HTF 402 National First Nations Telehealth Research Project

Findings across communities: Lessons learned

In this chapter, results from all four case studies are considered in light of what they reveal about the evaluation questions, as well as critical success factors and main lessons learned for implementing telehealth in remote First Nations communities.

1. Evaluation questions

Access to needed, quality care

To what extent do the telehealth applications respond to community needs, as defined by the needs assessments?

In general, the telehealth applications implemented in the project responded to community needs, although this was clearer in some sites than others. At issue are not only the definition of the needs, but also how the technology and organizational arrangements for using it can respond to needs. For example, telehealth can be used to address the issue of diabetes within a community in a number of ways, with some being more easily integrated than others.

To what extent do patients and families find each telehealth application acceptable?

It seems overwhelmingly clear that once initial reticences are overcome with a positive experience, telehealth is acceptable to the vast majority of patients and families who use it. Over 90% of patients in all the communities were satisfied with most aspects of their telehealth experience, and between 75% and 100% of telehealth patients said they would use it again. This is consistent with findings in the research literature. In addition, although the evaluation design did not permit assessment of the views of those patients who did not use the system, refusals to use the system were infrequent. It should be noted however, that the quality of many patients' experience with telehealth is a function of the quality of the care provided by nursing station staff and the relationships they have with them; when telehealth provides a new service, what is most salient to many patients is not the new technology but the new relationship and the new care received.

To what extent has telehealth improved access to needed, quality care?

The extent to which telehealth has improved access to needed care in the community depends on the extent to which it was used and integrated into ongoing health service delivery. When usage and integration were higher, telehealth certainly improved access to care within the community. Moreover, the quality of care provided was, insofar as can be estimated by this study, of quality equivalent or better to standard care. These findings are consistent with the research literature examined.

To what extent are services provided through telehealth consistent with established means of improving patient health outcomes?

Insofar as can be assessed in this study, services provided through telehealth are consistent with established means of improving patients' outcomes. In the views of the health professionals consulted, in no case was telehealth seen as inconsistent with established professional practice guidelines. Moreover, data from the encounter forms suggest that educational interventions delivered through telehealth to patients were generally consistent with established patient education guidelines, although some aspects were addressed more frequently than others.

Health services delivery

To what extent has telehealth use been organized successfully?

The successful organization of telehealth usage in this project varied among the communities, according to a number of factors. Key among these were the stability of staff during the implementation period and the quality of the relationships established with the remote provider sites. Stable, committed staff in the nursing station was a key success factor for effective implementation of telehealth in these communities. This is a problem that was not identified in the research literature, and may be more specific to isolated, Northern communities.

To what extent have the professional skills and competencies required for telehealth been identified and successfully addressed through training?

The main issue with respect to the development of professional competencies for telehealth through training was the constant need to provide training to new staff members due to turnover. The adequacy of training received was also a function of the user-friendliness of the technologies involved. Training received for the interactive video-based systems was generally felt to be adequate partly because the systems were very easy to use; this was not the case for the store-and-forward system.

To what extent are telehealth applications used by eligible patients in the community?

It is not really possible for this evaluation to answer this question adequately, as we have little information on the numbers of eligible patients (those with the health conditions which would make them candidates for using the available applications) who did or did not use telehealth during the study period. In some cases, it is clear that only a small fraction of eligible patients used the systems; while in others, the identification of new patents with health needs that had never before been addressed as a result of the implementation of telehealth suggest a high level of penetration. In addition, because of the lack of participating specialist in the remote sites, penetration as not as strong as it could have been.

To what extent does telehealth improve competencies and confidence of local health personnel?

In all communities, the implementation of telehealth brought new competencies to local health personnel, and in all cases, these were widely welcomed. Telehealth was seen as greatly improving access to outside expertise, reducing feelings of professional isolation, increasing confidence in judgments and improving the quality of patient care decisions made about cases in conjunction with remote experts. These results confirm those of existing studies in the area of tele-education for remote personnel.

How does telehealth affect staff workload, task allocation and professional practices?

When telehealth coordination responsibilities were assigned to a nurse within the nursing station who also had patient care duties, workload demand slowed full implementation. There were therefore advantages to assigning these to a separate individual, although it seems preferred that this person have some medical qualifications in order facilitate communication with remote providers. Other impacts on task allocation seemed limited, perhaps due to the only partial integration of telehealth into some of the community's practices. To the extent that nursing station staff participate in continuing professional education through telehealth, their practice scope and quality may be improved.

In terms of workload and practice shifts for remote providers, the overall pattern of responses would suggest that telehealth decreases efficiency. The appointments themselves are longer because of set-up time and perhaps increased attention to patients. The rate of no-shows also reduces efficiency and productivity for tertiary providers. While in many cases this has not been an issue so far because of the pilot nature of the project, there are several indications in our data that institutionalization of telehealth will require attention to ensuring adequate compensation to remote partners to compensate for the loss of productivity - a critical issue because of scarce resources in general.

To what extent does telehealth result in cost increases, decreases or shifts for health service delivery within the communities?

Overall, the pattern of results obtained in this evaluation suggest that the net effect of telehealth is generate greater access to care, and therefore more care, and therefore more costs. The increases are seen both in the numbers of patients receiving services -- services are now available where none were before - and in the intensity of services delivered - patients, especially in some applications, are seen more frequently and regularly using telehealth than they had been before. The increases in care provided are accompanied by increased indirect costs, over and above provider remuneration and telecommunications cost, in terms of auxiliary equipment supplies and maintenance, patient supplies and within-community patient transportation costs. In addition, some of our data suggest that telehealth sessions take longer than equivalent in-person sessions, thus reducing efficiency.

In terms of avoidance of patient transfers and their associated costs, the results over all the studies converge to suggest that telehealth will result in avoided transfers in about 30% of patient care utilizations. This is somewhat less than the rates that can be estimated from the few studies available in the literature, but not a striking difference. As a proportion of total telehealth utilization within a community, this rate will depend on the balance between patient care and other types of applications that the system is used for, notably continuing professional or community education. That is, the more a community uses its telehealth system for non-patient-care applications, the less of its telehealth utilization will result in patient transfers. In addition, avoiding transfers seems to be more appealing to patients whose lives or health are most disrupted by leaving the community - elders and families with young children --, and least appealing to those patients who are less inconvenienced by transfers and are in fact, convenienced by them. When a community chooses applications that are concentrated on these two extreme age groups, the proportion of transfers avoided out of all utilizations may be expected to be higher than when a community chooses applications for health problems that affect its population throughout the life span.

Some displacement toward the private sector was observed in one of the sites, where the increase in access to care generated waiting lists.

What is the level of technical success of the platforms, applications and suppliers in the implementing communities?

All communities experienced at least occasional technical problems, but these were resolved with adequate technical assistance in all but one community. In general, the interactive video platforms were found to be reliable and easy to use, although with occasional visual and sound quality limitations, depending on the application. Support provided by the three suppliers involved ranged from excellent to less than satisfactory, and was a critical success factor in telehealth deployment.

Linkages among health resources

To what extent is telehealth appropriated, integrated and sustained as a part of the community's self-governed health care system?

The extent to which telehealth was appropriated and integrated and will be sustained varied greatly from community to community in this project. In one community, appropriation and integration have exceeded both the community's and its partners' expectations, and sustainability and expansion of the initiative are almost certain. In the others, varying degrees of integration were associated with varying levels of community mobilization and support, stability within the community's health resources during the study period, technical success, and support provided by both existing telehealth initiatives and by the vendor.

To what extent have the telehealth applications become linked and integrated to provincial initiatives?

In those provinces where provincial initiatives exist, the First Nations communities in this project became linked with them according to their resources. Interoperability was not a barrier in any of these sites. These links provided access to a larger community of telehealth users and a broad support and development system, from which those communities benefited. The existence of such provincial networks and their capacity to bring the project communities into their fold was a critical success factor in the telehealth initiatives.

To what extent does telehealth improve access of secondary, tertiary and education providers to local health service providers?

Access of education providers to the communities was improved when there was an existing provincial network coordinating educational opportunities for network members, publicizing its activities, and in some cases covering the costs of the telecommunications links into the services.

To what extent does telehealth improve health service providers' awareness and knowledge of local conditions and resources?

In several cases, remote providers did maintain that the relationship created through the telehealth initiative had improved their awareness and knowledge of local conditions and resources, as well as challenges faced by the communities. This has led to increased sensitivity on the part of remote health service providers to the special situations of First Nations communities, as well as to relationships based on mutual trust and respect.

2. Cost consequences analysis

The cost-consequences methodology for assessing the cost-effectiveness of telehealth proposed by McIntosh & Cairns (McIntosh, E., Cairns, J. (1997). A framework for the economic evaluation of telemedicine. Journal of Telemedicine and Telecare, 3, 132-139.) is used below to provide an initial assessment of the potential cost-effectiveness of telehealth. While primarily qualitative, this methodology allows inclusion of the many intangible consequences of telehealth in the consideration of cost-effectiveness. Because of the low uptake levels in some sites, it should not be used at the community level.

The consequences and cost entries in the matrix were identified by reviewing all interview data from the evaluation, across all participating communities.

Cost-consequence matrix

Health consequences

• Consequence of telehealth: More frequent care for chronic conditions, better progress/management
  Reduces costs (to: ):
  Little difference in costs:
  Generates costs (for: ): SELECTED (community and remote health service providers)
  
  
• Consequence of telehealth: More timely care, decreased wait times
  Reduces costs (to: ):
  Little difference in costs: SELECTED
  Generates costs (for: ):
  
  
• Consequence of telehealth: More effective screening into appropriate care streams
  Reduces costs (to: ):
  Little difference in costs:
  Generates costs (for: ): SELECTED (community and remote health service providers)
  
  
• Consequence of telehealth: Access to new types of services
  Reduces costs (to: ):
  Little difference in costs:
  Generates costs (for: ): SELECTED (community and remote health service providers)
  
  
• Consequence of telehealth: Prevention of morbidity and disability
  Reduces costs (to: ): SELECTED (community health services: long term)
  Little difference in costs:
  Generates costs (for: ):
  
  
• Consequence of telehealth: Increase in patient knowledge and healthy lifestyle
  Reduces costs (to: ): SELECTED (community and remote health service providers)
  Little difference in costs:
  Generates costs (for: ):
  
  
• Consequence of telehealth: Reduced health risk from travel
  Reduces costs (to: ): SELECTED (community and remote health service providers)
  Little difference in costs:
  Generates costs (for: ):
  
  
• Consequence of telehealth: Prevention of loss of autonomy
  Reduces costs (to: ): SELECTED (community service providers, family: long term)
  Little difference in costs:
  Generates costs (for: ):
  
  
• Consequence of telehealth: Improved attention from specialists
  Reduces costs (to: ): SELECTED (community and remote health service providers)
  Little difference in costs:
  Generates costs (for: ):
  
  
• Consequence of telehealth: Better understanding by local staff of how to manage patient
  Reduces costs (to: ): SELECTED (community and remote health service providers)
  Little difference in costs:
  Generates costs (for: ):
  
  
• Consequence of telehealth: Creation of unmet demand for service, increased wait time, condition degradation
  Reduces costs (to: ):
  Little difference in costs:
  Generates costs (for: ): SELECTED (community and remote health service providers)

Non-health consequences

• Consequence of telehealth: Less travel
  Reduces costs (to: ): SELECTED (patients, community, FNIHB )
  Little difference in costs:
  Generates costs (for: ):
  
  
• Consequence of telehealth: Decreased anxiety due to shorter wait, visitation
  Reduces costs (to: ):
  Little difference in costs: SELECTED
  Generates costs (for: ):
  
  
• Consequence of telehealth: Improved access to outside expertise
  Reduces costs (to: ):
  Little difference in costs:
  Generates costs (for: ): SELECTED (community and remote health service providers)
  
  
• Consequence of telehealth: Staff education and development/ improved competencies
  Reduces costs (to: ): SELECTED (community and remote health service providers)
  Little difference in costs:
  Generates costs (for: ):
  
  
• Consequence of telehealth: Staff retention
  Reduces costs (to: ): SELECTED (comunity health service providers)
  Little difference in costs:
  Generates costs (for: ):
  
  
• Consequence of telehealth: Closer relationships with remote providers/organizations
  Reduces costs (to: ):
  Little difference in costs: SELECTED
  Generates costs (for: ):
  
  
• Consequence of telehealth: More judicious use of resources
  Reduces costs (to: ): SELECTED (community and remote health service providers)
  Little difference in costs:
  Generates costs (for: ):
  
  
• Consequence of telehealth: Training need
  Reduces costs (to: ):
  Little difference in costs:
  Generates costs (for: ): SELECTED (community health service providers, local and remote telehealth staff)
  
  
• Consequence of telehealth: Additional time per patient
  Reduces costs (to: ):
  Little difference in costs:
  Generates costs (for: ): SELECTED (community and remote health service providers)
  
  
• Consequence of telehealth: Need for practice protocols
  Reduces costs (to: ):
  Little difference in costs:
  Generates costs (for: ): SELECTED (community and remote health service providers)
  
  
• Consequence of telehealth: Scheduling systems
  Reduces costs (to: ):
  Little difference in costs:
  Generates costs (for: ): SELECTED (community and remote health service providers)
  
  
• Consequence of telehealth: Duplicate records coordination and management
  Reduces costs (to: ):
  Little difference in costs:
  Generates costs (for: ): SELECTED (community and remote health service providers)
  
  
• Consequence of telehealth: Loss of efficiency due to non replaceable missed appointments
  Reduces costs (to: ):
  Little difference in costs:
  Generates costs (for: ): SELECTED (community and remote health service providers)
  
  
• Consequence of telehealth: Development of community capacity to take on major health initiatives
  Reduces costs (to: ):
  Little difference in costs: SELECTED
  Generates costs (for: ):

These qualitative findings suggest that, in the short term for the isolated Northern communities, telehealth generates more costs than it reduces. Its main cost reducing benefit will be seen as some proportion of travel reduced, but more importantly, in terms of the prevention of morbidity and disability, as long-term savings for communities because of their healthier populations.