HTF 402 National First Nations Telehealth Research Project

Project Outcomes

2. Critical Success Factors

From the many lessons learned, it is possible to extract a list of Critical Success Factors for future potential telehealth implementation in First Nations and Inuit communities.

Project Area

• Community
  • Critical Success Factors
    • attainable expectations
    • informed
    • readiness
    • stable governance and nursing services


• Funding
  • Critical Success Factors
    • comprehensive
    • sustained


• Management
  • Critical Success Factors
    • decentralized
    • needs-based
    • local champion
    • evaluation criteria considered at outset
    • targeted performance goals (preferably quantified)
    • effective change management
    • effective time management
    • effective project management at the community level
    • communications strategy
    • access to technical expertise
    • training/capacity building


• Health Care/Educational Practice
  • Critical Success Factors
    • comprehensive provincial reimbursement of telehealth services provided by fee-for-service practitioners
    • formal agreements (MOU) with referral and educational centers
    • resolution of liability, licensing, accountability and insurance issues
    • standardized practice protocols and clinical guidelines
    • compliance with academic standards/curricula and accreditation
    • interprovincial licensing agreements
    • evaluations of clinical and educational efficacy
    • legal and technical provisions for privacy and confidentiality
    • ethics review
    • periodical training and 24/7 technical support for telehealth users


• Technology
  • Critical Success Factors
    • user-friendliness
    • ongoing technical support
    • security mechanisms
    • interoperable, plug-and-play solutions
    • access to the required bandwidth
    • telecommunications planning at the outset
    • sufficient testing and demonstration period


• Policy
  • Critical Success Factors
    • flexibility/choice in referral patterns
    • harmonization of F/P/T initiatives
    • positive evaluations of telehealth
    • federal coordination of non-insured health benefits/telehealth policies

3. Evaluation Outcomes

All findings of the evaluation - including detailed case studies of each community project - are documented in the Final Evaluation Report attached in Appendix A. These are summarized below according to the main research questions raised during the evaluation.

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.

4. Recommendations

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 Strategic Plan and a Costing Model (cost assumptions and estimates). The Strategic 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 Strategic 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 Strategic 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 Strategic 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.