HTF 402 National First Nations Telehealth Research Project
3. Main lessons learned for future telehealth development in
remote First Nations communities
Telehealth is about people, not technology
The experience gained in this project showed that telehealth,
when successfully implemented, is merely technology used to enhance
a human service or an adjunct tool which can become available as
part of a range of services. Its successful implementation in communities
and in links to remote providers, as well as its acceptance by
patients and families, depends to a very large extent on the commitment
and capacity of individual people in the community to make it happen,
in service to the community. Implementation of telehealth in this
pilot project was thus facilitated to the extent that such individuals
were present and involved throughout the study period; in future
implementations, it would be advisable to ensure, insofar as can
be predicted, that such people will be available to support and
nurture them.
Telehealth needs to be founded on and build good relationships
Telehealth needs to be founded on and build relationships, involving
trust, commitment and mutual respect. This applies at a number
of levels:
- First, patients must have a trusting relationship with their
local providers; this will facilitate their initiation into using
telehealth.
- Second, especially in the case of chronic health conditions,
patients must be able to develop rapport and trust with the remote
providers they deal with through telehealth. These relationships
are facilitated when remote providers are able to visit the community
and meet patients and local providers in person.
- Third, local and remote practitioners must be able work together
well, as they are dependent on each others' professional judgment
to ensure that their mutual responsibility for patient care can
be upheld through each others' actions. The development of relationships
founded on trust and mutual respect is key to ensuring that the
remote-community provider link can be successfully maintained.
The development of a cohesive inter-site team, through opportunities
for interactions and discussion, can facilitate the relationship-building
process. In this context, real-time technologies and applications
are advantaged over store-and forward arrangements.
- In another more literal sense, successful implementation of
telehealth requires good local-remote relationships: one of the
limitations experienced by these communities was lack of willing
remote specialists to provide services, and in one case, the
lack of perseverance of a specialist due to unfavorable financial
conditions associated with telehealth. Simply put, there can
be no telehealth in First Nations communities if there are no
providers at the other end. Locating those providers and developing
and maintaining relationships with them is both a prerequisite
for successful implementation and a challenge given their scarcity
and therefore their expectations of practice conditions which
best suit their requirements.
- The organizations and agencies involved must also be able to
develop relationships based on mutual respect of mandates and
capacities, and trust each other to be able to work in their
mutual best interests and those of their mutual patients. These
relationships can be challenging, as they involve resource issues
in times of constraints and fragility in most provincial health
systems, as well as within the contexts of transfers of health
management to First Nations communities. However, the development
of these relationships will be key to ensuring that when the
inevitable operational difficulties do arise, that the parties
will be able to work them out satisfactorily.
- Finally, the overall context of the relationships between Health
Canada-FNHIB and participating communities is also a backdrop
to successful implementations; requiring a foundation of trust
based on transparency and flexibility as a basis for project
development.
Appropriation is a long, organic process : you have to grow it
Although it may seem a misplaced metaphor, our impression of the
communities' processes of bringing telehealth into their communities
and working to ensure that they become part of the health care
system was more organic than technological. Like a plant slowly
taking root in a new environment, appropriation by the community
was facilitated by stable local conditions, without political or
organizations storms; it was facilitated by the fertilizer provided
by the injection of support and resources from outside, most notably
the provincial telehealth initiatives and vendors; it is was more
easily accomplished in the fertile soil of communities who had
already become prepared for and mobilized toward telehealth. Sustainable
growth cannot be expected to happen overnight, and it must be nurtured
and protected in its vulnerable early phases. However, once established,
the telehealth plant can sprout in all sorts of new direction,
providing unexpected benefits for patients and communities.
Telehealth generates care, so it generates costs
As stated in the previous sections, the net effect of telehealth
is to generate care and therefore costs, as least in the short
to medium term. In the long term, its effects in terms of prevention,
quality of care, and community development may offset the initial
capital and organizational costs, but this is not a reasonable
expectation in the short term in most communities.
Telehealth is vulnerable to existing instabilities in First Nations
health services
If we step back and examine the overall picture that emerges about
implementing telehealth in these communities, the single most important
contributor to success was the presence of stable and committed
staff throughout the implementation period. Staff turnover in Northern
communities has a high background rate to start with; the implementation
period for this initiative coincided with periods of additional
instability in some communities. While telehealth is sometimes
seen and promoted as a way of compensating for the difficulties
that northern communities have in accessing stable sources of quality
care, it is clear from this study that telehealth will be just
as subject as any other form of care provided through the community,
to the forces which produce frequent turnover among nursing station
staff. Operating an effective telehealth service requires a long-term
organizational and staff commitment, a stable care environment,
and conditions to support continuity of care. Telehealth cannot
directly address a main existing problem in First Nations health
services: the lack of permanent local capacity, and the resulting
reliance on external staff with the resulting discontinuities.
However, its successful deployment will respond to improvements
in these areas, and will be more certain to succeed in communities
which have been able to more effectively address these issues.
Conclusion
Overall, the results of this evaluation showed that telehealth
can be successfully implemented in isolated First Nations communities,
bringing with it access to needed, quality care; stronger relationships
with external health providers; and greater community capacity
to undertake such major health initiatives. In the long term, telehealth
can therefore potentially improve health of community members and
health service infrastructure within communities. However, successful
implementation requires several important conditions at the community
level, in terms of nursing station stability and community mobilization,
as well as good connections with remote providers in relevant health
domains and with provincial telehealth systems and effective technology
and supports.
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