HTF 402 National First Nations Telehealth Research Project

Case Study: Southend Saskatchewan

Community description

Southend is one of eight communities in the Peter Ballantyne Cree Nation, which has total membership of about 6,500. Southend, in north central Saskatchewan on the southern Shores of Reindeer Lake, has a population of just less than 1000. Its health services are managed by Peter Ballantyne Cree Nation Health Services Inc.

Southend's telehealth project

The needs assessment was conducted in Southend in spring 1999 by the project officer and community members and included a door-to-door survey of residents. Following the needs assessment, Southend selected real-time video-conferencing applications for specialist consults in psychology, pediatrics and dermatology; diabetic education and management, and staff and community education. The project was designed to link into the existing Northern Telehealth Network, a large provincial initiative. Staff were trained and the system was deployed in late spring 2000, with the first encounter forms received in June 2000.

Case study results

Utilization levels

Number and length of telehealth sessions

During the evaluation period, from June 2000 to mid-March 2001, a total of 74 telehealth

sessions were held: 53 for patient care (family physician, psychologist and other specialist consults), 6 for patient education, and 15 for staff or community. A total of 44 unique patients were seen: 38 in patient care and 6 in patient education. Six patients had repeat visits using telehealth.

The average number of visits per month was 6.9 with a high of 25 in September 2000. Visits lasted on average, one hour and 37 minutes. Five of 74 sessions had scheduling problems.

Types of care and education provided through telehealth

The proportion of patient care visits for which each type of personnel was present in the community and remote locations are shown in the tables below. For 21 of the sessions, the remote location was La Ronge, while for 16 it was Saskatoon and 13 of the sessions, it was Prince Albert and only two sessions in Pinehouse. Four visits were for urgent problems.

For patient education, five individual sessions and 1 group session (with six participants) were held. (total 11 participants). Three of these sessions were held in the telehealth office, while one was held in the mental health room.

For staff /community continuing education, a total of 15 sessions were held. The types of participants present in these sessions are shown in the tables below.

The types of care provided in the patient care sessions are shown in the table below.

According to the community encounter forms for patient care, in 41 of 53 patient care visits, follow-up was required, 26 with telehealth and 16 without. Eighteen patient care visits of 53 resulted in a transfer being avoided (with five additional "maybe" responses).

The topics covered in the patient education sessions are shown below.

Finally, for the staff and community education sessions, the table below indicates the topics covered.

Technical performance

The proportion of visits with each type of technical problem, for the community and remote sites, is shown in the tables below.

Southend: Technical Problems

In the key informant interviews, one remote provider mentioned that although there had been some technical difficulties, a session had never been cancelled because of them. He did note however, that room arrangements, camera angle and background colour were all important to his capacity to deal with the patient properly. Two others noted that audio problems had occurred fairly frequently; it was felt that better microphones and better placement of them would help.

Acceptability of telehealth to patients and communities

Forty-seven patients who had received either patient care or education completed patient satisfaction questionnaires, for which the data are summarized below in terms of numbers of dissatisfied patients.

Forty-two of 56 patients stated they would use telehealth again, and 44 of 46 stated they would recommend it to others.

Within the community, it was suggested that many community members are not yet aware of the telehealth service, and that more publicity could be carried out. According to key informants from the community, the telehealth system has not as yet become integrated into the community's health system: about a two on a scale of one to ten.

Quality of care delivered through telehealth

Nursing station staff and management stated that they feel telehealth has improved quality of care, by increasing the frequency of mental health sessions as well as the amount of information received by diabetic patients. However, they caution that it has only been in operation for five months, so it is too soon to tell what the impacts will be.

In the mental health area, there is consensus that telehealth has improved quality of care by increasing timeliness and continuity of care. Although it is more of a challenge for practitioners to make contact with patients, according to the practitioners, this can be overcome with ingenuity. A community worker recounted a story about a girl who had received counselling through telehealth, stating that the bond of trust with the therapist had developed much more quickly than if she had had to travel. Quality of care in mental health has also been improved because local staff are able to observe sessions and learn from this.

Remote and local telehealth coordinators and nursing staff noted that in some ways telehealth has improved quality of care in the community, because the specialists concentrate more on the patients and are more likely to ask the patient if he or she has understood. In addition, the presence of local personnel and/or translators helps remote personnel in understanding what patients are saying.

The remote providers outside of mental health were more reserved in their assessment of quality of care through telehealth. One practitioner felt that telehealth represents a clinical compromise, which is fine for most situations but may not be adequate for some others. In dermatology, the provider mentioned that telehealth provides an excellent tool in first-level screening, when the diagnosis is obvious and there is no major clinical problem. In these cases, telehealth certainly complies with quality of care. Similarly, a family physician noted that some situations are more appropriate than others for the use of telehealth: problems such as abdominal pain which require palpation are difficult to deal with over the link because the doctor and nurse may have different frame of reference when describing what the nurse is feeling, whereas a chest problem is more easily described in terms of what is being heard. A pediatric surgeon gave a theoretical example explaining that he felt that a hernia diagnosis conducted by a family physician with him attending over the telehealth link could provide quality service. It was noted that, for remote providers, there are significant trust issues in interacting with a practitioner who is conducting the examination on their behalf. Areas such as telepsychiatry and dermatology lend themselves best to telehealth, and the project had focussed on these strength areas.

One provider noted that it is important to have staff with medical training at both ends of the system; non-medical staff in the community site may not be experienced with patient handling and may not understand what the specialist requires. The non-medical telehealth coordinator also noted that it was important for her to have nursing staff available during the sessions, in order to be able to explain what the physician was saying to the patients. For providers, the shortened gaps in between patient visits helps them recall better the patient's condition. For both remote and community practitioners, using the system more often would make them more familiar with it, and would correct some quality problems such as blurry ECGs sent by fax, when they could be sent by the document scanner.

According to the data provided on the six encounter forms for diabetes education (a proxy measure of quality of care), the issue most often addressed was glucose monitoring.

Impacts on patient outcomes

Key informants interviewed stated that the main benefit to patients has been by improving the access time to specialists. For youth and children with mental health problems, community workers and the mental health coordinator reported that telehealth avoids having to send patients out of the community for assessments, which increases timeliness of treatment and lessens disruption to schooling. According to two interviewees, the fact that there are now two professionals involved in these assessments, instead of only the specialist, improves the process. One respondent also stated that she was able to access expertise from the remote providers on occasions when this was needed to support her interventions.

Through the staff and community education program, workers and community members are able to access information on a variety of topics, some of which have provided valuable new information to nursing and other health staff.

Impacts on access to health within the community

According to all key informants interviewed, telehealth has improved access to health within the community. This has occurred in several ways. First, the wait times to see specialists have been reduced in some areas (most notably psychiatry and dermatology: the usual three month rate is reduced to a few weeks), although providers caution that if the service is more widely used that this advantage may not be maintained. Second, telehealth represents an improved service for short follow-up specialist visits, especially appreciated by elderly patients and those with children. Third, in situations such as psychological services which benefit from frequent interaction between the patient and provider, telehealth can allow more frequent appointments and speed the course of treatment. Finally, in the mental health area, telehealth provides an important advantage in allowing immediate screening of problems as either psychological or physiological, allowing appropriate orientation of treatment and, in particular, avoiding using mental health resources and problems that are of physiological origin requiring medical treatment.

Some of the nursing station staff interviewed felt that impacts in the community could be enhanced if specialists were available to deal with some additional prevalent health problems through telehealth. The main example given was in ear-nose-throat consults, along with dentistry and optometry. The remote mental health practitioners interviewed also suggested that development of enhanced assessment and screening skills for early childhood development could be facilitated through telehealth.

Organizational, administrative and human resource issues

The telehealth coordination duties in Southend were initially assigned to a nurse within the nursing station. Following her departure, they were assigned to a non-medical staff member, and have now been re-assigned to a newly-arrived nurse who also has other responsibilities. According to key informants, each of these changes required some adjustment time and extra training resources. The nursing staff are very busy and find it difficult to take hours away from their other work to devote to telehealth; they state that while they would have liked to see the system get more usage, they have been too busy to do so. It was stated that increasing the familiarity of all personnel with the system would reduce reliance on the coordinator and contribute to increased usage.

For the nursing station staff, one of the lessons learned was that implementing telehealth successfully took much more time than expected. The role of the project officer, with adequate time dedicated to moving the project forward, was critical. Many hurdles were overcome and enthusiasm maintained throughout the long months of planning and negotiation because of this resource.

The physical arrangements for telehealth in the Southend nursing station are less than satisfactory for its users. The main telehealth room is a small office; very cramped when a table is also used as is required in some assessments. The mental health room, used for group sessions, as a multi-purpose room and suffers from a lack of privacy. The equipment can also be used in the emergency room, but must be cleared out immediately if an emergency arrives.

Missed or cancelled appointments have been an issue in this project, with one specialist dropping out of participation because of the lost revenue incurred from it. Other remote providers also expressed concern about the rate of missed appointments, although one felt it was not more prevalent that in his face-to-face practice. The nursing station staff feel that patients need to be made more aware of the importance of keeping their appointments: there is a perception that because the system is so accessible, missed appointments or late arrivals can be made up easily. They have now required patients to get a new referral if they miss an appointment.

Remote providers interviewed varied in their views of the effects of telehealth on their practice. According to one, seeing patients takes more time using telehealth than in face-to-face consults, because of the time required for patients to be prepared for the examination and to properly orient the camera. This reduces the number of patients that can be seen in the same time period, and would affect revenues if the sessions were not part of a pilot project. Another stated that he is used to doing telephone consults, and telehealth merely adds another dimension to that practice.

Linkages within provincial health systems

The Southend project has had linkages with the provincial Northern Telehealth Network, with strong relationships between the telehealth coordinators in Southend, La Ronge, Prince Albert and Saskatoon. This was facilitated by the choice of the same vendor for the Southend as for the provincial system. According to key informants, the experience of the provincial program seems to have benefited Southend, especially in terms of setting up the program, developing operational procedures and clarifying the role of telehealth coordinators. Human resources from other sources such as the NTN network and the Regional Health Authority in La Ronge have also willingly contributed to this project and helped make it work. Moreover, the NTN offers a very active program in continuing medical and health education, of which Southend staff are regularly informed. This program has reached over 2000 people including workers from Southend who participated, for example, in sessions offered by the Canadian Diabetes Association. However, the provincial program representatives feel that linkages could be strengthened further if there were a clear mandate and dedicated time for the local coordinator to participate in provincial coordination meetings and maintain relationships with the other sites.

The mental health practitioners consulted noted that the relationships to be built with the community have to work to overcome years of previous bad experiences with culturally insensitive services, lack of continuity and engagement. This represents an additional challenge for telehealth, when the relationship is established through remote technology.

Cost effectiveness

The level of usage in Southend is as yet too low to make any valid statements about cost-effectiveness of telehealth. The total number of visits which resulted in transfers being avoided was 18 during the nine months of operation; this would not constitute a significant offset to the capital and human resource costs of the system. The provincial program representatives interviewed noted that the same services could also likely be achieved with lower cost equipment. Maintenance costs would then also be reduced accordingly.

Sustainability

In general, the key informant interviews suggested that Southend's telehealth project has the potential for sustainability but that it is still in its infancy as far as integration into the community's health system is concerned. Community workers remarked that the system could be expanded in community education, as nurses are too busy to fulfill this role. Areas of need mentioned were: AIDS, cancer prevention, and healthy sexuality. One tertiary provider remarked that telehealth is still being driven by administrators and physicians' interests, not by patient demand. Sustainability, in his view, will require more awareness and active interest from patients. Another noted that telehealth still has to prove itself in the eyes of many of his colleagues, and that this will hamper expansion into other needed areas. This assessment was echoed by nursing station staff. According to one respondent, telehealth has become part of everyone's everyday business in order to be effectively used for a wide variety of applications. However, the nursing station management as well as the provincial representatives are convinced that sustainability and expansion of the system are in the best interests of the community.