Yukon Telehealth Network

Health and the Information Highway Division, Health Canada
January 22, 2004

Table of Contents

• Project Steering Committee
• 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 - Lessons Learned
• 8.0 Appendices

Project Steering Committee

Joy Kajiwara

Chair, Project Partner, Director, Community Nursing and Emergency Medical Services, Health Services, Government of Yukon

Paula Pasquali

Director, Community Health Programs, Health Services, Government of Yukon

Irene Szabla

Executive Director, Child Development Centre

Elvira Knaack

Director, Patient Services, Whitehorse General Hospital

Scott Wilson

Medical Advisor, Physician

Pam Briemon

Planner, Information & Communications Technology, Department of Highways and Public Works, Government of Yukon

Derrick Law

Network Systems Administrator, Health Services, Government of Yukon

Chris Bookless

Manager, Finance, Systems & Administration, Department of Health & Social Services, Government of Yukon

Pat Bragg

Executive Director, -Yukon Family Services Association

Lori Duncan

Director of Health, Council of Yukon First Nations

Marie Fast

Clinical Manager, Mental Health Services, Community Health Programs, Health Services, Government of Yukon

Bea Felker

Telehealth Coordinator, Department of Health & Social Services, Government of Yukon

Julian Somers

Director, Centre for Telehealth, Mental Health Evaluation & Community Consultation Unit, UBC

Robert Hanson

Ex-Officio Member - Senior Program Consultant, Innovation and Investment Division, Office of Health and the Information Highway, Health Canada

Implementation Consultants

Roberta Staveley

Senior Consultant, Telehealth Resource Group

Natalie Leonard

Senior Consultant, Telehealth Resource Group

Project Evaluation

Mal Malloch

Malloch Graham & Assoc.

Russell Graham

Malloch Graham & Assoc.

Basia Siedlecki

Principal investigator

Penny Jennett

Advisor, Health Telematics Unit, Faculty of Medicine, University of Calgary

Mo Watanabe

Advisor, Health Telematics Unit, Faculty of Medicine, University of Calgary

1.0 Introduction

The Department of Health and Social Services of the Government of Yukon is dedicated to working with the communities of the Yukon Territory to ensure quality health and social services for its citizens. This mandate includes helping individuals acquire the skills needed to live responsible, healthy and independent lives and providing a range of accessible, sustainable services to assist individuals, families and communities to reach their full potential.

The Yukon government is faced with many challenges in delivering healthcare services in remote Northern communities. Challenges include the restricted and expensive access to specialist services, difficulties in meeting the health needs of Yukon First Nations and non First Nations close to home, difficulties in the recruitment and retention of health care providers and professional isolation. These factors hold throughout the Yukon, but are more acutely felt and the impacts are substantially greater in the smaller rural communities than in Whitehorse.

The Department of Health and Social Services reviewed the benefits of a telehealth project and concluded that this was a feasible approach to improve access to services for residents in currently under served communities, and to improve professional development and professional supports so that Yukon professionals are able to stay current in their field and are more willing to remain working in the Yukon.

The Yukon Government successfully applied to the Canadian Health Infostructure Partnership Program (CHIPP) for funding to launch a telehealth project in the Yukon (the Yukon Telehealth Network, or YTN).

With CHIPP funding support, the Yukon government established a telehealth information and services network in nine Yukon communities:

• Whitehorse - Yukon's capital city 2697 kilometers northwest of Vancouver
• Watson Lake - 459 kilometers east of Whitehorse
• Haines Junction - 158 kilometers west of Whitehorse
• Mayo - 400 kilometers northwest of Whitehorse
• Dawson City - 536 kilometers northwest of Whitehorse
• Old Crow (inaccessible by road) - 800 kilometers northwest of Whitehorse
• Beaver Creek - 457 kilometers west of Whitehorse
• Destruction Bay - 266 kilometers west of Whitehorse
• Pelly Crossing - 282 kilometers northwest of Whitehorse

Whitehorse was selected because many services and professionals are centralized there. The communities outside of Whitehorse were selected based on a combination of factors:

• availability of an adequate bandwidth connection to the community to support the telehealth technology
• the anticipated volume of use, based on population
• the perceived need within those communities for the health services and community supports offered at the time of start-up
• travel time to Whitehorse (favoring the selection of communities with a longer travel time)

Telehealth Applications

All nine communities involved in the project are equipped with video conferencing workstations. In addition, each community is provided with digital cameras and hardware with X-ray store and forward capabilities. In the CHIPP funding period, the network was used to deliver these telehealth services and programs:

• Telementalhealth;
• Telelearning;
• X-ray emergency support
• Telefamilyvisits
• Early Childhood Development Services
• Therapy Services
• Discharge Planning

Communications Infrastructure

To implement YTN, considerable resources were required to upgrade the underlying telecommunications infrastructure serving the project sites. The Yukon government committed funding for necessary infrastructure improvements. The Connect Yukon program was implemented and provided the necessary foundation for YTN's implementation and success. The timing and order of the YTN site community installations were coordinated with the Connect Yukon program rollout schedule.

Managing the Operational Change Process

The aim of YTN was to develop an operational model for telehealth programs that would become an integral part of the health care delivery system. Integration is crucial if telehealth technology is to become an efficient and effective healthcare tool in Yukon. However, initiating a change of this magnitude into the business practices of healthcare providers can add stress to an already stressed system. For this reason, YTN was specifically designed to build user confidence with the technology and enable gradual adoption and expansion of the technology into the health care system. YTN utilized the telelearning application as a way to familiarize users, build early successes and promote professional and public support for and acceptance of the technology. Clinical applications were initially limited in Phase I to only the telementalhealth program, where there was already a very high degree of professional interest and support for the program. Additional clinical applications were subsequently added, specifically Early Childhood Development Services, Therapy Services and Discharge Planning.

YTN Technologies

The network topography of this project is complex and challenging. For the first time in Canadian telehealth experience, a single project utilized H.323 protocols on terrestrial frame relay and satellite frame relay networks and connected via gateways to H.320 systems running on a satellite frame relay network and terrestrial Switch 56. This model is a first step toward the interconnectivity across networks required for a national health infostructure.

The Connect Yukon project, operating on NorthwesTel's frame relay service, provides a minimum of T1 data services to each of the YTN site communities. Frame Relay Service allows inter-community trunk bandwidth to be shared by multiple customers to maximize economic benefit, while retaining the same security and privacy provided by dedicated facilities. This service is connection-oriented and contains discrete, pre-defined circuit end points limited to the Yukon communities identified in this schedule.

The enhanced video conferencing communications tool enables the sites to conduct interactive real time audiovisual sessions for the delivery of education sessions and information, delivery of specific direct clinical and consulting programs, and facilitation of family visits. A simple store and forward technology is being utilized for the X-ray emergency support.

The video conferencing systems facilitate point-to-point connections between two sites. The implementation plan included access to a video conferencing bridge to allow the network to connect all six sites simultaneously. The initial videoconferencing and store and forward systems were to run on an IP-based frame relay LAN telecommunication service and utilize a switch 56 gateway to the ISDN switched network in the Southern Canada. The set top video conferencing systems use H.323 standards over the frame-relay network. An H.323 to H.320 gateway is part of the video conferencing bridge and allows interconnectivity with project affiliates in other jurisdictions.

Project Outcomes

In the past, clients often refused treatment because of the need to travel from jobs and family to access services in distant communities. Unfortunately, such decisions may serve to exacerbate health conditions and limit the providers' ability to provide timely, effective interventions to restore well-being and functional abilities. Telehealth can allow clients to receive some basic health care services in their home communities where they also have access to the support of their friends and family. The telehealth option also means that care may be more quickly accessed when it is needed, rather than postponed until the date of the next travelling clinic which could be several months away. If patients do require treatment away from home, the vital link with family and service providers in the home community can be maintained with televisits and teleconsultations. Better health outcomes are anticipated because visits can aid in recovery and consultations can facilitate or support continuity of care when the patient returns to their home community.

As anticipated, clinical consultation with peers and specialists coupled with continuing education opportunities supports health care providers working in remote communities. By breaking down professional isolation, these services make it possible for remote providers to become part of a much larger network of care providers and enjoy the sense of collegiality and shared care that is an essential part of the working environment of most health care providers in large urban centres.

2.0 Project Description

The Yukon Telehealth Network is led by the Department of Health and Social Services of the Government of the Yukon and involves partners from British Columbia and Alberta. The Yukon Telehealth Network will help meet the health care challenges in remote Northern communities which include:

• the restricted and expensive access to specialist services to Yukoners living in communities outside Whitehorse,
• difficulties in meeting the health needs of Yukon First Nations and non First Nations close to home, and
• difficulties in the recruitment and retention of health care professionals.

The telehealth programs defined for this project were delivered to nine participating sites in the following Yukon locations:

• Watson Lake
• Haines Junction
• Old Crow
• Mayo
• Whitehorse
• Dawson City
• Pelly Crossing
• Destruction Bay
• Beaver Creek

With the majority of specialist services contracted outside the Yukon, partnerships were required with the clinical service providers. Locations of these partners are as follows:

• Children's & Women's Health Centre of British Columbia (C&W)
• BC Children's Hospital
• BC Women's Hospital and Health Center
• Sunny Hill Health Center for Children
• University of British Columbia
• Mental Health Evaluation and Community Consultation Unit (Mheccu)
• Alberta Ponoka Hospital, Ponoka, Alberta - partner of Mheccu

Services included:

• Telementalhealth
• Telelearning
• Telefamily visits
• Emergency radiology consults (Store and forward of digital image of x-ray for emergency consultation with emergency Physician at Whitehorse General Hospital
• Therapy services
• Early Childhood Development Services
• Discharge Planning

The system operates on an IP-based frame relay LAN telecommunication service provided by Connect Yukon. Connection to a maximum of four Yukon sites utilizes the Multi Cast Unit capability purchased with the Whitehorse videoconferencing equipment. Connection to the ISDN switched network in Southern Canada utilizes Switch 56 and a gateway functionality purchased with the Whitehorse videoconferencing equipment.

3.0 Achievements

3.1 Goals Reached

The objectives for this project were identified based on business challenges and opportunities in providing health and social services to Yukon communities. Most of the original objectives were achieved and include:

• Implementation of a Telehealth network in nine Yukon communities
• Knowledge transfer from the implementation team to the Yukon project team as evidenced by implementation of three additional sites by the Yukon Telehealth Team
• Installation of videoconferencing workstations in all nine communities
• Implementation of x-ray store and forward capabilities to improve the timeliness and quality of treatment decisions for emergency triage in rural communities
• Implementation of four initial applications: telementalhealth, telelearning, x-ray emergency support and telefamily visits
• Implementation of three additional applications: therapy services, early childhood development services and discharge planning
• Utilization of telehealth in the delivery of selected health programs.
• Improved quality of service for persons diagnosed with serious mental health problems by providing:
  a) Psychiatric services from Vancouver to Whitehorse - regular monthly sessions with pediatric and geriatric psychiatrists, and twice monthly sessions provided by an adult psychiatrist.
  b) Allied mental health services from Whitehorse to the rural Yukon communities.
• Improved utilization of scarce professional resources by facilitating consultations without the need for travel
• Increased access for remote health care providers to Yukon relevant distance education sessions on a monthly basis, enhancing client care, and increasing job satisfaction
• Improved access to health education programs; previously only available in Whitehorse, that foster self-care for rural residents.
• Increased Yukon and Canadian telehealth systems knowledge and expertise for both domestic and export purposes by documenting and reporting on technology innovation and implementation processes, performance and lessons learned.

*Appendix A - YTN Timelines - Accomplishments

Contributing factors to achieving the goals of the project were:

• Small number of health care stakeholders, due to population of Yukon, enabled easier back and forth communication and problem solving
• Enthusiasm for the project by key stakeholders and members of the project team
• Contracting an implementation team with knowledge and expertise in the technical and operational aspects of a Telehealth project
• Expanding telehealth to three additional sites provided an opportunity for local YTN staff to purchase, install, train and support the expansion without the involvement of outside consultants
• Identifying "champions" of technology which lead to champions of Telehealth
• Identifying local site coordinators early in the process who received training and became champions of Telehealth and maintained the program focus in each community
• Standardization of equipment - through the RFP process the contract for videoconferencing equipment was awarded to Tandberg
• Building confidence and support among health care providers through regular, relevant education sessions
• Working on an individual basis with health care providers and program managers to identify ways of using telehealth to improve health services, and piloting or implementing these new clinical applications

Obstacles or challenges that impacted achievements were:

• Health care providers' understandable concern about confidentiality was addressed by:
  1. Improving soundproofing in rooms used for clinical applications in all Yukon sites
  2. Using white sound devices outside clinical rooms
  3. Providing the option to use headphones
  4. Utilizing Switch 56 and the videoconferencing equipment's internal bridging capabilities instead of a telecommunication company's bridge services for clinical applications delivered from outside the Yukon.
• The lack of knowledge and exposure to videoconferencing technology among a large percentage of health care providers was addressed by:
  1. Providing training opportunities and demonstrations of videoconferencing
  2. Addressing concerns about privacy and confidentiality
  3. Permitting health care providers to determine their level of participation, e.g., physiotherapists began by offering only follow up telehealth sessions with clients previously seen face-to-face but by the end of the project were scheduling initial appointments for appropriate cases
• The perception that users and providers had not been adequately consulted during the proposal development stage due to staff turnover and length of time from initial consultations and roll out of project was addressed by:
  1. Providing background data, goals and timelines during training sessions
  2. Providing all interested employees and other health care providers with an orientation to Telehealth
• Limited evaluation data available due to the small population (30,000) was addressed by:
  1. Asking for and receiving an extension of the project for an additional six months
• Slower resolution of network issues due to involvement of four parties (NorthwesTel, Information Communication and Technology Unit, Department Health and Social Services, and Whitehorse General Hospital) was resolved by:
  1. Improved communication between departments at both regular and critical junctures (e.g. when changes are proposed or planned within any department's network structure)
• Compromised quality of videoconferencing due to the absence of quality of service provided by telecommunications provider was addressed by:
  1. Purchasing and implementing quality of service routers.

3.2 Additional Successes

The response of health care providers to professional development provided via telehealth went beyond regular attendance at scheduled sessions. Many health care providers found or sought out additional opportunities on their own, and brought them to the attention of their colleagues and/or the telehealth coordinator(s). This suggests that some health care providers have already begun to think about how telehealth can be used to meet their own professional development needs. This can be considered one measure of the extent to which telehealth has become integrated into the business of health care services.

A parallel success was seen among telehealth coordinators. The Yukon's Telehealth Coordinator became part of a network of coordinators across the country, each of whom shared their experience, local programs, and insights with each other. This has resulted in a far richer schedule of telelearning offerings (for example, the Yukon has and continues to participate in the public education sessions provided by Saskatchewan Telehealth), and expanded thinking about future clinical applications and innovations.

With the permission of CHIPP, cost savings due to efficiencies in implementation was directed to implementing telehealth technology in three additional communities. Whereas the initial training of site coordinators and rural health care providers was provided face to face by a team of outside experts, the implementation of the three new sites was accomplished using the expertise of local telehealth coordinators. As well, virtual training replaced the more costly onsite training in these communities. Initial indications are that virtual training can be as effective as face-to-face training when accompanied by user friendly and detailed manuals and other supporting materials.

An indicator of success is that one of the three new sites arranged a clinical session within ten days of start-up. The rapidity with which this site came "on line" may be attributable to several factors, including the success of training, the presence of a local champion, and the awareness that telehealth applications had been successfully implemented in other communities. The greatly accelerated uptake of telehealth in this community is a further indication that the use of telehealth technologies has been integrated into the thinking of some health care providers, including those who have had limited direct exposure to telehealth.

3.3 Unreached Goals

1. An agreement for Bridging and Gateway services with NWTel, the telecommunications provider in the Yukon, was not finalized within the life of the project. The bridge services, originally planned, would have enabled all sites in the Yukon to be connected simultaneously.

   Contributing factors:

   • A prolonged strike by NWTel employees
   • A change in the original costing arrangement with the local telecommunication provider
   • The length of time between the initial discussion with the telecom provider, submission of the CHIPP proposal and the final approval for the project
   • The necessity to consider and meet the needs of YTN within the broader context of meeting the televideoconferencing needs of many YG departments and services.

   As a result of the above all sites can not be linked simultaneously. Until such an agreement is finalized, the YTN continues to utilize the Multi Cast Unit capability purchased for the Whitehorse videoconferencing equipment. Connection to the ISDN switched network in Southern Canada utilizes Switch 56 and a gateway functionality purchased for the Whitehorse videoconferencing equipment. This solution enables four sites to be connected within the Yukon (three rural sites and Whitehorse). When connecting to a southern site via Whitehorse utilizing the Switch 56, two rural sites can be added to the connection.

2. Using Telehealth networks to enhance health agency collaboration and sharing of education programs with Nunavut and the NWT for the purpose of improving Yukon and pan-territorial population health did not occur during the project.

   Contributing factors:

   • Bridge and Gateway were not implemented during the project and no costing agreement was achieved with the local telecommunication provider
   • Several sessions were planned utilizing Switch 56 but never occurred due to cancellations or staff turnover
   • Varied implementation schedules across the three Territories

   On the other hand, many relationships between service providers and referral pathways occur along the North-South rather than East-West axis, and there are many examples of enhanced collaboration, case management, and shared educational programs with providers and services in both BC and Alberta.

3. Finalizing the Contribution Agreement with Health Canada took longer than originally anticipated. The original agreement had to be rewritten and resubmitted when the original funding request was accepted but for a decreased funding amount. This delay resulted in compressing the purchase of equipment, and implementation of Telehealth into a much shorter time frame than originally planned. This may have contributed to less user "buy in" which is a critical component of any change management plan.
4. Due to the decreased funding and the desire by the YTN to implement a sustainable program the project had to be reconfigured. This resulted in a change to the teleradiology component. Originally x-rays were to be transmitted to a radiologist for diagnosis using a digital scanner located in each rural facility. This was replaced with the use of a simple digital camera to take a picture of a x-ray and e-mailing the picture to the physician in Emergency at WGH for triage purposes. The change in the teleradiology application was generally regarded as less valuable than the originally proposed service. Although rural physicians perceived the change from diagnosis to triage as being of little value, nursing staff in some communities reported this tool assisted them with triage decisions.
5. Eligibility criteria for accessing the telefamilyvisit program were not developed as originally planned. However, a protocol outlining the operational requirements and steps for arranging telefamily visits was developed with input from the medical social worker and was used successfully. The visits that were arranged, while few in number, did expose some factors which could be developed into more formal eligibility criteria. These factors include the assessed health benefit to the patient, the length of hospital stay, the degree of social isolation of the patient, and the relative ease with which family members and others can visit in person.
6. Monthly psychiatric services from Vancouver to Watson Lake did not occur. Procedures have been developed and presented to the itinerant practitioner but never finalized by the practitioner. The absence of priority given to implementing telepsychiatry sessions on the part of the practitioner, local service providers and clients may mean that needs are being well met with the existing itinerant service.

3.4 Documents or Products Generated

While implementing telehealth in the Yukon, a number of documents and tools were developed. The table below outlines the types of documents that were involved in the CHIPP project, and includes items that will be used in the future. All electronic and paper documents will be made available in digital form on CD-ROM for Health Canada.

Document /Product Name	Available in Paper and/or Electronic Form	Licence Fee Required for use (Yes/No)	Previously Provided to Health Canada (Yes/No)	Appendix Name /Number
Template(s) for vendor RFP	Electronic	No	No	Telehealth Equipment RFP B-1 Telehealth Evaluation RFP B-2
Template(s) for vendor contract(s)	Paper - standard YTG contract	No	No	Can provide on request
User Guide(s) and/or Training Manual(s)	Electronic Electronic	No Yes	No No	Site Coordinator Manuals: Tandberg 800 B-3 Tandberg 1000 B-4 Whitehorse Manual B-5 Tandberg 800 user pdf. Format B-6 Tandberg 1000 user pdf. Format B-7
Template(s) for equipment testing	Electronic	No	No	Network Test Plan B-8 MCU Testing B-9
Policy and Procedure Manual(s)	Electronic	No	No	Whitehorse Manual B-5 Also duplicated in B-3, B-4
Job Descriptions and/or recruitment material	Electronic	No	No	Job Descriptions B-10
Clinical Training Protocols	Electronic	No	No	Whitehorse Manual B-5
Clinical Program Protocol(s)	Electronic	No	No	Whitehorse Manual B-5
Video Conference Protocols and Etiquette Guide	Electronic	No	No	Whitehorse Manual B-5
Quality Assurance Procedures	Electronic	No	No	Whitehorse Manual B-5
Confidentiality and Privacy documents	Not Telehealth Specific
Consent Forms	Not utilized
Sustainability Plan	Being developed
Data collection tool	Electronic	No	No	Statistical Gathering Tools B-11

4.0 Main Impact

The evaluation report addresses the issue of health related impacts. As with any new technology or substantial change in "the way of doing business" there is a need to support users through the change process, identify and address real or perceived barriers to change, and provide real opportunities to create "buy in" to the use of the technology. The feedback from health care providers in the rural sites has been positive regarding education. Telehealth has provided regular opportunities to participate in one or two hour education sessions. Travel and absence from the work site prevented participation in short education sessions in the past, and it may be that more frequent shorter sessions are as or more effective than infrequent attendance at longer workshops or conferences.

There is an increasing awareness of telehealth amongst health care providers and the general public. This is reflected in increased requests to utilize videoconferencing to access education as well as utilizing it for interviews, meetings, focus groups, community consultations and clinical consultations.

There are no tools developed at the current time that enable the comprehensive evaluation of clinical practice and health care outcomes in the telehealth setting. The low number of clinical sessions during the project and the relatively short time frame also limits our ability to determine the impact that telehealth has had on health status and health care delivery in the Yukon.

4.1 Human Resources Impact

Site coordinators were identified in each community for the project. These individuals, whose substantive positions provided clerical or administrative support to health programs, became "champions" of telehealth. They were provided with training during implementation and then became the trainers for new staff and telehealth participants. Ensuring that there was a site coordinator in each site decreased resistance to change by clinicians, and made it possible for health care providers to benefit from the clinical and educational applications without having to spend time testing the equipment and establishing connections. Some coordinators commented on the fact that their expanded responsibilities provided them with a new challenge and new skills that can be utilized in their current positions or when applying for other jobs or positions.

The job descriptions for site coordinators and a coordinator position have been redefined based on the experiences of the project.

While there is an increased demand on personnel for some applications there is an improved access to services not previously available in the community. Telehealth clinical sessions are similar to face to face sessions - "no shows" lead to down time for busy professionals. This issue was addressed by providing telephone reminders a day or two before a booked session to confirm the client's participation.

4.2 Privacy and Protection of Information

Privacy and protection of information is managed through existing legislation, professional Codes of Ethics and standards, and facility or organizational policies. Examples include:

• Yukon Government Access to Information and Protection of Privacy Act
• Canadian Nurses Association Code of Ethics
• Yukon Registered Nurses Association - members are guided by the Canadian Nurses Association Code of Ethics
• Canadian Medical Association Code of Ethics
• Yukon Medical Association - members are guided by the Canadian Medical Association Code of Ethics
• Whitehorse General Hospital - employees are guided by Territorial and Federal legislation, professional bodies code of ethics and standards, and internal policies regarding privacy and protection of information
• Community Nursing, Department of Health and Social Services, Yukon Government - employees are guided by Yukon Government Access to Information and Protection of Privacy Act, professional registering bodies code of ethics and standards, and internal policies and procedures regarding privacy and protection of information

Procedures for each clinical application outline the responsibility for records and consent. The Yukon Telehealth Network sought and received legal advice about specific consent for the use of televideoconferencing. In our opinion, no specific consent is required because the incremental risks associated with the use of telehealth were judged to be small, and procedures were in place to minimize those risks. Telehealth is a means of providing the patient/client with access to a service, and it is the responsibility of the individual service provider to ensure that the patient/client has consented to treatment. It is important to note that no client has refused to participate in a telehealth session since implementation.

Issues of confidentiality were addressed by: improving soundproofing in rooms used for clinical applications in all Yukon sites, use of white sound devices outside clinical rooms, providing the option to use headphones and utilizing Switch 56 instead of a telecommunication companies bridge services for clinical applications delivered from outside the Yukon.

The Yukon participated in the CHIPP Privacy and Security Survey conducted in August 2002. To date there has been no report returned to the Yukon with recommendations.

The Yukon is in the process of investigating the impact of PIPEDA on clinical services.

4.3 Policy and Research Implications

Telehealth will have an impact on future policy and research decisions.

Areas that will require consideration are:

• Pre-assessment of clients via telehealth before approving costly travel to see a specialist
• Using telehealth to provide accessibility to scarce professional resources without that resource having to lose travel time, resulting in higher efficiency.
• Integrating telehealth as a communication tool, much like the fax or the telephone and being able to use the most effective and efficient tool for each outcome.
• Distance education sessions are a valuable telehealth application. They provide the opportunity for healthcare practitioners to maintain their professional status.
• Telecommunications costs to connect multiple sites within Yukon or to connect to southern sites can prevent the sustainability of Telehealth with existing health care dollars.
• Providers may have to develop a new skill set in order for televideoconferencing to be maximally effective.
• Pan Canadian scheduling implications - the need for a simple steamlined way to schedule activities taking into consideration time zones, cancellations, and resources such as bridges and equipment availability.

Applied research implications

What is the best practice for using videoconferencing for education purposes?
To answer this question effectively, there must be the development of an evaluation tool that clearly differentiates evaluation of the technology from evaluation of the presenter's style and the content of the presentation. The evaluation tools currently in use provide general, global evaluative data on telelearning activities from the perspectives of both the presenter and participant, however, some questions may confuse presenter and presentation content effects with effects solely attributable to the technology. A more refined evaluation tool would differentiate among these factors and determine what, if any, adaptations or modifications must be made to presentation skills and format in order for telelearning sessions to be as effective as face-to-face presentations.

While enthusiasm and acceptance of telelearning opportunities is generally positive, clinicians have approached clinical applications, particularly those involving direct clinical services to clients and their families, with some wariness. This reluctance is understandable and likely reflects many factors such as concern about confidentiality and the more general resistance to change.

An additional factor, which would benefit from applied research, is the extent to which assessment and intervention skill sets must be modified in order to be maximally effective in the televideoconferencing environment. The most obvious example, of course, is the inability to conduct physical examinations or interventions, and the need to find alternative methods to perform these functions (e.g., working with and through a health practitioner who is on site with the client.) More subtle examples include the greater difficulty in assessing facial expressions and colour, body posture, and other non-verbal behaviours, particularly when the equipment is not working optimally. It may be that modifications to interviewing techniques, "bedside manners," and better use of the videoconferencing and peripheral features would optimize the clinical "richness" of the televideoconference session.

Finer grained evaluation tools and more sophisticated research techniques (e.g. self analysis of clinician behaviour from videotaped interviews) may provide valuable information to assist clinicians as they transfer clinical skills to the televideoconferencing environment and/or modify or add to their existing repertoire of skills.

As in virtually every area of health, there is a great need for research on factors which promote the adoption of clinical practice guidelines or best practices into everyday practice. A parallel research question is what are the factors which encourage (or discourage) clinicians and program managers from integrating televideoconferencing into their work day. Research into knowledge exchange and technology transfer specific to telehealth would be very valuable.

5.0 The Future

Videoconferencing is another tool to assist in providing comprehensive sustainable health care to Yukon communities. Building upon the successes of the past eighteen months, the Yukon Telehealth Network is in the process of moving from the project phase to program phase.

There has been ongoing discussion with all partners regarding sustainability of telehealth. Non- governmental partners are pursuing funding options, while other partners are prepared to continue providing in-kind services such as space. Representatives of YTN continue to participate as part of a Yukon intersectoral group which has a mandate of bringing together users of videoconferencing and other (distance education) telecommunications services to discuss the possibilities of sharing resources. As a result, an effective working group has been established. The forum will continue as a means of exchanging information on key initiatives, challenges and issues and keeping the lines of communication open.

Analysis of what the Yukon has learned is ongoing and assists in determining if greater efficiencies can be realized from what we have learned. We are continually looking at the least costly and most effective way of providing videoconferencing services. This is evidenced by the utilization of a simple, relatively inexpensive digital camera as a patient camera. Initial exposure to telemedicine/telehealth in the Yukon occurred during the 1997 CANARIE project. Evidence of an increased awareness and utilization of telehealth is evidenced by providers and users suggesting ways of utilizing telehealth or initiating telehealth sessions.

One of the lessons learned was the advantage of having site coordinators to train staff and public as well as coordinate activities and disseminate information. This support will be required into the future until all users are comfortable with the technology, scheduling is integrated at the user level and new programs can be self initiated and sustainable. The largest cost in the near future will be salary dollars for site coordinators and telecommunication charges for multi site and out of Yukon connections. Into the future there will be equipment replacement and expansion costs as the program moves out to other rural sites. At present two communities in the Yukon can not be linked until there is increased bandwidth into those communities. The evaluation of the Yukon Telehealth Network will be reviewed by the Department of Health and Social Services. This analysis may result in the preparation of a submission to Management Board requesting ongoing funding.

6.0 Communications

Communications is important in generating support for projects, support in the community and among other interested groups. The table below outlines the types of documents that were developed for the CHIPP project, and includes items that will be used in the future. All electronic and paper Appendices documents will be made available in digital form on CD-ROM for Health Canada.

Methods or Tools	Date	Targeted Audience	Documents or Presentations Produced	Appendix Name /Number
Site Coordinator Conference	2003-05-27	Site Coor-dinator	Site Coordinator Job description	Site Coordinator Job Description New B-9
Media Events	2002-03-27 2002-11-28	Yukon Citizens Yukon Citizens	Official Launch - Ribbon cutting & Press Release Press Release and article in Whitehorse Star	Paper copy on request News release C-6
Publications	2002-08 2002-08 2003-09	General Public Client Public and clients	Pamphlet Pamphlet Pamphlets reprinted and updated	Telehealth 1 pdf. C-1 Telehealth 2 pdf. C-2 C-1 & C-2
Open House & Public Demon-strations	2002-03-27 2002-04-11 2002-04-11 2002-05-14 2002-09-20	Mayo residents Watson Lake residents Haines Junction residents Old Crow residents Dawson City residents	None None None None None	N/A
Marketing / Adverti-sement	2003-01 2003-03 2003-06	Profes-sionals General Public Public and Profes-sionals	Various articles in newsletters, local papers in rural sites	Article 1 C-3 Article 2 C-4 Article 3 C-5
Website (please provide the Website address)	2002-04 2002-09	Yukon Gov't. employees Profes-sionals and general public	Telehealth Booking Calendar - utilizing Government Outlook Education sessions posted on YMA public website and Yukon Gov't website	www.yma.yk.ca/ public/telehealth.htm http://internal.gov.yk.ca/ depts/hss/Telehealth /index.html

7.0 Other - Lessons Learned

Experience shows that ready accessibility is a key to adoption. Where possible, telehealth equipment should be located close to the users area of work. Trips to other departments or buildings are a severe challenge to general adoption.

Ideally proof of concept testing should take place with conditions as similar as possible to the proposed usage. There was no MCU when doing the proof of concept for the purchase of videoconferencing equipment. It was assumed that there would be a Bridge and Gateway provided by the telecommunications provider during the early stages of the project. As it turned out the Yukon never did have the conditions that were originally planned.

The majority of telehealth networks utilize ISDN technology. Other Yukon Government departments had tested the IP technology. As a consequence network testing was limited prior to initiation of the project. Network testing should include periods of peak utilization to ensure the robustness of the network is fully tested.

Resistance to change and utilization of new technology can be decreased by:

• Providing non threatening exposure to the technology such as participation in education sessions.
• Permitting people to progress at their pace with support from more experienced person, or ensure that help is a phone call away.
• Follow up of original training sessions with refresher sessions.
• Providing for "mock" sessions, if a new application is being introduced, to provide a greater comfort level.
• Including telehealth as part of orientation of new staff.

There is a need for better evaluation techniques and tools

• Requirement for clarity around what information is necessary and what would be "nice to know" when developing evaluation tool
• Need to differentiate between technology and material presented on evaluation forms

High turnover of staff in rural sites can be addressed by:

• Site coordinators are necessary to ensure continuity and ongoing training
• Include telehealth as part of orientation of new staff
• Easy and adequate access to technical support
• Detailed "quick cards" - a balancing act between enough information but not so much that no one reads it

8.0 Appendices

Appendix A - Yukon Telehealth Network Timelines - Accomplishments

Appendix B - Documents or Products

1. Telehealth Equipment RFP
2. Telehealth Evaluation RFP
3. Tandberg 800 User Manual
4. Tandberg 1000 User Manual
5. Whitehorse Manual
6. Tandberg 800 User Manual pdf. Format
7. Tandberg 1000 User Manual pdf. Format
8. Network Test Plan
9. MCU Testing
10. Job Descriptions
11. Statistical Gathering Tools

Appendix C - Communication Tools

1. Telehealth 1 pdf format (Pamphlet)
2. Telehealth 2 pdf format (Pamphlet)
3. Article 1
4. Article 2
5. Article 3
6. News Release