HTF 402 National First Nations Telehealth Research Project

Project Outcomes

There are four main types of project outcomes:

1. Lessons Learned, identified during each phase of the methodology;
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.

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. The following three elements are critical to achieving success if they are concurrently taken into account; otherwise there is a high risk of project failure:

A more detailed account of lessons learned pertaining to each of these critical elements, in addition to a brief discussion on policy issues raised by the project, are provided.

Human Resources

More and better information on communities (on available resources within those communities and within regional referral centres) is needed to improve the process of selection of communities in which telehealth is to be implemented. Time invested in community needs assessment and feasibility studies prior to selection can increase the chances of success and greatly facilitate the implementation process. It is important to determine if telehealth fits into the strategic plans of the community and connecting health/educational organization(s). Find out what human resources are already available at the main and referral site(s). Ask the question: "What is the impact of telehealth on community and referral/educational centre human resources?" The human infrastructure that supports telehealth must be developed. This development, however, is hindered by the lack and instability of human resources available in remote First Nations and Inuit communities.

It is important to manage high community expectations by communicating that telehealth is not a panacea or an easy fix to all community health problems. Generally, some community members will believe that telehealth can deliver locally complicated diagnostics (e.g. ultrasound). Community members often cite cases where "if only telehealth had been there" a better outcome would have resulted, but this is not always likely. However, while community members are showing an interest in telehealth, the majority are also waiting to see if any significant changes to health care delivery will result before endorsing the technology. The communication strategy adopted by project managers will be more complex and time-consuming the larger the community. More elaborate communication strategies enable broader-based decision-making which later contributes to more consistent support for the project's direction. Public education materials on telehealth should be developed for and with users of telehealth in remote and rural areas (and ideally, with users in First Nations communities).

It is important for communities to be ready for the ways in which telehealth can change health care delivery. A change management strategy is necessary; this strategy must take into account the organizational impact of telehealth, that is, its impact on existing community health care resources. Management of a telehealth project that is new to an organization, and/or its users, requires extra investment of time and effort, as well as education and training. Adequate initial and periodical training of health staff is critical to ensure rapid adaptation and high continued usage of the telehealth equipment. A sufficient testing and demonstration period is required to familiarize staff with the equipment at the inception of the system and as new staff come on board. Clinical protocols for the use of telehealth are required and should be developed by the project team. Be alerted to the fact that a project bringing about change will create uncertainty. This is often accompanied by considerable resistance to the changes in question. However, providing community members and health care providers with educational materials and demonstrations of telehealth applications will help them understand what telehealth is about and the impact it may have on their community. It will also increase the likelihood of project success. For instance, such an orientation may alleviate the concerns specialists may express with liability, especially as it relates to the technical quality of transmitted medical images. Other concerns expressed by health care professionals, in the context of the National Project, were: insurance, interprovincial licenses (needed to deliver telehealth from one province to another), scheduling (determining how much time is required for teleconsultations), patient confidentiality (particularly the presence of community translators and other family members in teleconsultations). Lastly, patients should be kept informed of the various options available to them, from the use of telehealth to other modes of service delivery (e.g. waiting for a face-to-face consultation at the community site, traveling to the referral site etc.). The use of telehealth should be an informed choice made by the patient.

Communities and their health teams should be aware that technology companies may be knocking on their door to sell them equipment. They should be aware of the many aspects of telehealth implementation that are not purely technical. It is important to inform community leadership on the many steps involved in the effective implementation of telehealth that can include securing the commitment of the local health team, involving other community human resources, training staff and negotiating with external service providers. Community/organizational leadership should determine how to best integrate telehealth into the current practices of health care delivery. Community leadership will need to negotiate Memoranda of Understanding (MOU) or other forms of written agreement with provincial/territorial facilities in order for infrastructure and resources to be shared with their community. Both parties have to agree to an acceptable level of service that will respond to the needs identified by the community and that is also manageable by the staff at the referral site. An agreement must be reached before moving forward with the purchase of equipment. A close relationship with the implementation team of the provincial/territorial telehealth network, if such a network is in place, is also essential for success. This relationship depends on the willingness of provincial/territorial governments, the federal government and First Nations and Inuit communities to collaborate and jointly develop their telehealth initiatives.

Most provincial governments have not set rates of reimbursement for services offered through telehealth. That is, telehealth services are not considered insured services and are, therefore, not reimbursed under provincial health care insurance plans. Governments that have agreed to reimburse telehealth services have done so on an application-by-application basis. Comprehensive telehealth fee schedules do not exist at this time. Costs of the National Project were increased because of the need to compensate specialists for services rendered to the pilot communities through telehealth. These costs cannot be sustained in the long term. As well, federal/provincial jurisdictional issues relating to health service reimbursement in First Nations communities further complicated project implementation. Of course, if salaried providers dispense telehealth services to communities then reimbursement is not an issue. This was the case in Berens River where salaried providers employed by the Northern Medical Unit of the University of Manitoba could provide additional telehealth services with no additional professional fees to take into account. Notably, Nunavut has stipulated in all contracts with health service providers that they must use telehealth to deliver health care where appropriate. Finally, health services reimbursement issues go beyond fee-for-service providers. They also relate to non-insured services such as mental health and rehabilitation services.

Project implementation timetables were difficult to maintain for a variety of reasons:

• In certain cases, the effort required to implement telehealth successfully was underestimated.
• Additional community human resources were needed. Current personnel are invested in other responsibilities. Consequently, communities have been very dependent on the contracted project officer to manage and drive the implementation process.
• Part-time project officers working on contract have other professional commitments. Because they must work at the pace of the community, they have been required to shift time lines and, when possible, rearrange their other workloads.
• Changes in project governance structures at the community level have caused some difficulties for decision-making.

The National Project has also had to deal with community events/crises that negatively impacted project timetables and successful implementation. To date, here are examples of such events: elections; resignation of nurses and other project champions; health problems of project team members; tragedies such as motor vehicle accidents, forest fires, suicides; the arrival of an early Spring and the loss of the winter/ice road; unavailability of project team members due to rodeo, blueberry picking season, vacations etc. Ergo, it is important to manage community and providers' expectations with regards to timelines.

Communities need expertise in project planning and management. Training is required for community project officers. Or, funding is required to hire external project officers. Project officers are trainers, facilitators, mediators, coordinators and, at times, advisors, but never decision-makers. If possible, project officers should be hired based on their provincial/territorial knowledge and contacts, and familiarity with the First Nations community. However, in order to build economies of scale, centralization of expertise may be considered as an alternative to each community separately contracting external consultants. The structure and organization of this centralization is a matter for ongoing discussions. Centralized activity might include negotiations for telecommunications access, equipment purchase and support, training, program management etc.

The nursing stations/health centers need a telehealth coordinator. A telehealth coordinator is a key resource to promote and operate the telehealth system. A coordinator schedules all uses of the equipment. Coordinators are trained on the basics of setting up a telehealth consultation, on operating the equipment, on establishing the outside connection and on conducting the follow-up work (documentation). It is important for more than one community health provider to be trained in the use of telehealth equipment to ensure that there is always someone able to operate the equipment in case of sickness or turnover of staff. The coordinator trains new staff members to use the equipment. This is critical since most communities face frequent staff turnover. Events can be organized by the coordinator to inform and encourage community members to use the equipment. Communities can choose to train a nurse, a Community Health Representative (CHR) or someone else as coordinator depending on who is available and interested in the position. If a non-certified health professional is selected, there may be liability and scope of practice issues to consider. Identifying community members to be trained as telehealth coordinators is a challenge. This role demands skill in a broad range of areas including clinical practice, administration, scheduling, communication/socialization (people skills), translation, information/file management.

Community leadership must be made aware that they will need to commit significant resources to the purchase of telehealth equipment and, in the case of proprietary equipment, perhaps commit to a long-term relationship with the vendor. Independent legal counsel and, if possible, independent technical expertise should be contracted during the process of negotiation with the equipment supplier. This process can be tied to capacity building at the community level: allowing community members to view demonstrations of telehealth equipment and ask questions, reflect on issues and processes, work out divergent perspectives until a consensus emerges etc. The process may also benefit the vendor who may be better prepared to address the specific needs and settings of First Nations once contracted.

The information management and information technology (IM/IT) requirements of telehealth should not be underestimated. The need for an integrated IM/IT technical support plan should be identified at the national level. The rapid introduction of new technologies and information systems cannot be supported by the current technical support infrastructure. Linkages with other health infostructure initiatives (mainly, the First Nations and Inuit Health Information System and Electronic Health Record) will allow the creation of economies of scale and prevent duplication of effort and information mismanagement.

Initial involvement of the project evaluators in the planning and implementation of the project is crucial. Project evaluators should familiarize themselves with the community sites and be encouraged to develop relationships with community teams sooner rather than later. Provisions of federal and relevant provincial/territorial privacy legislation should be respected and worked into the evaluation component of the project to the agreement of all parties involved. Ethical principles - beneficence, nonmaleficence, autonomy and justice (fairness, confidentiality, integrity, competence, dignity, respect of others) such as those applied in the National First Nations and Inuit Regional Health Surveys - should be included in the design of any telehealth research project. In most cases, an ethics review process should be undertaken. As well, professional codes of ethics and conduct should be respected.

The lack of FNIHB resources at the regional level caused some project delays. In certain cases, FNIHB regional personnel was too busy to invest the time required to participate in community telehealth projects. In regions where third level services have been transferred, there is confusion about the role of regional FNIHB personnel. The expected role of FNIHB regional offices must be further discussed.

All members of the community project team should be regularly updated by the project officer to ensure that information is shared equally among participants. Community teams should also be in contact with federal and/or national and/or provincial/territorial decision-making bodies (in the case of the National Project, the Steering Committee) to foster community ownership. When meetings of decision-making bodies are held, community teams should receive notes of these meetings. Ideally, representatives of community teams should be included in these decision-making bodies. There should be clear guidelines in the Project Accountability Framework that define under what conditions a community project can be abandoned by the funder. As well, such guidelines should define what aspects of the project will be funded and to what extent.

Telehealth is all too new to everyone involved. The lack of community precedents to learn from and the complex and technical nature of the project created obstacles to implementation. This is why it is important to share lessons learned with other communities, for instance, through workshops and conferences (e.g. Assembly of First Nations Health Conference in February 2001). As well, in the context of a larger project involving several communities, bi-annual teleconferences should be held inviting community teams from all participating communities to share their experiences (and not solely reuniting project officers).

Financial Resources

While a full-fledged feasibility study, including a cost-benefit analysis, could in itself be costly and time consuming to conduct, to do so is highly recommended because it enables local health service planners, administrators, government and/or alternative funding sources to consider the telehealth project proposal and to support funding requests.

In preparing the telehealth project proposal, be prepared to estimate the costs for each of the following items, including both one-time and ongoing costs. Ball-park estimates are also provided.

Capital costs - One Time
hardware;
telecommunications infrastructure
software; interfaces; peripherals;
facility upgrades;
one-time software licensing fees.

Non-capital costs - One Time and Ongoing
feasibility, needs analysis, process and outcome evaluation studies;
FTEs (project manager, telehealth site coordinator, technicians etc.);
office facilities and cost of meetings;
telecommunications link (monthly connection fee, rate per minute);
training and skill maintenance costs;
insurance and administrative costs;
installation costs (include facility upgrades, testing, transportation);
technical support and maintenance;
provider remuneration adjustments, service contracts with provincial health care and educational institutions.

Average funding allocations per site by major cost item (based on estimates from the National Project that do not take into account economies of scale)

Project management/Administration - $50,000
Evaluation - $10,000
Community Site Coordinator - $30,000
Technical Expertise/Support/Maintenance - $20,000
Training - $10,000
Service contracts with provincial health and educational facilities - $20,000
Office supplies - $5,000
Telecommunications (equipment if required and usage charges) - $40,000 - $100,000
Telehealth equipment - $60,000

Communities need to purchase telehealth technology (software/hardware/peripherals) to deliver the services that meet their needs. They also need to contract continued technical support and maintenance to update and to keep the equipment running. The nursing stations/health centers need space for the telehealth equipment. The room that houses the equipment must be properly designed and configured for telehealth. Funds may be required to modify rooms to comply with videoconferencing technical standards, such as lighting, paint color, sound proofing etc. In some cases, proper exterior mounts are required for the satellite equipment. Communities may need some minor capital funds for furniture for the telehealth coordinator such as a desk and a chair, no-glare meeting tables, blinds etc.

Communities need telecommunications infrastructure and bandwidth to match selected telehealth applications and the purchased telehealth equipment in order to connect this equipment from the community site to the referral/educational sites and to ensure an adequate quality of service. It is important to know what telecommunications infrastructure is available in the community before planning a budget and selecting telehealth applications. Telecommunications may be the single most expensive item of telehealth implementation in the community. Telecommunications costs can include equipment, line rentals, site preparation and usage charges (such as long distance fees). Installation and maintenance contracts for telecommunications equipment are also required.

Communities need to negotiate service contracts (MOU) with external health care providers and referral centres. These contracts need to provide for reimbursement of fee-for-service providers in cases where the provincial government does not recognize telehealth as an insured service.

The community will need to assess the impact on the local economy, especially on local transportation and accommodation facilities, of introducing telehealth (i.e. especially if a reduction in patient/provider travel is considered likely).

The community will need to estimate sustainability costs, that is, annual costs of supporting and operating telehealth (including telecommunications costs, site coordinator salary, new services planned/equipment required, evergreening plan for aging equipment).

Technical Resources

Communities are concerned that telehealth technologies are easy to use and allow for their gradual adaptation. Initial and ongoing technical support, including 24/7 telephone support and remote troubleshooting, is essential to ensure that these technologies are used correctly It is important for community users to be well trained, comfortable and supportive of these technologies.

Companies may sell telehealth equipment directly to communities without explaining the complications of connecting to health care providers. Communities can benefit from access to adequate and independent technical expertise that is helpful in negotiating with telehealth companies.

Proprietary telehealth equipment developed by various vendors is not typically interoperable. At the time of purchase, it is important to ensure that the equipment will be compatible with the equipment implemented in the sites to which you want to connect.

The request for proposals (RFP) should include a precise description of the project requirements, such as a price range for the various types of services required, a commitment to, and penalties around, fixed delivery dates, the need for training, maintenance and long-term technical support. To save time and legal fees, included in the RFP can be a contract that the selected vendor would be expected to sign with only minor modifications.

More communities are demanding access to high bandwidth telecommunications capacity as they become aware of the potential associated with this higher capacity. The usefulness of telecommunications links in other community sectors such as education, justice and economic development, is being recognized as the Smart Community model. It offers an alternative to the traditional "stovepipe" government service delivery approach. As government departments all endeavour to "connect" to First Nations communities to deliver their services electronically, the deployment of high bandwidth telecommunications will become a priority for different levels of government (federal, provincial/territorial, regional).

There is a direct relationship between the type of health service a community wishes to deliver using telehealth and the necessary bandwidth to deliver this service adequately and effectively. Although there are many technological options to deliver a broad array of telehealth services, including store-and-forward or low bandwidth telecommunications solutions, we have learned that certain applications - for example, mental health services and urgent/emergent services - are preferably not undertaken without a minimal telecommunications capacity of 384 kilobits per second. This capacity enables clarity of picture.

Telecommunications turned out to be the most expensive cost item in two of the five pilot sites of the National Project. Consequently, it had a large impact on telehealth application selection and delivery. In the future, it is recommended that telecommunications planning be part of the initial community priority setting activities and applications selection process. This will safeguard against giving community members the misleading impression that technology is not a determining factor in selecting telehealth applications.

Policy Issues

It was originally planned in the National Project that telehealth service delivery would not disturb existing referral patterns in the five communities. That is, with telehealth, patients would be connected to their usual health care providers and facilities. Notwithstanding, one pilot community decided to change the primary care referral pattern and two other communities are liaising with new facilities to complement their access to speciality services. Of course, telehealth has the potential to connect communities to wherever they may want to go, outside of existing referral patterns. We can anticipate that, in time, more communities will choose to go where the expertise is available to meet their needs. In such cases, FNIHB's Non-Insured Health Benefits' (NIHB) travel policy would be affected.

Are communities expected to reallocate savings that might be incurred from reduced patient travel to sustained funding of telehealth? Or, can communities reallocate these savings to other health related activities, such as increasing nursing staff?

Telehealth will incur increased costs in NIHB Allied Health Services, more specifically in mental health, home care and rehabilitation services. Questions remain as to whether provinces will agree to fund diabetes and other forms of patient education using telehealth, as to whether dental therapy can be delivered using telehealth and as to whether telehealth will dramatically impact the delivery of other NIHB Allied Health Services.

Telehealth companies are interested in establishing partnerships with the federal government to provide technological infrastructure to communities. It is important for FNIHB to develop a clear mandate and strategy to deal with potential private sector partners. Telecommunications companies also wish to partner with FNIHB to provide remote community connectivity. FNIHB will need to review these offers and develop a larger health infostructure strategy that considers the needs of all its current and potentially future initiatives (i.e. the First Nations and Inuit Health Information System, telehealth and electronic health records). In addition, a number of other federal departments are considering the joint delivery of telecommunications solutions to mutually benefit from these connections (i.e. the Connecting Aboriginal Canadian strategy led by INAC).

It is important for FNIHB to examine the impact of telehealth on current nursing practice, especially on training, support, recruitment, retention, liability and scope of practice. FNIHB and provinces are dealing with a constant staff turnover and shortage of nurses. Telehealth can potentially improve nurse retention by addressing some of the difficulties experienced by health providers working in remote areas: lack of support, isolation and lack of continued training opportunities.

It is important for FNIHB to review the socio-economic benefits of earlier diagnoses and improved continuing care made possible through telehealth, such as savings in lost employee productivity.

In order to leverage knowledge, to build economies of scale and to increase the likelihood of success, FNIHB may wish to focus on dealing with "across the board" community health crises (such as respiratory disease or diabetes) if/when implementing telehealth on a larger scale. It may wish to determine how telehealth can contribute to the standardization of care and to the support of health needs in areas such as home care, diabetes management, mental health and continuing education.

It is important for FNIHB to review potential sources of future funding once the National Project is completed, particularly if the evaluated cost-consequence ratio is deemed satisfactory by communities and FNIHB. Of course, ultimately, communities must be allowed to choose whether they wish to use telehealth if it becomes an ongoing FNIHB program. A funding model for sustainable telehealth programs needs to be developed that details what items are funded by federal (national or regional offices) and provincial/territorial governments, partnerships with the private sector, research and educational institutions, or other sources. It is also important to determine whether funding should be earmarked for certain activities (needs assessment/community consultation, evaluation etc.).

Does the implementation of telehealth imply that provinces are to provide insured services on-reserve, the current responsibility of the federal government? While the Canada Health Act may warrant this shift in responsibility, will provinces view telehealth as an increased cost to their health care delivery systems? It is important for FNIHB to review the impact of telehealth on cross-jurisdictional issues, specifically the potential negative impact on FNIHB regional funding envelopes.

Legally, the Canada Health Act provides for universal access to health services for all Canadians. Knowing this, is FNIHB obligated to implement telehealth since it has the potential to even out geographical disparities in access to health services?

Until telehealth equipment is standardized and made interoperable, equipment vendor monopolies established by provincial/territorial telehealth networks can greatly restrict First Nations and Inuit communities from connecting to each other and participating in joint initiatives. These monopolies force them to adhere to the provincial/territorial network standard, a standard that generally centralizes expertise in tertiary - and, at times, secondary - care centres. This trend goes against community capacity-building. As well, if provinces/territories decide to change vendors or upgrade equipment, will FNIHB grant the funds required to keep pace with these network modifications? In cases where provincial/territorial telehealth networks have not yet been implemented, does FNIHB wait to see what will be implemented prior to undertaking a telehealth project in First Nations and Inuit communities within those provinces/territories to ensure compatibility down the road?

Furthermore, it is important to consider the dilemma of who will be responsible for establishing in First Nations and Inuit communities links to provincial/territorial health and educational facilities. What cost-sharing mechanisms can be developed? For instance, the La Romaine community participating in the National Project was denied the subsidization of its telecommunications link to the Quebec telemedicine network (RTSS) because its telehealth project was a federal initiative and not a provincial one. First Nations and Inuit communities have, as of yet, been excluded from this network.

As well, provincial/territorial health information and/or telehealth networks may have developed their own processes for tracking system usage and evaluation. These processes must be taken into account in the implementation of telehealth in First Nations and Inuit communities since they raise issues of ownership, control and access to health research and information.

In conclusion, clearer models of federal/provincial/territorial cooperation should be constructed to guide telehealth implementation in First Nations and Inuit communities. Cooperation will result in cost savings and greater efficiencies in health service delivery.