HTF 402 National First Nations Telehealth Research Project

Case study : La Romaine, Québec

Community description

La Romaine is a community of about 900 Montagnais (Innu) people, located on Québec's North Shore at the mouth of the Olaman River. Its band council, the Conseil Unamen Shipu, assumed governance of its health system in 1998. Nursing staff at the nursing station are linked in terms of first-line medical authority to the health center in Blanc Sablon.

La Romaine's telehealth project

The needs assessment for La Romaine was conducted in spring 1999 by the project officer. The La Romaine community had initially intended to implement interactive video applications for the health issues identified as priorities: diabetes, cardiovascular disease, dermatology and ENT problems. Supplied by regular telephone service, it sought to reach an agreement with the provincial secure health telecommunications network but this could not be achieved at an affordable cost. The project thus re-oriented its choice of technology to store-and-forward system using internet to transmit digitized images. Imaging equipment was installed in the nursing station in La Romaine, and the necessary decoding software was installed in the remote offices : Blanc Sablon (the general practitioners servicing La Romaine, for reading of ECGs); in Québec City (for reading of dermascope images); and in Sept- Iles (for reading of otoscope images). The equipment was deployed and staff trained in spring 2000, with the first encounter forms received in April 2000. The implementation period coincided with a staff crisis within the nursing station and the departure of the director and some long-term staff.

Case study results

Utilization levels

The telehealth initiative in La Romaine was beset by a number of technological problems, which were never completely overcome. During the study period, from April 2000 to the middle of March 2001, forms were received for a total of 58 telehealth transmissions. Fifty-five of these were for ECG readings; however due to telecommunication problems (described below), all of these were sent by fax to the physicians on duty in Blanc Sablon. This physician was not aware that they had been generated through the equipment purchased for the telehealth project. The other three forms were for transmissions of dermatological images: these were sent to Québec City in November 2000, but not found and read until January 2001. Finally, one test ENT transmission was sent to the specialist in Sept-Iles, but he found it of inadequate technical quality; he received no further transmissions. These transmissions pertained to a total of 56 unique patients.

The table below shows the type of health problem that led to each transmission. Nineteen of 54 visits were for urgent problems.

Technical performance

Problems in maintaining communications on the principal line were the main difficulty encountered: the connection would drop partway through transmission for unknown reasons. Despite visits from the vendor's technician and numerous telephone support sessions, this problem was never resolved. In addition, nursing staff felt that the software involved in file transmission was not user-friendly enough (requiring file manipulation and programming skills that they did not have) for them to be comfortable with it, especially with long time lapses between patients. (Other telehealth experts consulted seconded this opinion of the software.) Moreover, the relationship between the telehealth staff and the vendor cannot be described as supportive or trusting: the vendor stated that the staff had been meddling in the software, while the staff said they had been accused of sabotage. This led to another change of coordinator. Other problems, such as with the ECG printer, were more easily resolved, although one of these happened during an emergency case. In that situation, the nursing staff had to describe the ECG readout to the physician over the telephone.

Acceptability of telehealth to patients and the community

In the opinion of those interviewed, the telehealth project is not well known in the community. Despite the presence of posters promoting the service in the nursing station, according to nursing staff, no patient has come forward to ask to receive care through telehealth. When transmitting ECGs, the nursing staff do not generally explain to patients that this is a potential telehealth application.

Thirty-three patients completed satisfaction forms; these data are summarized in the table below in the form of the number of dissatisfied patients on each item.

(Note that this questionnaire was generally translated to patients verbally, as French is not their first language.)

Thirty of thirty-three patients said they would use telehealth again, and thirty-one of thirty-two would recommend it to others, but only 11 of 32 would choose telehealth over a face-to-face visit with the doctor.

Quality of care delivered through telehealth

In terms of image quality, the nursing station staff found it to be generally excellent, although the ENT specialist was not satisfied with the quality of the test image he received. The nursing staff pointed out that better quality ECG images could be obtained from other types of non-telehealth equipment. Since they were not using the ECG machine in a telehealth mode anyway, they felt that for the same cost, they could have access to better quality images. However, this did not affect the quality of care received by patients.

Impacts on patient outcomes

Key informants working in the community felt that the ECG machine had had significant impacts on patient outcomes in several cases, where either transfers that would have turned out to be unnecessary had been avoided, or where a chest pain situation was revealed to be an urgent heart problem and transfer was done immediately. According to Band management, these latter situations are credited with saving lives in the community.

Impacts on access to health within the community

Both patients and community members generally saw transmission of ECG images to the physician in Blanc Sablon as a positive extension of their existing services from that hospital. No other impacts on access to health in the community have been observed, although nursing centre staff believe that telehealth has the potential to do this.

Administrative, organizational and human resource issues

As stated above, the implementation period for the telehealth project coincided with an unstable situation within the nursing station due to a conflict between nursing station and band management. The individuals initially responsible for implementing the telehealth initiative were at the core of this situation. The Band representatives interviewed felt that their responsibility was to first resolve the conflict and so directed their energies towards this; the telehealth initiative became of secondary priority. The staff turnover associated with this crisis meant that responsibility for telehealth coordination was shifted several times during the implementation period. It was suggested that had the community been able to wait to implement the telehealth initiative until the nursing station situation was stabilized, it might have been more successful. However, at this point, responsibility for coordination of the telehealth system has been re-assigned, and efforts are being made to increase integration into nursing station practices. Support being provided by the telehealth coordinator in the Québec City hospitals is facilitating the organizational arrangements for transmission and interpretation of images there; however, the mandate of this person in the overall project is not clear.

The partnership arrangements for links to specialists from La Romaine are also problematic. For the few patients who had images transmitted to specialists, these lines of communication create a professionally uncomfortable if not untenable situation for nursing station staff, whose normal channels of referral must first involve the generalists at the Blanc Sablon Hospital. Sending images directly to other specialist was tantamount to going over the generalists' head, which not only threatened to disrupt the existing relationship between the nurses and their front-line physicians, but also to discredit these physicians in the eyes of patients. Nursing staff were especially concerned that this changed pattern of referrals not jeopardize the development of a more trusting perception of health staff among community members.

Linkages within provincial health systems

According to the key informants interviewed, Québec is in the process of implementing the telecommunications infrastructure of a province-wide telehealth program, and an inter-ministerial committee within the provincial government is currently developing a policy which addresses some of the legal and medico-professional issues involved. Another committee is addressing technical problems and user needs. However, the refusal of the provincial health telecommunications network to provide service to La Romaine at an affordable rate in the initial stages of the project suggests that the inclusion of First Nations communities within this provincial system may not be automatic.

As suggested above, linkages of the La Romaine project within the overall provincial health system are tenuous. While on the one hand, the centre of telehealth activity in the province, in the Québec City university hospital system, is keen to work with La Romaine and supply both technical expertise and links to specialists, this connection cannot really be fully established without full partnership for all applications of the primary referral site, because of the line of medical authority referred to in the above section. Several key informants suggested that the project should have established a telehealth centre in Blanc Sablon, so that the physicians there could be come involved in the telehealth referrals of patients to the specialists in other locations (Sept Iles and Québec City).

Cost effectiveness

The level of true usage of telehealth in La Romaine was too low to make any valid statements about its cost-effectiveness. Although twenty-nine out of 54 visits resulted in transfers being avoided during the twelve months of operation, these were all through use of the ECG equipment in La Romaine with the results faxed to the remote medical facility rather than being read through the store-and-forward software.

Sustainability

It seems clear that the telehealth initiative in La Romaine is unlikely to be sustainable, at least in its present form. According to nursing centre staff interviewed, other avenues of increasing access to specialist will be pursued, including more frequent in-person visits from a larger number of specialists. Although all those involved see potential for telehealth to complement health services available in the community, it is unlikely to be a first priority for health care delivery in the community, at least using store and forward technology, or until the primary referral centre becomes more involved.