HTF 402 National First Nations Telehealth Research Project

Project Purpose

1. Project's Overall Goal

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". [ Ibid. ] Telehealth can encompass the delivery of a broad range of health and social services. In the United States of America, the term "telemedicine" is used to designate these services and, in Europe, the phrase "health telematics" is common. Telehealth traffic - that is, what travels on telehealth networks - includes: health information (clinical information such as patient records, administrative information such as costs or service utilization data, research information such as analyses and findings), images (still or moving), signals (vital signs, ECGs), audio (heart beat, voice) and multimedia (audio, image, text).

Some broad types of telehealth are:

• telemedicine: all forms of medicine-at-a-distance;
• inter-institutional and health information networks: the exchange of patient and clinical records and databases;
• tele-education: for professional education (e.g. Continuing Medical or Nursing Education) and for public education (e.g. self-care)
• tele-monitoring and telecare: for triage, remote home care and emergency networks.

Telehealth mainly serves to:

• collect, share/access and disseminate data (images, audio, text);
• advise, support, triage, consult, monitor and overall manage patient care;
• educate, train, coach, support and mentor health care practitioners.

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. It was prompted by important federal initiatives, seeking to support this new technology in its next phase of development: the integration of telehealth into mainstream health care delivery. Such initiatives include the Government of Canada's Science and Technology Strategy and Information Highway Action Plan, Health Canada's National Task Force on Health Information and National Forum on Health, Industry Canada's support of key, high export, knowledge-based Canadian businesses. More recent federal initiatives have built on achievements of previous strategies by focusing on F/P/T partnerships and by contributing more considerable investments: the Connecting Canadians strategy and National Broadband Task Force, the Office of Health and the Information Highway, the F/P/T Advisory Committee on Health Infostructure and the Canadian Health Infostructure Partnerships Program (CHIPP).

During the last decade, the convergence of key drivers in the telehealth industry has been witnessed on a worldwide scale: cost containment and health care reform (service integration, accountability mechanisms), an aging population, high technology investments in the health care market (portable medical devices, biotechnology, genetics research and engineering, health informatics), increasing consumer demand for health information, decreasing cost, increased capacity of information and communications technologies, and global partnerships to advance health (e.g. G7). Key drivers and strategic federal investments have given rise to provincial/territorial telehealth networks across Canada.

Telehealth initiatives vary in their purpose and direction. The Provincial Vision Statement of Telehealth, elaborated by the British Columbia Government, is: "A health system in which telehealth technology is used effectively as a tool to improve the health of the people of the province, by enabling the delivery of accessible, affordable and efficient quality health services." [ British Columbia Ministry of Health, Telehealth in British Columbia: A Vision for the 21st Century, August 1999 (http://www.moh.hnet.bc.ca/him/moh/img/paper.html#intro). ] The Technology in Government Week 2000 Conference outlined a vision for telehealth as follows: "The vision for Telehealth is to offer fully integrated citizen-centred health services over short or long distances, and in urban as well as remote areas." [ Technology in Government Week 2000, "Telehealth: Delivering Primary Health Care Services On-Line", Abstract (http://www.webeventregistration.com/registration/ session_home?v_session_id=8336). ] During the First International Congress on Telehealth and Multimedia Technologies, hosted by the Telehealth Technology Research Institute of the University of Alberta, a draft Alberta Declaration on Telehealth was formulated. This Declaration begins with the vision: "Health Everywhere from Anywhere." [ First International Congress on Telehealth and Multimedia Technologies, Draft Alberta Declaration on Telehealth, Edmonton, Shaw Conference Centre, August 1999 (http://www.ttri.ualberta.ca/ttri.html). ] Although these visions are very diverse, they all emphasize access to better health regardless of location through the use of information and communications technologies. These technologies act as enablers to enhance health service delivery and share health information and expertise.

As demonstrated in this fused Canadian Telehealth Vision, the impetus for telehealth diffusion in Canada is the need for improved access to health services. Ergo, First Nations and Inuit communities would seem to be a natural environment for telehealth implementation if the the following conditions are taken into account:

• Significant human hardships and financial costs result from transporting patients from remote locations to medical facilities.
• Roughly one third of First Nations and Inuit communities are located over 90 kilometers from physician services.
• Geographic isolation restricts access of these communities to specialist health services, health information and professional education for community health providers.
• Geographic and professional isolation of primary care service providers working in First Nations and Inuit communities hinders recruitment and retention of these providers.

2. Project's Objectives

• Relating to Health Care:
  • To improve linkages between the community health facility and provincial primary/secondary/tertiary care centers and/or educational facilities;
  • To reduce unnecessary travel and hospital stays of community members by delivering new services from the community health facility;
  • To provide training opportunities locally for community health providers;
  • To improve access of community members to health information/education;
  • To improve access of community members to specialist health care.
  
  
• Relating to Knowledge:
  • To conduct an evidence-based assessment of the benefits to the community of telehealth;
  • To learn the most effective and appropriate ways to introduce telehealth in First Nations communities and how to provide opportunities for First Nations to contribute to telehealth implementation;
  • To learn ways to increase the involvement of community members in health-related activities by adapting the project to the community's needs and culture;
  • To elaborate partnership-building strategies based on negotiations with provincial health organizations and equipment suppliers;
  • To share lessons learned with other telehealth projects in Canada, obtaining an extensive understanding of Canadian telehealth.

3. Strategic Importance

First Nations and Inuit telehealth is a distinct component of Canadian telehealth. While telehealth in Canada is not a new phenomenon, its implementation in First Nations communities is a recent initiative that has received much attention by people active in the field. For many telehealth enthusiasts, the implementation of telehealth in First Nations and Inuit communities seems like a natural fit for these main reasons: 1) over 1/3 of First Nations 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; 4) telehealth has the potential to reduce the high costs of patient travel.

Geographical Isolation

Health Canada is mandated to provide for the delivery of health care services to over 600 First Nations and Inuit communities by funding 565 health care facilities and by offering a range of community-based programs such as home care, diabetes prevention, prevention of Fetal Alcohol Syndrome, pre-natal nutrition etc. 252 of these facilities are located over 90 km from physician services. For this reason, they are classified as Remote-Isolated, Isolated or Semi-Isolated.

Geographic isolation hinders a community's access to health care and community health providers' access to professional support. It has many dire consequences for communities, including: hardships resulting from travel experienced by patients and health providers, and difficulties in recruitment and retention of community health providers. In eliminating some patient and provider travel by offering services remotely, telehealth alleviates some of these hardships.

Inequities in Health Services and Outcomes

According to the First Nations and Inuit Regional Health Survey, approximately 60% of respondents believed that health services available to First Nations and Inuit are unequal to those available to the general Canadian population. Respondents also identified those services in greatest need of improvement: pediatric services, disease prevention, medication awareness, diabetes education, homes for the elderly, home care and mental health services. [ Fred Wien and Lynn McIntyre, "Health and Dental Services for Aboriginal People," First Nations and Inuit Regional Health Survey National Report 1999 (Ottawa: First Nations and Inuit Regional Health Survey National Steering Committee, 1999) 241. ] Inequities in health outcomes were also revealed in the survey, such as:

• Infant death rates are twice as high among First Nations and Inuit than among Canadians.
• Chronic conditions are more prevalent among First Nations and Inuit elders than among those of the Canadian population.
• Type 2 diabetes is 2-5 times higher in the Aboriginal population.
• Disability rates among Aboriginal peoples are more than double the Canadian rate.

Service inequality is reflected dramatically in nursing and physician shortages in First Nations and Inuit communities. Depending on the region, from 15% to 53% of nursing positions in these communities are either vacant or staffed on a temporary basis. [ Health Canada, FNIHP, Action on Nursing: Nursing Retention and Recruitment Strategy (Ottawa: Health Canada, 1999) 2. ] Communities can experience a delay of 8 to 10 months before staffing a vacant position. Filling a vacant position can cost upwards of $35,000. The situation is only expected to worsen. Canada faces a projected shortfall of 59,000 to 113,000 nurses by 2011. [ Ibid. ] This is due in part to the aging of the nursing workforce, whose current average age is 44 years.
[ Ibid. 3. ]

The number of generalist physicians in rural Canada fell by 15% from 1994-1998. In 1996, only 14.3% of generalist physicians and 2.9% of specialists served 9 million people living in rural Canada. In the North, nearly two thirds of the population is 100 or more kilometers from the nearest physician. In 1993, areas that did not consist of large or small urban centres had 23% of the Canadian population, but had access to only 9% of physicians (including 3% of specialists).
[ Edward Ng, Russell Wilkins, Jason Pole and Owen B. Adams, "How Far to the Nearest Physician?," Health Reports 8.4 (Spring 1997): 19-31. ] The physician shortage in rural Canada is no doubt experienced in First Nations and Inuit communities. For instance, Manitoba's Burntwood Health Region - 60% of whose residents are First Nations - has the highest population to physician ratio (3,817) in the province.

Priorities in First Nations Health

The table below demonstrates how telehealth can respond to strategic priorities in matters of First Nations health identified by Health Canada and the Assembly of First Nations (AFN).

Health Canada, Plans and Priorities in Aboriginal Health, 2000-2001 [ Health Canada, 2000-2001 Estimates: Part III - Reports on Plans and Priorities (http://www.tbs-sct.gc.ca/tb/estimate/20002001/rH_____e.pdf) 78-86. ]

Overall Objective: To assist Aboriginal communities and people in addressing health inequalities and disease threats and in attaining a level of health comparable to that of other Canadians, and to ensure the availability of, or access to, health services for registered First Nations people and Inuit.

Priority 1

• Strategic Priorities
  • Sustainable health services and programs: reduced health inequalities and disease threats; First Nations and Inuit autonomy and control.
  • Planned Results:
    • Better health and reduced health inequalities among non-Aboriginal and Aboriginal populations.
    • Informed First Nations and Inuit population and raised awareness of health factors and behaviors.
• Possible Response by Telehealth
  • By improving access to high quality health care and existing federal programs (e.g. Aboriginal Head Start, addictions programs, Home and Community Care, Community Health Nursing Practice, Aboriginal Diabetes Initiative, dental health, Canada Prenatal Nutrition Program, environmental health and nutrition), reduces health disparities.
  • Promotes a comprehensive, holistic approach to health service delivery with applications in mental health, traditional medicine, spiritual healing, community and economic development, education, prevention.
  • Builds community capacity (training, community and economic development, research).

Priority 2

• Strategic Priorities
  • Effective health care services available and accessible to First Nations and Inuit people.
  • Planned Results:
    • Service and health systems integration.
• Possible Response by Telehealth
  • Linkages with other information and communications technology initiatives (FNIHIS, electronic health records).
  • By reinforcing linkages amongst providers and facilities, improves regionalized health service delivery.
  • Promotes cost-effectiveness, especially in the area of non-insured health benefits.
  • Builds on partnerships with organizations such as the AFN, Inuit Tapirisat of Canada, P/T telehealth initiatives, provider associations etc.

Priority 3

• Strategic Priorities
  • Increased First Nations and Inuit management of, and accountability for, health care services and the non-insured health benefits program.
  • Planned Results:
    • Transfer of health programs to First Nations and Inuit.
• Possible Response by Telehealth
  • Supports community-driven projects and health systems.
  • To be implemented in accordance with standards and accountability frameworks developed in consultation with First Nations and Inuit (e.g. flexible accountability mechanisms and joint accountability to government, community & partner).

Assembly of First Nations, Health Priorities, 2001-2002 [ AFN Health Secretariat, AFN National First Nations Health Technicians Network and the AFN Chiefs Committee on Health, First Nations Health Priorities, 2001-2002 (Http://www.afn.ca/Programs/Health%2...irst_nations_health_priorities.htm). ]

Priority 1

• Strategic Priorities:
  Sustainability
  Building and sustaining First Nations Health
  and Health Care Systems
• Possible Response by Telehealth
  • By improving access to high quality health care, reduces health disparities.
  • Provides for needs-based and flexible implementation strategies to accommodate diverse community approaches.
  • By reinforcing linkages amongst providers and facilities, improves regionalized health service delivery.
  • Promotes cost-effectiveness, especially in the area of non-insured health benefits.
  • Improves community capital infrastructure and provides sustained resources to meet infrastructure needs
• Strategic Priorities:
  Sustainability
  Human Resources Development, Capacity
  Building and Training
• Possible Response by Telehealth
  • Increases training opportunities for First Nations and other community health care workers and administrators.
  • Delivers Aboriginal health careers programs.
  • Establishment of a training fund and program for telehealth coordinators.
  • Development of standards of practice/protocols for telehealth training, implementation and operation.
• Strategic Priorities:
  Sustainability
  Enhancement of Under Funded Programs (i.e.
  diabetes surveillance)
  • Possible Response by Telehealth
    • Provides remote diabetes surveillance, screening, diagnosis, treatment and education services.

Priority 2

• Strategic Priorities:
  Health Research and Infostructure
• Possible Response by Telehealth
  • Partnerships among telehealth users/integrators and health researchers such as the the National Aboriginal Health Organization, the Aboriginal Peoples' Health Research Institute, the First Nations and Inuit Regional Longitudinal Health Survey, the First Nations Statistical Institute and others, can be established.
  • Enables community members to be trained remotely in evaluation.

Priority 3

• Strategic Priorities:
  Jurisdictional Issues
• Possible Response by Telehealth
  • Jurisdictional issues pertaining to telehealth implementation and use to be outlined.
  • Strategies for ensuring that these issues are addressed in First Nations/F/P/T leadership forums are targeted.
  • A formal policy for dealing with these issues is developed.

Priority 4

• Strategic Priorities:
  Mental Health
• Possible Response by Telehealth
  • Delivers remote mental health services to First Nations communities, including suicide prevention programs targeting youth.
  • Delivers remote training programs for community health workers relating to mental health services, including community crisis response strategies for suicide, family
    violence and other crises.

Priority 5

• Strategic Priorities:
  Children's Health/Gender Health
• Possible Response by Telehealth
  • Delivers remote early childhood development programming and training.
  • Delivers remote screening and diagnostic tests for cancers (e.g. tele-mammography).
  • Delivers remote support programs for cancer victims/survivors.

Priority 6

• Strategic Priorities:
  Smoking
• Possible Response by Telehealth
  • Delivers remote smoking prevention, cessation, treatment and training programs.

Priority 7

• Strategic Priorities:
  Environmental Health & Infrastructure
• Possible Response by Telehealth
  • Delivers remote environmental health awareness and emergency measures training programs.