing management structure consisting of a management committee and a site coordinators committee. Both committees expanded their membership as new sites were added. A College of Medicine representative was also added to recognize the College's increasing role in the operation of the network and the content delivered over the network. The CHIPP tasks have had a major impact on TS's activities and it is recognized that with the completion of these tasks the governance needs to be reviewed. This will take place at a strategic planning session to take place in May.

Some new sites have established regional telehealth paling committees to facilitate the introduction and expansion of telehealth to their region.

4.1 Human Resources Impact

The CHIPP project has had an impact on human resources.

• Five new half time positions and two full time positions have been developed. These positions are considered permanent and will be funded by Saskatchewan Health after the completion of the project. During the project, the site coordinator's positions were formally evaluated by Saskatchewan Joint Job Evaluation process and established as positions within the scope of the Health Sciences Association of Saskatchewan
• The project confirmed earlier findings that sites require the presence of site coordinators if they are to achieve maximum benefit.
• All of the current and past site coordinators have acquired new IT and management skills. All of them have a much better understanding of IT technology and two of them have developed their skills to the level where they are expert troubleshooters on IT issues. Three of the original site coordinators and the Network Operations Manager have been promoted to more senior positions within their respective organizations.
• There has been an increase in activity levels at all rural sites with no increase in staffing. This implies increased productivity. TS has not conducted a formal job satisfaction survey but there has been a high level of enthusiasm for telehealth with all site coordinators looking for methods of promoting telehealth in their community. There is however a need to address a number of policy issues through a strategic planning initiative or there is a high risk that the site coordinators will feel a lack of a sense of direction for the telehealth program.
• The only area where there has been a measurable resistance to change is in the move from Sasktel's ISDN/SW56 to CommunityNet's IP. The site coordinator's primary reason for the resistance is the reliability of the new network, not the IP technology. The concern is understandable and is lessening they gain experience on the new network

4.2 Privacy and Protection of Information

From the onset of Saskatchewan's telehealth project, patient confidentiality and security of information have been a primary concern.

All telehealth equipment is physically secured, all clinical sessions are in closed rooms with the door in the background so patients can see if anyone enters the room; all most all sessions are in real time with no data storage; When using SaskTel ISDN (3 lines) or SW56 (6 lines), a hacker would have to break into all lines to eavesdrop. CommunityNet is a secured WAN. A description of the security measures is in Appendix N. The store and forward data for xray is transferred over CommunityNet and then to the Saskatoon Health Region's (SHR) LAN and stored on a secured server. SHR has a credentialling process for granting access to this server.

Since we have dealt with health professionals who are always aware of confidentiality issues, most of them ask about security and confidentiality before they agree to use TS. TS staff and providers have always been aware of the patient confidentiality issues and have considered them as part of the program/clinic planning

TS has a number of policies designed to ensure patient confidentiality (See Appendix A). However these are all under review taking into consideration Saskatchewan's new HIPA legislation. The existing polices have not been a barrier to use and there have not been any patients who have refused consent based on confidentiality concerns.

TS will be undertaking a Privacy Impact Assessment using the HIPA guidelines. Saskatchewan Health is working with the region's CIO's to review the HIPA implications. The goal is to have a provincial approach to patient confidentiality issues.

Our discussions have always involved representatives of HISC (Formerly SHIN) who is the manager of CommunityNet our communications carrier. The TS project manager has had several discussions with Saskatchewan Health's HIPA policy consultant.

TS was using a paper consent (Appendix A) but discontinued this practice after consulting with legal counsel. TS has adopted a "Standard of Care" approach to TS sessions and this will require the site coordinators to provide each patient with an explanation of what to expect from the telehealth session including explaining that they have the right to refuse to use telehealth and see the provider in person

4.3 Policy and Research Implications

Major finding #1: Organizational Readiness. All new communities completed a " Self Assessment of Preparedness for Telehealth" but more work was required to establish some of these sites than with others and more work was required than with most of the original sites. There were certainly a number of significant distracters (I.e. reorganization of the health system) present during the project but there appears to be a "point of readiness " that needs to be present to establish a new telehealth service. There is a body of research on this issue but it would interesting to do further research on this issue in the Saskatchewan context. The policy implication is that telehealth sites would only be established in sites where organizational readiness, not just individual readiness, was present. Part of the organizational readiness profile would include determining individuals at all level of the organization who are committed to telehealth and determining their reasons for supporting telehealth.

Major finding #2: Interjurisdictional Telehealth. Many telehealth consultations are now interprovincial and can make more effective use of scare resources (Specialists) by helping them to reduce the number of traveling clinics required to serve a population. Interjurisdictional telehealth consultations can also reduce or eliminate costly travel for patients who do not have to leave their province to see specialists who restrict their practices to large metropolitan cities
The policy implications are that there needs to be interprovincial agreements defining the credentialing requirements and liability implications of these consults.

Major finding #3: Sustainability Many jurisdictions recognize the qualitative benefits of telehealth but are reluctant to commit their own funding to support telehealth because these investments do not always translate into bottom line savings. The policy implication is that telehealth programs need to identify applications that do, directly or indirectly, contribute to an organization's bottom line The first step would be to identify programs/applications the can utilize telehealth to reduce costs (I.e. travel and accommodation cost) and save time (Travel time). The next step would be to quantify these savings then develop policies that will provide funding to help support telehealth.

5.0 The Future

What are your plans for maintaining or developing your project once CHIPP funding ends? If you have already prepared a sustainability plan, please attach it as an appendix.

Saskatchewan Health has committed $500,000 a year to telehealth and our CHIPP proposal was based on the assumptions that;

• The $500,000 would be ongoing and
• Our annual operating expenses would be $500,000 after the CHIPP funding ended.

In other words we cut our cloth according to the permanent funding we knew would be available when the CHIPP funding ended.

Prior to the CHIPP funding, Saskatchewan had incorporated telehealth consultations into the physician fee schedule so any physician consultations are not part of the TS expenses.

By migrating the network to CommunityNet, almost all communication costs were eliminated. TS no longer has to pay any line rental costs or volume driven toll charges for Sessions within Saskatchewan. Since TS now has its own gateway and bridge, TS will no longer have to pay Telus toll charges. There has been an incremental cost to HISC for technical support, however HISC is developing a 24/7 IT support service for several other provincial IT initiatives so the cost of the TS component of the support is small compared with the fees/charges that TS was paying.

In 2002, Saskatchewan announced it Action Plan for Health Care and this is the government's strategic plan for the delivery of health services. The action plan includes the use of telehealth to link the provinces provincial (5), regional (6), district (9) and northern hospital (4). This is a network of 24 hospital. There are two northern nursing station sites from the initial pilot project and TS will continue to support them. During last falls election, one of the government's commitments was to expand the number of sites to 26.

Most of Saskatchewan's health regions are very large and members of the management and health care teams have to travel long, time consuming distances to conduct their business or deliver health care. Many of these regions are developing business cases for regional networks that will result in travel cost savings that will flow to their bottom line. They are also aware that the use of telehealth will result in much more efficient use of their employee's time if they can save several hours traveling for a short meeting, clinic or education session. There is a strong feeling that many regions will be able to demonstrate comparatively short pay back periods for investment in lower end video conferencing equipment.

Telehealth has been included in the province's IT strategic plan that was developed by Saskatchewan Health and the thirteen health Regions.

The College of Medicine is using a distributive education model and many of their residents and JURSI's take part of their training in rural communities and many of these communities are now being served by TS. The College is also anxious to use TS for their extensive CME programs. TS and the College very quickly realized that the College activities between Saskatoon and Regina were consuming much of the TS sites time with resident and JURSI training so the College acquired two pieces of video conferencing equipment for their use. TS can use the equipment when it is not in use by the College.

Future expansion of the network will be accomplished by requesting incremental operating costs (Primarily salaries) and one time equipment and installation costs through the regular budgeting process. Telehealth will have to compete with other health priorities for funding. However the use of the network to avoid staff travel costs will generate some real cost savings that will help support the case for expansion.

The current source of funding is from Saskatchewan Health with the regions absorbing some of the costs from their current budgets. TS officials are discussing other partnerships such as the Department of Learning and other organizations that provide fee based education programs or have the potential to save staff travel costs by using TS.

At the March 11th 2004 meeting of the Telehealth Saskatchewan Management Committee, it was agreed that we need to have a Saskatchewan Health led strategic planing session, probably in May, to review and if required, revise issues such as;

• Mission and our goals
• Governance
• Staffing levels
• Provincial IT strategic plan (Technical needs)
• Funding requirements and additional sources of funding
• Agreements with other jurisdictions (Many of TS'e education programs are viewed by sites in Manitoba, Alberta, Nunavet, Northwest Territories and

Saskatchewan and Alberta are currently engaged in discussion regarding schedulers that will meet both our business and technical needs. Alberta has also had discussions with Manitoba on this issue. Alberta has a superb "front end" scheduler and TS has purchased the software/hardware and a license from Forgent for their Media Manager, a scheduler. Saskatchewan and Alberta are going to try to integrate the software from the two systems but may require additional funding. Funding for a pilot involving Alberta, Saskatchewan and Manitoba would be beneficial for telehealth in Canada.

6.0 Communications

Methods or Tools	Date	Targeted Audience	Documents or Presentations Produced	Appendix Name/ Number
Conferences	2001, 2002, 2003	TS Site coordinators have attended all three CST conferences		-
Conference	October 2002	Project Manger presented a paper at the CST Annual Conference	IP Technology - Is it Worth the Cost?	-
Conference	October 2002	Project Manger presented a paper at the CST Annual Conference	What Happens When the Grant Money Is Gone?	-
Media Events	August 2001	Provincial residents	Saskatchewan Minister of Health and Health Canada Minister announcing the CHIPP funding	-
Media Events	June 2003	Provincial residents	Saskatchewan Minister of Health Announcing five new TS sites	-
Open House	Various dates	Local citizens and health care providers	Brochures and tear sheets	-
Marketing / Advertisement	April 2004	Potential TS users and providers	Two brochures with description of the telehealth program and instructions to presenters on how to prepare for an education session	-
Website (please provide the Website address)	April 2004	Anyone on the Internet	Several web pages describing TS, identifying sites and contacts, protocols for education	-

7.0 Other Documents

CHIPP's report outline seeks documentation of Telehealth Saskatchewan's achievements, the obstacles and the factors that contributed to success in working through these obstacles. The report identifies a number of obstacles that were faced and describes processes that were followed to resolve them. The responses in this report do not describe the most important element that contributed to this project's successes. That element was the people who were part of the Telehealth Saskatchewan Team.

Some team members have been with Saskatchewan's telehealth program since its inception in 1997. Some team members left the team for other opportunities. Some team members only recently joined the team.

Team members came from administrative, clinical and technical backgrounds.

Some team members were the strategic thinkers that saw the potential for using telehealth to bring patient care and educational opportunities closer to the individual's homes in rural Saskatchewan and other parts of Western Canada. In the beginning, they may not have fully appreciated telehealth's potential for bringing scarce clinical and educational resources from all parts of Canada to all Saskatchewan residents and health care providers. Several of these individuals are in senior positions within Saskatchewan Health, Health Canada, Saskatoon Health Region and the College of Medicine and they helped make Telehealth Saskatchewan a reality by ensuring that their respective organizations provided funding to build and operate the network.

Some team members were conceptual thinkers with the expert knowledge required to conceptualize, test and retest concepts that ultimately enhanced Telehealth Saskatchewan. SHIN's former Chief Network Architect who led Telehealth Saskatchewan's migration to CommunityNet. Saskatoon Health Region's former Director of IT Services felt it would be possible to send x-rays from rural Saskatchewan to Saskatoon and ultimately to viewing stations conveniently located in Saskatoon's three hospitals. Both were supported in their work by other team members who carried our much of the testing and the implementation of the results of these tests. Saskatoon Health Region's Manager of Medical Imaging, one of their biomedical engineers and The La Ronge site coordinator provided major contributions to the success of these initiatives.

Leading edge IT is of little value if it is not used effectively to carry the telehealth programming that is intended to help patients, healthcare providers and the public. Telehealth Saskatchewan's Network Operations Manager brought a very professional approach to the program development required to make Telehealth Saskatchewan a valuable tool for the delivery of health care services. She was supported by a dedicated group of site coordinators who actively extolled telehealth's value in improving Saskatchewan residents access to health services and education.

Other team members hold administrative positions in the participating health regions and they have supported Telehealth Saskatchewan by providing resources from their region's budgets to renovate telehealth suites and to underwrite operating costs not funded by Saskatchewan Health or Health Canada.

Without this team, the Telehealth Saskatchewan/CHIPP project would not have achieved the high degree of success outlined in this report.