HTF 402 National First Nations Telehealth Research Project

Introduction

1. The First Nations Telehealth Research Project Objectives

Telehealth -- the delivery of health information, resources and services through technology -- is becoming increasingly accessible as part of comprehensive health care systems. For underserved and remote communities, telehealth offers the promise of reducing the constraints imposed by distance and poor infrastructure while improving health and well-being. As one of several telehealth demonstration and evaluation projects funded through the Health Transition Fund, the First Nations' Telehealth Project deployed applications of telehealth in five isolated First Nations communities. This document reports an independent evaluation of the Project.

The overall objectives of the First Nations' Telehealth Research Project were:

1. to improve patient and community access to high quality health care, including timeliness of access to medical advice, services and health information;
2. to improve the delivery of cost-effective health services in the communities; and
3. to improve linkages of isolated health care centers to secondary, tertiary and educational facilities in each province.

The communities involved in this project, each of which received funds to implement three telehealth applications, are diverse. Four have assumed governance of a major portion of their health systems, and the fifth is negotiating its transfer. The health resources available within each community differ, as do their access to secondary and tertiary care.

The table below summarizes the telehealth applications, which were implemented in each community. These applications were chosen by the communities following a needs assessment involving extensive community consultations about health priorities and issues relating to telehealth. The needs assessment process involved: qualitative interviews with key informants (nursing station personnel, community leaders and opinion leaders, and secondary/tertiary center partners); review of health status information gleaned from local or regional health statistics or records; review of background information on communities' social and demographic characteristics.

Table 1: Characteristics of and Telehealth Applications Selected by the Five Communities

• Community: La Romaine ¹
  Population: 897 members, 65 off-reserve
  Referral Sites: Sept-Iles Health Center Blanc Sablon Health Center Laval University Hospital, Quebec City
  Telehealth Applications Implemented: Store and forward technology:
  Specialist consults: Dermatology, ECG; Ear-Nose-Throat
  
  
• Community: Berens River, Manitoba
  Population: 1759 band members
  Referral Sites: Health Sciences Center, Winnipeg North Eastman Health
  Authority Northern Medical Unit
  Telehealth Applications Implemented: Interactive video technology:
  Diabetes care and education Specialist consultation: psychiatry,
  infectious disease Continuing professional education
  
  
• Community: Southend, Saskatchewan
  Population: 918 in community, one of several in Peter Ballantyne Cree Nation
  Referral Sites: La Ronge Health Center Prince Albert Hospital Royal University Hospital, Saskatoon
  Telehealth Applications Implemented: Interactive video technology:
  Specialist consults Diabetic education and management
  Staff/community education
  
  
• Community: Fort Chipewyan, Alberta
  Population: 2900 total1864 in area
  Referral Sites: Northern Lights Health Centre, Fort McMurray
  Telehealth Applications Implemented: Interactive video technology
  Rehabilitation services: Occupational, speech and physiotherapy
  Televisitation Continuing professional education
  
  
• Community: Anahim Lake²
  Population: 659 band members 400 non band members 5,000 tourist
  season
  Referral Sites: Williams Lake Hospital
  Telehealth Applications Implemented: Trauma triage and early intervention Cardiology Mental health services

¹ Although initially conceived as an interactive video-based project, the La Romaine initiative was modified to become store-and-forward system due to the high cost of securing high bandwidth;

² Implementation of the Anahim Lake telehealth project was delayed until April 2001 due to the difficulties experienced in obtaining the required telecommunications infrastructure. Evaluation data about this community will be collected over the coming year.

2. Project structure

Health Canada First Nations and Inuit Health Branch (FNIHB) assumed overall project management. It assigned a project officer to each community to coordinate the needs assessment and telehealth implementation processes, including facilitating the negotiation of Memoranda of Understanding between the community and provincial authorities, and the vendor selection and contracting processes. Each community identified a telehealth coordinator who assumed responsibility for managing the system and coordinating arrangements with the remote sites (Throughout the report, we use the term "remote" to mean far from the participating First Nations communities, i.e., in the secondary or tertiary centres in larger urban settings.).

3. Literature review of telehealth applications

The research literature on telehealth applications and telehealth assessment has grown considerably in the last decade. A systematic review of this literature was conducted in order to identify findings which could inform expectations about the clinical effects, patient satisfaction, implementation processes and cost-effectiveness of the applications selected in his project. The complete literature review may be found in Appendix 8, but is summarized very briefly below.

Cardiology/ECG (La Romaine)

• Although there were few relevant studies and none using store and forward technology, there seem to be some significant advantages in the reported clinical outcomes of cardiology patients using tele-ECG as compared to face-to-face (FTF) care, because patients benefit from being treated earlier (Casey et al., 1998; Lusignan et al., 1999).
• Lusignan et al. (1999) concluded that telemonitoring of ECGs was acceptable to patients.
• No study examined implementation issues.
• Cost-effectiveness analyses in two studies suggested that compared to a conventional referral, a cardiac teleconsultation was substantially cheaper (Afset et al., 1996; Shanit et al., 1996).

Continuing Medical Education (Berens River, Southend, Fort Chipewyan)

• The available studies suggest that educational support through videoconferencing offers support equivalent to FTF instruction (Demartines et al., 2000; Hays et al., 1996).
• Overall, user satisfaction of tele-education seems high (Burge et al, 1993; Demartines et al., 2000; Sawada et al., 2000; Gul et al., 1999; Gammon et al., 1998).
• Implementation issues were not examined in the existing studies.
• Cost-effectiveness analysis was undertaken in one study, showing the tele-education system to be effective after eight sessions (Screnci et al., 1996), when costs included equipment for one system, line charges, testing, and audiovisual preparation but excluded direct labor.

Dermatology (Berens River, Southend, La Romaine)

• According to the existing studies of teledermatology, it is unclear whether or not a video-conferencing (VC) system is as effective as FTF in reported clinical outcomes (Gilmour et al., 1998; Loane et al., 1998; Oakley et al., 1997; Perednia et al., (1998). The most recent studies (Lamminen, 2000; Wooton, 2000) concluded that there are no significant differences in reported clinical outcomes between VC and FTF. However, the quality of care patients receive was seen to have improved in some cases (Perednia et al., 1998). Other studies (Lowitt 1996; Perednia, 1998; Phillips, 1998) found that the teledermatologist had significantly lower degree of confidence in his diagnosis - often for technical reasons (poor image quality, lack of ability to do a diagnostic procedure).
• Patient satisfaction with tele-dermatology is high (Gilmour et al., 1998; Loane et al., 1998; Lowitt, 1996), although the latter study showed a slight increase in preference for in-person exams with age.
• Implementation of tele-dermatology was not addressed in the existing studies.
• According to two studies, the economic benefit of tele-dermatology is uncertain (Lamminen et al., 2000; Wooton et al., 2000).

Diabetes (Berens River, Southend, La Romaine)

• The clinical outcome of diabetic patients is positively affected by diabetic education (Brown, 1990; Thompson, 1999; Albisser, 1996; Piette, 1997; Shultz 1992).
• Although few studies examined patient satisfaction, those that did noted high satisfaction rates (Piette et al., 1997; Mitchell et al., 1996).
• A successful implementation process is crucial to the effectiveness of diabetic tele-care and tele-education (Mitchell et al., 1996).
• Only two studies included cost analysis; neither can speak to the costs of current technology. However, Brown's (1990) meta-analysis cautions that the number of hospitalizations, hospital days, sick calls, doctors' office visits, missed work days are not always factored in to cost analyses of diabetic education services.

ENT (La Romaine)

• The use of telemedicine in ENT is just as effective as FTF in determining clinical outcomes (Furukawa et al., Pederson et al., 1994). However, the quality of care provided can sometimes be compromised by store and forward technology (Stern et al., 1998).
• Patient satisfaction, although not included in most of the trials, was high in one study (Pedersen et al. 1995).
• Few of the studies reviewed were concerned with implementation. One study using store and forward technology (Stern et al., 1998), however, argued that since store-and-forward consultations include less information and do not provide immediate feedback, a well defined clinical protocol is needed for assembling the electronic consultation.
• No study in tele-ENT addressed cost-effectiveness.

Mental health (Berens River, Southend)

• Six studies (Kennedy, 2000; Gammon, 1996; Ruskin, 1998; Urness, 1999; Zaylor, 1999; McLaren, 1996) compared the effectiveness of a telepsychiatry program with conventional FTF methods; while another (Ball, 1995) examined how the outcome of clinical tasks in a psychiatric unit differ when using four different modes of communication (FTF, telephone, hands-free phone, LCVC). In most studies (Kennedy 2000, Zaylor 1999, Urness 1999) patient outcomes do not seem to be negatively affected by the use of videoconferencing tele-psychiatry, and diagnostic reliability is not affected (Ruskin et al., 1998). However, technical difficulties can compromise the tele-psychiatry sessions (Gammon et al., 1996).
• Patient satisfaction in tele-psychiatry is generally high (Callahan et al., 1998), although satisfaction is lower for older patients (Montani et al., 1997). Zarate et al. (1997) found that video interviews were well accepted by schizophrenic patients.
• Many of the articles reviewed on tele-psychiatry address the importance of successful implementation. Doze et al (1997) and Urness et al. (1999) note a series of implementation steps to follow in tele-psychiatry.
• Many of the tele-psychiatry articles reviewed find the service to be cost effective, although they differ on the utilization rates deemed necessary for cost effectiveness (Mielonen et al., 2000; Doze and Sampson, 1997; Trott et al., 1998). Doze et al. argue for the inclusion of all economic variables and insist on the need to consider the impact of telepsychiatry on existing systems of care into which it would be introduced.

Pediatrics (Southend)

• According to the available evidence, pediatric care through telemedicine is just as effective as FTF in determining patient outcomes ( Finley et al.,1997; Mulholland et al., 1999). Quality of care in pediatrics seems to improve with the use of telemedicine, and Mulholland et al. (1999) point to the benefits of early diagnosis and the avoidance of unnecessary transfers.
• Patient satisfaction was favorable in two studies reviewed (Blackmon et al., 1997; Dick et al., 1999).
• No study addressed the question of implementation for pediatric telehealth.
• According to several studies, pediatric tele-care is cost effective. (Vincent et al.,1997; Finley et al., 1997; Rendina et al.,1999) . Families have benefited financially from pediatric tele-care (Dick et al., 1999).

Rehabilitation (Fort Chipewyan)

• Tele-rehabiliation via VC seems to be as effective as FTF consultations in determining patient outcomes (Couturier et al., 1998; Lemaire, 1998; Sparks et al., 1993). Quality of care does not seem to be compromised by the technology used, but Burns et al (1998) suggest that telerehabilitation should not be used to replace the hands-on involvement of clinicians especially for initial assessment.
• Only one study reviewed mentioned patient satisfaction, finding it to be high (Couturier et al., 1998).
• Implementation of tele-rehabilitation programs was of concern in quite a number of articles, with concerns arising about standards, technology compatibility, interoperability, networking and Internet; and issues of access and ease of use of these systems by people without technical training (Burns et al., 1998).
• Whether or not tele-rehabilitation is cost effective is unclear in the studies reviewed (Burns et al., 1998). Couturier et al (1998) reported that orthopedic teleconsultations took much longer than conventional consultations. Although this finding suggested cost implications, the authors did not provide a cost analysis.

In summary, the results of this literature review suggest that quality of care and patient outcomes are generally equal to those obtained in conventional care, although the evidence is stronger for some types of applications than other. Patient satisfaction is uniformly high, although slightly less so in older patients. Cost-effectiveness has been demonstrated for some applications but not for all; however, these analyses tend to include only some of the overall costs.