HTF 402 National First Nations Telehealth Research Project

Executive Summary

In the February 18, 1997 Budget, the Government of Canada announced the creation of the Health Transition Fund (HTF). This Fund, responding to a recommendation of the National Forum on Health, supports large-scale pilot projects in key areas of health system modernization. These projects are the basis for evaluating what should be added to, or refined in, the public health care system of the future. The Fund was a three-year federal investment of $150 million to support national, provincial and territorial projects contributing to Medicare modernization. Decisions on projects and priorities were made by Canada's Ministers of Health.

This Final Results Report is an amalgamation of experiences and lessons learned by participants in the 2 million dollar National First Nations Telehealth Research Project (HTF402 - September 1998 - March 2001), mainly of five, isolated First Nations communities. It also contains evaluation outcomes collected and analyzed by an independent evaluation team. The Report has been reviewed by each community project team, as well as by the project Steering Committee and Peer Review Team.

Telehealth is most commonly defined in Canada as "the use of communications and information technology to deliver health and health care services and information over large and small distances". [ Jocelyne Picot, Telehealth Industry: Part I - Overview and Prospects (Ottawa: Industry Canada, 1998) 1. ]

Although the potential of telehealth has been explored in Canada for over four decades, the boom in telehealth activity began four to five years ago, prompted by important federal initiatives and the convergence of key drivers (e.g. health care reform, increased capacity of information and communication technology etc.). Many provincial and territorial projects and networks emerged during this time. While the visions of these initiatives are very diverse, they all emphasize access to better health regardless of location through the use of information and communications technologies as enablers to enhance health service delivery and share health information and expertise.

It would seem that, since the impetus for telehealth diffusion in Canada is the need for improved access to health services, First Nations and Inuit communities are a natural environment for telehealth implementation if the the following conditions are taken into account:

1. over 1/3 of First Nations and Inuit communities are located in isolated locations;
2. significant inequities in health outcomes among the Canadian and Aboriginal populations have been documented;
3. telehealth has the potential to address many priorities in First Nations health identified by Health Canada and the Assembly of First Nations.

The National Project involved the planning, implementation, operation and evaluation of telehealth in five First Nations communities: Anahim Lake (British Columbia), Fort Chipewyan (Alberta), Southend (Saskatchewan), Berens River (Manitoba) and La Romaine (Quebec). These communities were selected by the First Nations and Inuit Health Branch's (FNIHB) regional offices because they satisfied the following criteria:

• remote, isolated or semi-isolated community;
• Chief and Band Council support of the project;
• Community Nurse and Health Director support of the project;
• support from FNIHB's Regional Nurse/Physician;
• support from Regional Director.

While the design of each community telehealth research sub-project was adapted to the needs and culture of the community at hand, the National Project was implemented in eight main phases: (1) drafting of the Accountability Framework; (2) needs assessment; (3) applications selection; (4) sending out Requests for Proposals and selecting the vendor; (5) negotiating agreements with provincial health and educational facilities; (6) securing access to the required telecommunications infrastructure; (7) installation/testing of the equipment and training of personnel; (8) evaluation and ethics review.

The National Project is a pioneer in the implementation of telehealth in First Nations communities. Its design and process are unprecedented and, for this reason, it encountered many issues and obstacles that had never before been tackled. Some issues/obstacles compelled the project to deviate from its initial methodology in the following ways.

• Two project extensions were granted.
• Implementation of the Anahim Lake telehealth project was delayed until April 2001 due to the difficulties experienced in obtaining the required telecommunications infrastructure.
• The La Romaine telehealth project had to switch from a real-time videoconferencing system to a store-and-forward system to deliver its selected telehealth applications due to the high cost of securing high bandwidth;
• Some selected telehealth applications could not be implemented due to limits in financial resources and human resources (i.e. limited scope of practice, temporary staffing and time management).
• Staff turnover created disturbances in all five community telehealth projects, ranging from low usage of the equipment to the need for additional training.

These deviations did not hinder the success of the project. Rather, they contributed many lessons learned, valuable outcomes of the National Project.

With respect to experiences of the National Project, four main types of project outcomes are highlighted:

1. Lessons Learned;
2. Critical Success Factors for any new telehealth implementation in isolated First Nations and Inuit communities, derived from the lessons learned;
3. Evaluation Results, compiled from analysis of the data collected during the operational phase of four community telehealth projects;
4. Recommendations, based on a review of outcomes identified above.

1. Lessons Learned

   The main lesson learned during the National Project is the realization that a variety of elements can potentially guarantee or hinder success in adopting, implementing and sustaining a telehealth project. Lesson learned were categorized according to three elements, critical to achieving success if they are concurrently taken into account:

   Telehealth Element A: Human Resources

   Telehealth is not a panacea, it cannot do all things for all people. It is for the purpose of conquering the "panacea" vision that community expectations regarding the potential of telehealth should be managed. A detailed communication plan is an important step in the implementation process. The success of any telehealth project will largely depend on human interaction and stable/sound relationships rather than on interaction with the technology.

   "Getting your people to buy into the IDEA of Telehealth."

   
   

   Telehealth Element B: Financial Resources

   There are many anticipated and unanticipated cost items. Start-up and operating costs should be distinguished.
   Sources of sustained funding need to be identified to ensure the long-term viability of telehealth services.

   "Finding the money to do it."

   
   

   Telehealth Element C: Technical Resources

   If technology companies come knocking on the door, it is important to be informed of all the steps and considerations involved in telehealth implementation, many of which are not technology related. Although important, technology is often the last piece of the implementation puzzle.

   "Putting the tools in the hands of those who need them."

   
   
2. Critical Success Factors

   From the many lessons learned, it is possible to extract a list of Critical Success Factors for potential future telehealth implementation in First Nations and Inuit communities. These relate to key elements in the implementation process, namely community, funding, management, health care/educational practice, technology and policy.

3. Evaluation Results

   The National Project hired independent project evaluators to create a framework and tools, in consultation with community project teams and provincial health care and educational facilities. The evaluation addressed three main questions pertaining to the implementation and impacts of telehealth in the communities, specifically to (1) the impacts of telehealth on patient and community access to needed, quality care; (2) the role of telehealth in health services delivery, including cost-effectiveness; and, (3) the linkages created through telehealth with existing health resources. Several data collection methods were used:

   • ongoing monitoring of frequency, nature and implications of telehealth usage through forms completed by staff in both the community and referral sites;(Over the evaluation period, information was received about 927 telehealth sessions involving 176 patients. The number of sessions per community varied from 40 to 755, and the number of patients seen from 17 to 59.)

   • patient satisfaction assessment, through a total of 110 questionnaires completed by patients using telehealth in each community;

   • 43 qualitative interviews with 65 key informants including telehealth coordinators, Band and nursing station managers, nursing staff, health centre board member, elders, patients (in one community only), tertiary care providers and management, provincial telehealth representatives, and Health Canada representatives.

   A case study of each community was produced based on the above data. A cross-case analysis summarized below examined the findings in light of the evaluation questions, the consequences of telehealth in relation to costs, and the main lessons learned.

Access to needed, quality care

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

In general, telehealth applications responded to community needs, although this was clearer in some communities than others. At issue are not only the definition of needs, but also how the technology and organizational arrangements can respond to needs. For instance, telehealth can be used to address the issue of diabetes within a community in a number of ways, with some ways 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 concerns are overcome with a positive experience, telehealth is acceptable to the vast majority of patients and families who use it. Consistent with the findings in the research literature review, satisfaction levels are high, and almost all patients would use the system again. 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 due to 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 obtained 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 referral centres. Stable, committed staff in the nursing station was a key success factor for effective implementation of telehealth in these communities. This is an issue that was not identified in the research literature, and may be unique to isolated
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 result 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 little information was made available 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 suggests a high level of penetration.

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 professionals.

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

When telehealth coordination responsibilities were assigned to a nurse in 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 to 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 using telehealth, their scope and quality of practice 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 patient no-shows also reduces efficiency and productivity for tertiary care providers. While, in many case,s 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 for the loss of productivity - a critical issue compounded by the general scarcity of resources.

To what extent does telehealth result in cost increases, decreases or shifts for health service delivery at the community level?

Overall, the evaluation suggests that the net effect of telehealth is to generate greater access to care, thereby, increasing costs. Cost increases result both from increases in the numbers of patients receiving services -- services are now available where none were before - as well as in the intensity of services delivered - patients, especially in some applications, are seen more frequently (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 the 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 suggest that telehealth will result in avoided transfers in about 30 to 40% 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 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 lifespan.

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

All communities experienced, at minimum, 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, integrated and will be sustained varied greatly from community to community. 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. In addition, the capacity of the initiative to develop the committed, trusting relationships necessary to ensure good communication and problem-solving was critical to appropriation and integration. Relating to this issue, real-time technologies and applications are advantaged over store-and forward systems.

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

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

To what extent does telehealth improve access of secondary/tertiary care 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 link.

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.

Recommendations

Taking into account lessons learned, critical success factors and evaluation results, FNIHB - in consultation with the community project teams and Peer Review Team - recommends the following next steps to build on achievements of the National Project:

1. A concerted approach to the lack of connectivity in rural and remote communities, and especially Aboriginal communities, is required. This issue is one that cannot be resolved by FNIHB, nor by Health Canada, in isolation. The National Broadband Task Force and the Connecting Aboriginal Canadians strategy will no doubt raise the profile of this issue. However, their effectiveness in increasing infrastructure deployment will depend on the allocation of dedicated funding to this end.

   A concerted approach to connectivity would not be designed to solely benefit the community health care system. Rather, it would adopt the Smart Community model that enables the uptake of technology for community and economic development, education, health, social services, law enforcement, band management etc.

2. It is recommended that new research be undertaken to further explore issues raised in the context of this project and to build a unique body of knowledge needed for the implementation of successful telehealth initiatives in First Nations and Inuit communities. New research could be used to: develop implementation strategies based on type, needs and capacity of a community; to develop funding models for sustainable telehealth initiatives once again based on the unique community situation; to conduct enhanced cost-benefit analyses; to develop models of F/P/T cooperation guiding telehealth implementation, particularly in rural and remote communities. New research should be undertaken over a longer amortization period to substantially increase its value.

3. Opportunities to undertake telehealth (including research) should be offered in a manner that is equitable and sustainable across all First Nations and Inuit communities. Many First Nations communities do not have the structure nor resources to undertake major proposal writing. As well, a clear commitment to provide sustainable funding should be made at the outset. New project timeframes should be adapted to the implementation process required in First Nations communities (a minimum of 3-5 years).

4. New research should study the system-wide impact of telehealth on various funding envelopes and on human resource infrastructures of communities, provinces and FNIHB. Research data will contribute to the building of a Business Case for telehealth in First Nations and Inuit communities. [ The Business Case is a comprehensive analysis of the full potential of what can be achieved by telehealth thanks to identified strategic investments. It is a means of addressing the main concerns of decision-makers and funders and encouraging them to ultimately support an ideal scenario for telehealth implementation. The main components of the Business Case are the Environmental Scan, a list of tangible and intangible benefits, a Tactical Plan and a Costing Model (cost assumptions and estimates). The Tactical Plan determines who, when, where and how telehealth will potentially be implemented in First Nations and Inuit communities. This is critical to determining a costing model for potential future telehealth communities (i.e. how many sites). The Tactical Plan anticipates what would occur if funding is granted for large-scale implementation. The scope of this possible funding is not known and, therefore, the Tactical Plan explores, and remains flexible to deal with, various funding options. ] Sustaining telehealth activity in the long term will have significant impact on current funding levels in the following ways: it will decrease, and in some cases, increase the costs of patient travel; it will increase the costs of certain allied health services; it will introduce new health services (and, thereby, new costs) to the community; it will increase the pressures on human resources at the community level, at the provincial level and at the FNIHB regional office level.

5. It is recommended that strategies be elaborated to ensure that telehealth effectively contributes to capacity-building, service integration and sustainability in First Nations and Inuit communities. These are shared priorities in First Nations health of FNIHB and of the Assembly of First Nations.

6. Increased awareness/understanding of, and communication to, First Nations and Inuit stakeholder in matters relating to telehealth will enable them to take advantage of new and existing initiatives and funding opportunities. A rising interest among these stakeholders in the deployment of information and communications technology to benefit health has been demonstrated. However, beyond interest, it is important to gather the knowledge of First Nations and Inuit on why and how this deployment should take place within specific communities, regionally as well as nationally. A primary vehicle for information-sharing and feedback is the creation of a Standing Working Group composed of First Nations and Inuit representatives appointed by national and regional associations, in addition to FNIHB representatives. The primary mandate of this Working Group will be to design a Blueprint and Tactical Plan for potential telehealth implementation.

7. Linkages between telehealth and other initiatives of the Aboriginal Health Infostructure (such as FNIHIS, EHRs and health research initiatives), as well as with Canadian Health Infostructure initiatives, are critical in order to leverage investments to benefit Aboriginal peoples.
   [ A preliminary vision of the AHI was elaborated by the Advisory Council on Health Infostructure in 1999. It is intended as a distinct component of the Canadian Health Infostructure. Main principles of the AHI were suggested by the Council: self-determination, knowledge as power, and building human resource capacity and autonomous institutional development. Currently, development of the AHI is being undertaken by a Planning Committee composed of representatives of Aboriginal organizations and of FNIHB. ]A concerted approach to health infostructure development - emphasizing harmonization, linkages and leveraging of investments - will ensure that policy and other issues are addressed concurrently, and that economies of scale are created wherever possible. For instance, a comprehensive information management/technology framework - for health information systems, automated records, telehealth systems etc. - could be made available that is culturally adapted and coordinated with community capacity-building strategies. It is important to ensure that Aboriginal interests are represented in F/P/T discussions and partnerships involved in the development of the Canada Health Infoway. More specifically, awareness should be raised concerning unique federal/provincial/Aboriginal jurisdictional issues.