HTF 402 National First Nations Telehealth Research Project
Project Activities
1. Methodology
The HTF National project (2 million dollars) HTF, was managed
by Health Canada's First Nations and Inuit Health Branch (FNIHB).
It 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 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.
Accountability Framework
The Accountability Framework was finalized with all project participants
during a meeting in Winnipeg in October 1998.(The Minister
of Health announced the launch of the National Project on September
8, 1998.) It outlined the National Project's organizational
chart, objectives, expected outcomes, principles and assumptions,
roles and responsibilities, workplan (including a checklist of
tasks/activities), budget, risks, categories of potential telehealth
applications, main communication messages, management structure
and preliminary evaluation plan. The Accountability Framework was
instrumental to identifying key members of the national and community
project teams, i.e. the National Project Manager, Community Project
Officers, Regional Project Coordinators, Community Site Leaders,
Community Health Authorities/Managers/Providers, Community Political
Leadership, Telehealth Technical Consultant, Technical Vendors,
Telehealth Evaluator Specialists, Peer Review Team and Project
Steering Committee.
Needs Assessment
In September 1998, community health providers were asked to complete
a Pre-Site Visit: Data Gathering Instrument. The evaluation team
then provided Community Project Officers with Community Needs Assessment
Guidelines and Tools. Needs assessments were undertaken during
the Winter of 1999. Key informant interviews were conducted with
health and social services personnel, service providers outside
health, community leaders (including elders) and provincial secondary
and tertiary care resources. Health records and data collected
by Health Canada concerning patient transportation, life expectancy
etc. were also studied. Information was compiled and analyzed according
to a grid intended to match identified needs to potential telehealth
applications. The grid's three main categories of evaluation criteria
were: response to needs; community readiness; and, feasibility.
Application Selection
To limit the scope of the project and increase its feasibility,
communities were asked to select up to three telehealth applications
based on identified needs. Applications selected by each of the
communities are outlined below.
Community
- Anahim Lake
- Applications
- Urgent/Emergent Telehealth: real-time, on demand
teleconsultations between the Anahim Lake Nursing
Station and Cariboo Memorial Hospital in Williams
Lake for emergency assessment/triage and support.
- Fort Chipewyan
- Applications
- Telerehabilitation: remote supervision of a Rehabilitation
Assistant in the Fort Chipewyan Nursing Station by
senior professionals at the Northern Lights Regional
Health Centre (Fort McMurray) to conduct occupational,
speech and physical therapy sessions;
- Televisitation of family members with patients
hospitalized in Fort McMurray.
- Southend
- Applications
- Teleconsultations in the areas of General Practitioner
(GP) and specialist services with a main focus on
dermatology;
- Remote educational sessions on diabetes management;
- Remote mental health services provided from Saskatoon.
- Berens River
- Applications
- Remote diabetes prevention and intervention: foot
care program (education and video examination of
feet), community-based screening activities with
training and referrals conducted over the audio-video
link to health educators and specialists;
- Remote mental health services: patient assessment
and counseling, specialist consult and group therapy;
- Continuing education programs for health staff,
administrators and para-professionals.
- La Romaine
- Applications
- Remote diabetes monitoring from the patient's home:
use of electronic glucose monitor connected by telephone
line to La Romaine Nursing Station and tele-ECG;
- Teledermatology: store-and-forward system (i.e.
an asynchronous communication where voice, video
and/or data is "stored" in a computer and than "forwarded" to
a computer in another location);
- Tele-Ear/Nose/Throat (ENT): store-and-forward system.
Request for Proposals and Vendor Selection
A Request for Proposals (RFPs) template, was developed for purchase
of the telehealth equipment (i.e. videoconferencing, peripherals,
network technologies). Community Project Officers sent RFPs to
a maximum of ten potential equipment suppliers. Submitted proposals
were then evaluated by the officers according to a Bid Review Package.
The main groups of criteria pinpointed in the package were: Group
1 - Compliance with Submission Requirements; Group 2 - Vendor Profile;
Group 3 - Vendor Commitment; Group 4 - Costs; Group 5 - Equipment
and Software. In some cases, equipment suppliers were invited to
present their proposed solution to the community project team.
The Peer Review Team and Steering Committee were also asked to
evaluate the proposal selected by the community project teams according
to a list of assessment criteria.
In the majority of cases, partnerships were struck to share provincial
resources with pilot communities. The Mental Health Services Program
of BC Health and Ministry Responsible for Seniors contributed $30,000
to the cost of purchasing the videoconferencing system installed
at Cariboo Memorial Hospital. Southend was linked into the Northern
Telehealth Network created by SaskHealth. The Winnipeg Health Sciences
Centre contributed the use of its pre-existing videoconferencing
equipment to conduct teleconsultations with Berens River. Thanks
to the technical simplicity of the store-and-forward system, no
additional equipment was required at the secondary and tertiary
care centres delivering telehealth services to La Romaine except
for the secure software required to open transmitted images.
Memoranda of Understanding (MOU)
Successful partnerships were negotiated with provincial secondary
care centres, tertiary care centres and educational centres to
ensure delivery of remote services to the five participating First
Nations communities. Community Project Officers guided discussions
between community leadership and provincial facilities/authorities
(i.e. hospitals, regional health authorities, colleges etc.). Often,
officers were asked to draft an MOU that was then reviewed by legal
advisers of both parties. MOU included, in some cases, agreements
to transfer funds from the community to the provincial facility
to refund costs related to professional fees and administration.
In British Columbia, Alberta and Quebec, teleconsultations conducted
in the context of the National Project were not recognized by the
provincial government as an insured service. For this reason, provincial
fee-for-service health care providers delivering services using
the telehealth link were compensated with funds originating from
the Project's budget. In the table below is the list of provincial
partners involved in the National Project.
Community Partners
- Anahim Lake Nursing Station, Ulkatcho Band (Anahim Lake)
- Provincial Partners
- Cariboo Memorial Hospital, Central Cariboo Chilcotin
Health Council (Williams Lake).
- Nunee Health Authority, Athabasca and Misikew Cree First
Nations (Fort Chipewyan)
- Provincial Partners
- Northern Lights Regional Health Centre, Northern
Lights Regional Health Council (Fort McMurray)
- Southend Health Centre, Peter Ballantyne Cree Nation Health
Services Inc. (Southend)
- Provincial Partners
- Northern Telehealth Network (more specifically,
La Ronge Hospital, Victoria Hospital in Prince Albert,
Royal University Hospital and Saskatoon City Hospital
in Saskatoon, SaskHealth )
- Berens River Nursing Station, Berens River First Nation
(Berens River)
- Provincial Partners
- J.A. Hildes Northern Medical Unit, University of
Manitoba
- Winnipeg Health Sciences Centre (Winnipeg)
- Centre de santé Unamen Shipu, Conseil des Montagnais
Unamen Shipu (La Romaine)
- Provincial Partners
- Centre hospitalier régional de Sept-Iles
(Sept-Iles), Centre hospitalier des universités
de Québec Quebec City)
Telecommunications Access
The level of access to the required telecommunications infrastructure
varied from one community to the other. Since the type of telehealth
application determines the level of telecommunications bandwidth
required, initial research aimed at identifying the extent of available
telecommunications infrastructure was conducted during the needs
assessment to ensure that unfeasible applications would not be
selected. A summary of the telecommunications made available to
each community in the context of the National Project is provided
below.
Community
- Anahim Lake
- Telecommunications Access
- Prior to the project, telecommunications access
was restricted to bad quality Plain Old Telephone
Service (POTS). A satellite C-Band 3.7M to C-Band
2.4M (384 kbps raw link) communication link between
the Anahim Lake Nursing Station and Cariboo Memorial
Hospital had to be established. Telesat was contracted
to provide this service under its R&D program,
allowing the community to purchase space segment
at 15-minute increments. As well, the installation
and testing were conducted free-of-charge by Industry
Canada's Communications Research Centre. Notwithstanding,
the high cost of the satellite communication link
required the negotiation of a cost-sharing partnership
with the BC office of Indian and Northern Affairs
Canada (INAC). INAC agreed to contribute $75,000
to the satellite link if Internet access could be
provided to the Band Administration Office.
- Fort Chipewyan
- Telecommunications Access
- At the outset, the community had high line speed
availability thanks to 6 sets of switched-56 lines
converted to ISDN using Telesync adapters (high point
is 336 kbps).
- Southend
- Telecommunications Access
- At the outset, the community had high line speed
availability thanks to switched-56 lines. Its connectivity
to the Northern Telehealth Network was feasible.
- Berens River
- Telecommunications Access
- Prior to the project, telecommunications access
was restricted to low speed (33.6) POTS. A satellite
C-Band 3.7M satellite communication link between
the Berens River Nursing Station and the Winnipeg
Health Sciences Centre had to be established. Telesat
was contracted to provide this service under its
R&D program, allowing the community to purchase
space segment at 15-minute increments. As well, the
installation and testing were conducted free-of-charge
by Industry Canada's Communications Research Centre.
A cost-sharing arrangement was made with the tertiary
care center to cover the civil works costs related
to the installation of the satellite earth station
at the Winnipeg site.
- La Romaine
- Telecommunications Access
- The community has access to ISDN but requires a
new cross-connect digital switch to access a dedicated
T1. This capacity was required for the community
to connect to the private telemedicine network of
the Quebec Health and Social Services Ministry. Called
the Réseau de télécommunication
socio-sanitaire (RTSS), the network links all
provincial health care facilities, including the
secondary and tertiary care centres that deliver
health care to La Romaine community members. The
network is established and maintained by a partnership
between Bell Canada, Telebec and QuebecTel. La Romaine's
access to the RTSS was evaluated at $10,000 per month
by the provincial government. This high cost prevented
the community from linking into the network and,
therefore, set up any videoconferencing link with
its referral centres. It instead chose to build a
store-and-forward system using a dial-up Internet
account.
Installation/Testing/Training
Installation/Testing/Training took place during the Spring of
2000, except in Anahim Lake. Additional training sessions were
held during the Fall 2000 and Winter 2001 in La Romaine, Berens
River and Southend. These sessions were needed mainly due to staff
turnover.
Evaluation and Ethics Review
There is no standardized evaluation framework for telehealth.
Some researchers, such as Marilyn Field [ Marilyn J. Field, Telemedicine:
A Guide to Assessing Telecommunications in Health Care (Washington,
D.C.: National Academy P, 1996). ], are known for their development
of telehealth-specific evaluation methodologies. There are two
general approaches used to evaluate telehealth: program evaluation
and health technology assessment. Program evaluation assesses the
effectiveness of a service delivery program. It can include several
sub-components such as a needs analysis, an economic analysis (cost-benefit,
cost-effectiveness or cost-consequence analyses), formative (process-oriented)
or summative (outcomes-oriented) evaluations. Health technology
assessment relates to the safety and performance of the technology,
as well as to the costs of the technology.
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 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. It
is important to note that the constrained project timeframe of
2.5 years did not allow an evaluation period of more than an average
of 8 months. As background information for their Final
Report, the evaluation team completed a literature review of evaluations
of selected telehealth applications in rural settings [ Applications
consisted of cardiology, continuing medical education, dermatology,
diabetes management, ENT, mental health/counselling, ophthalmology,
neo/post-natal and pediatric assessment, rehabilitation, respiratory
problems, trauma and emergency medicine. ], also attached in
Appendix A.
Since the National Project was, first and foremost, a research
project and since it involved human subjects, an ethics review
process was undertaken by each community project team. That is,
during their first visit to the pilot communities, the evaluation
team appealed to community members and leadership to approve the
research procedures to be utilized in the data gathering and analysis.
Upon request, some communities made available formal letters of
approval of the research ethics involved in the project. In November
2000, consolidated ethics review submissions were then prepared
for ethics review committees of tertiary care centres/universities
participating in the project, mainly the University of Manitoba,
the Centre hospitalier des universités de Québec,
the Northern Lights Regional Health Centre and Royal University
Hospital. This submission compiled all the ethical rules of these
centres, as well as the Code of Research Ethics developed by the
National Steering Committee of the First Nations and Inuit Regional
Health Survey in 1997. Each centre was contacted in order to extract
their protocols, questionnaires etc. No requests to appear before
an ethics review committee has yet to be received from these centres
by the main project investigator (FNIHB).
2. Deviations in Project Methodology
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. However, such
deviations did not hinder the success of the project. Rather, they
contributed many lessons learned, valuable outcomes of the National
Project. Below is a description of the principal project deviations
experienced.
Project Extensions
Two project extensions were granted by the Health Transition Fund
Secretariat (from March 2000 to September 2000; from September
2000 to March 2001). These allowed the National Project to adapt
its methodology to community needs and processes. Furthermore,
extensions allowed project team members to familiarize themselves
with the technical and human components of telehealth implementation
(i.e. negotiating agreements with provincial health care providers,
securing satellite communication links, negotiating agreements
with Band and Tribal Councils to guarantee protection of their
inherent treaty rights and funding envelopes).
Delays in Anahim Lake Project Implementation
Despite project extensions, telehealth applications were not operational
in Anahim Lake before the end of the National Project. This inability
to collect usage data is due primarily to the lack of telecommunications
infrastructure. Various solutions were sought. Negotiations were
undertaken with Telus and Telesat. While satellite communication
was selected as the only available option early in 2000, obstacles
were faced relating to the feasibility of using Telesat equipment:
the high cost, the issue of potential inadequacy of the roof of
Cariboo Memorial Hospital to carry a satellite earth station, and
the switch from KU-Band to C-Band equipment due to lack of space
segment. As previously indicated, a contribution of $75,000 made
by INAC was successfully negotiated to partly subsidize the high
cost of the satellite equipment. As the situation now stands, the
satellite equipment will be installed in Anahim and Williams Lake
in April 2001. The project will begin its testing and training
phase at that time. It is expected that data will be collected
in Anahim Lake until March 2002. This data will be analyzed according
to the evaluation framework outlined in the context of the National
Project. The analysis will contribute further to the continued
effort of building a Business Case for telehealth implementation
in First Nations and Inuit communities.
Switch from Real-Time to Store-and-Forward
in La Romaine
Once again, the lack of telecommunications access impeded the
implementation of telehealth in a second community, La Romaine.
However, in this case, the applications selected (tele-ENT, teledermatology
and remote monitoring) did not, in and of themselves, require real-time
videoconferencing. It was, therefore, possible to implement a store-and-forward
system using dial-up e-mail accounts (whose infrastructure is POTS).
Notwithstanding, the community's expectations were no doubt disappointed
by this switch in the system design. It is possible that this switch
partially contributed to the low level of usage of the tele-ENT
and teledermatology applications (see Final Evaluation Report in
Appendix A).
The Will to Do More in the Face
of Limited Resources
In some communities, applications selected according to the needs
assessment process were not implemented due to a lack of financial
resources. [ These applications were mainly: the use of a defibrillator
to expand the tele-ECG application in La Romaine, a link to Medicine
Hat College to train a community member as a rehabilitation assistant
in Fort Chipewyan, tele-mental health and addictions counselling
as well as tele-ultrasound in Anahim Lake. ] These applications
required additional equipment that could not be purchased within
the limits of the allocated funds. The expansion of existing community
telehealth projects is an important issue that has been raised
during recent negotiations for sustained funding.
Secondly, community expectations relating to the potential of
telehealth are, at times, not achievable due to limited scope of
practice, competencies and time of nurses. In Anahim Lake, specialists
at Cariboo Memorial Hospital suggested that the use of ultrasound
to remotely diagnose internal injuries would greatly increase the
effectiveness of the urgent/emergent telehealth application. In
addition to the exorbitant cost, the lack of qualified personnel
to capture ultrasounds available at the community level made this
application unfeasible. Clear protocols relating to the use of
telehealth in urgent/emergent cases had to be developed by the
FNIHB zone nursing officer, the community nurse, a project consultant
with a nursing background contracted by Cariboo Memorial Hospital,
and a clinical advisor employed by the equipment supplier to ensure
compliance with nurses' scope of practice.
Confronting Challenges Precipitated
by Staff Turnover
Staff turnover at the community level impacted all five community
telehealth projects as demonstrated in the table below.
Community
- Anahim Lake
- Instance(s) and Impact of Staff Turnover
- During project planning, the community lost its
Nurse-in-Charge in two separate instances. Notwithstanding,
the project was able to advance. The current Nurse-in-Charge
has been actively involved in protocols development.
- Fort Chipewyan
- Instance(s) and Impact of Staff Turnover
- The inability to train a community member as a
rehabilitation assistant by establishing a link to
Medicine Hat College due to limited financial resources
jeopardized the feasibility of the telerehabilitation
application. Thankfully, the community was able to
recruit a Rehabilitation Assistant to participate
in the project. The community member initially targeted
for training was able to participate in the project
as the telehealth coordinator.
- Southend
- Instance(s) and Impact of Staff Turnover
- The loss of a nurse temporarily disrupted the project's
progress. However, the community was quickly able
to recruit a new telehealth coordinator, a community
member, who then partnered with a new nurse to form
the telehealth team.
- Berens River
- Instance(s) and Impact of Staff Turnover
- The loss of three nurses each of whom had over
ten years experience in the community was an unfortunate
consequence of the transfer of health services management
from FNIHB to the Band Council. Innovatively, a community
health representative (CHR) was able to take over
the telehealth project by acting as its coordinator.
With additional training, the new coordinator allowed
the project to move forward and promote community
involvement.
- La Romaine
- Instance(s) and Impact of Staff Turnover
- The loss of the nurse coordinator and health director
impacted progression of the project during the Summer
of 2000. Temporary staffing during this time prevented
any resources from being dedicated to telehealth
coordination. However, a new telehealth coordinator
was appointed and a new training session scheduled
in September 2000.
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