October Issue, Canadian Healthcare Technology

Telehealth agencies strive to turn their services into mainstream medical offerings

Like old soldiers, Canadian telehealth isn’t dying, but rather slowly fading away – as many of its proponents fervently hope. In at least three of the geographically largest healthcare jurisdictions championing it, there’s growing evidence that telehealth is simply morphing into better, wider-spread healthcare.

“Our vision is to make telemedicine a mainstream part of healthcare,” says Dr. Ed Brown, the chief executive officer of the Ontario Telemedicine Network (OTN). “We’re not there yet, but last year (2011) we had a 50 percent growth in the number of telehealth consultations and this year the rate is even more accelerated.”

And Ontario is not alone in its aim to make telehealth ubiquitous. Manitoba’s fledgling 21-site telehealth network of a decade ago has burgeoned to serve 124 locations province-wide today.

“We’re a large province with a small population that’s widely dispersed outside of Winnipeg; so that helped telehealth to really take off here in Manitoba,” says nurse Liz Loewen, now the director of coordination of care for Manitoba eHealth, overseeing the MBTelehealth program. “But now that telehealth is well established here, what we are pursuing is convergence of telehealth with the other tools of healthcare, such as the eChart Manitoba solution, our provincial electronic health record that we also have in place.”

Meanwhile in Quebec, a province where government was initially slow in spurring on telehealth, remote access initiatives have surged in the last few years, and now stretch from the suburbs of Montreal all the way up to native villages of the sub-Arctic.

A May telehealth conference in Montreal this year attracted over 200 care providers associated with McGill University’s Réseau Universitaire Intégré de Santé (RUIS) network. At the meeting, presenters offered a cornucopia of telehealth success stories for a vast region of western Quebec serving 1.8 million people.

The far-flung RUIS network spans nearly two-thirds of the province, running from West Island Montreal, skirting by Ottawa through the Outaouais region, on up to Abitibi-Temiskaming, ending ultimately at Hudson Strait and the Nunavik health region at the very tip of northern Quebec.

In that northerly sweep, RUIS, through the co-ordinating efforts of McGill’s Telehealth Office, links seven regional health authorities and 19 community care access centres with expert clinical, research and administrative staff at four partner Montreal teaching hospitals: McGill University Health Centre, Jewish General Hospital, St. Mary’s Hospital Centre, and the Douglas Mental Health University Institute.

“For almost a decade, RUIS has been a network in action, helping to improve access to healthcare, develop learning opportunities, promote training, and increase services and expertise in telehealth, says Dr. David Eidelman, the RUIS’s recently appointed president as well as McGill’s Dean of Health Affairs.

Moreover, this RUIS link-up is multi-lingual. English and French, bien sûr, but also RUIS telemed interpreters can understand what Cree patients are saying and also what a Nunavik elder might be explaining in difficult-to-learn Inuktitut.

RUIS’s multilingualism reflects the McGill University Telehealth Office’s mandate to implement a sustainable, multipurpose telehealth infrastructure. Some of its initiatives were trumpeted at the May conference:

• a nursing best-practices partnership involving the remote collaboration of six health jurisdictions

• three tele-ophthalmology initiatives screening for diabetic retinopathy, including one Health Canada-supported program for First Nations communities

• gynecology and obstetrics telemedicine partnerships linking the Rouyn-Noranda and Temiskaming regions, and a similar initiative for Nunavik

• a telehealth eating disorder consultation service, available at 11 sites on the RUIS network

• a three-region collaborative providing remote clinical supervision by “nurse navigators” in cancer and palliative care

• a remotely accessible “Cyber Learning” centre for professional mental health care givers hosted by the Douglas Institute

• other telehealth initiatives involving: dashboards and performance indicators; home telemonitoring of chronic disease patients; pediatric telecardiology and nephrology care; as well as virtual ambulatory and rehab clinics.

A very wide gamut, in other words, of regular healthcare.

Concludes Yves Bolduc, Quebec’s former Minister of Health and Social Services – somewhat bureaucratically but accurately: “By closely linking front-line support with specialized leading-edge care, research, training and practice, RUIS networks have achieved remarkable results. The RUIS structure has clearly led to new forms of co-operation and encourages the optimization of resources and state-of-the-art expertise.”

Perhaps nowhere in the world is telehealth more state-of-the-art than at OTN in Ontario.

“We’ve had a long history in our premier service of using leading-edge technologies such as videoconferencing and medical devices like hand-held exam cameras and digital stethoscopes that improve access and reduce travel, particularly for rural areas,” says OTN’s CEO Dr. Brown. “But more recently one of the really exciting developments for us is store-and-forward technology.”

And first out of the gate to use store-and-forward on the OTN have been dermatologists, referring physicians and their patients.

“If someone comes to their primary care provider with a funny rash or mole and needs a dermatology consultation, then the local physician can take a bunch of pictures, add some clinical information and send it all off to the dermatologist,” explains Dr. Brown. “That allows the dermatologist to find the time for full consideration of the case and send back a thorough diagnosis and treatment plan. That’s become very popular and we now have 250 referring physicians using the service.”

Based on that success, OTN is now planning similar store-and-forward services, the first for remote ophthalmology using locally snapped pictures of a patient’s retina that are then sent off to eye specialists. For the health of Ontarians, this is more than a nice-to-have.

“The eye and those retinal pictures can virtually tell a patient’s whole health history,” says Dr. Brown. “And it’s amazing how much pathology is being discovered this way for people who don’t have regular eye exams, particularly for diabetics.”

That’s one more example of a telehealth technique dissolving into the mainstream of chronic disease care.

It’s ironic that the same video-conferencing technology which spawned this kind of consultative telehealth is also one of the barriers to its expansion. The cost of its cameras, monitors, and high-speed links, as well as its need for a dedicated “studio” means that such telehealth can’t be deployed everywhere.

Enter Vidyo.

“Vidyo is our attempt to roll out a less expensive, PC-based video conferencing system,” explains Dr. Brown. “And we have close to 100 physicians now doing their video conferencing using the Vidyo application at their desktops. Also, we will be rolling Vidyo into a telemedicine portal which will make it not only available to physicians’ own computers but on their mobile devices, as well. That should be out to them this Fall.”

It’s yet another effort to make telemedicine mainstream, says Dr. Brown: “We want to keep making it simpler, easier to access, and less expensive. And most importantly, make sure that the service integrates readily into a physician’s workflow.”

Workflow was also top-of-mind, adds Dr. Brown, when OTN released this year its Telemedicine Directory: “The directory is a place where you can find consultants; see what they do and what sort of patients they would accept; and therefore make it simpler to organize your care.”

Similarly, OTN is releasing a Site Finder so that if a physician has a patient in a small community, the doctor can readily find the closest site that will accept the patient for a telemedicine appointment.

To help such remote doctors keep up their skills the OTN last year launched its first mobile app, dubbed the Learning Centre. “Right on your iPhone or other mobile device you can find the education event or courses nearest you that you want to attend or take,” says Dr. Brown. “You can also ask the Learning Centre to send you alerts. So if you are interested in cardiology, it will automatically email you the details as soon as the details of that cardiology event are made public.”

That service is also helping OTN move into the mainstream of medical education.

“We had 13,000 medical education events of one kind or another last year,” says Dr. Brown, “and the growth in those events was stimulated partly by the technologies we added to our education services, including multi-point video conferencing, live webcasts over the internet that can also be archived and watched later. We also added web conferencing, so anyone on our network who wants to can run live webinars for whoever wants to join them.”

These initiatives and others have made OTN grow every year.

“Our membership now includes over 300 community mental health agencies, over 100 family health teams, almost 100 long-term care facilities, and a number of native communities who have all set up OTN studios within their walls,” says Dr. Brown. “In all we have 1,500 physical “sites” as we call them on the OTN, but that number becomes less relevant as we move into store-and-forwarding as well as into mobile applications. On the videoconferencing side, we now have 2,800 platforms that have gone to the network. We also link with two other telehealth networks in northern Ontario that service the communities without roads stretching right up to Hudson’s Bay.”

With a large territory to cover, Manitoba has also seen financial benefits for government and for patients .

Distance is a challenge in Manitoba,” says Manitoba eHealth’s Liz Loewen. “Our recent benefits evaluation work demonstrated that in 2010-11 in terms of travel avoidance, our telehealth system saved about $2.6 million dollars in patient travel.”

In an example of telehealth becoming a more mainstream tool, says Loewen, Manitoba eHealth cited the work of the Manitoba Adolescent Treatment Centre and the psychiatric services it offers: “They’ve been working with youth living in northern and remote locations who are presenting in a crisis. In the past they would be transported south, maybe escorted by the RCMP or healthcare staff. But by time they get to an urban treatment centre, often the crisis has passed and they are judged no longer eligible for care at that centre. So they are returned back.”

Now through videoconferencing a rapid assessment of the patient and crisis can be made by remote experts working with local care providers – they can together determine whether the youth in crisis really needs to be transported out of the community. And if not, the remote specialist can help plan and monitor the care to be executed in the home community.

In 2011, Manitoba eHealth and the other care agencies involved in the program won a “service excellence” award from the provincial government for their efforts.

It’s an example of how Manitoba eHealth is integrating telehealth with mainstream care.

“We’re moving towards using technologies that are lower-cost, easy to use, mobile, and readily integrated into caregivers’ workflows,” says Loewen. “And oncology is certainly one of our biggest activities on the network. CancerCare Manitoba supports chemotherapy sites across the province. So we have telehealth technology in place at those sites to help address individual patient complications. That means patients can not only get their therapy but they can also see their specialists at the same time, and without an extra trip into Winnipeg.”

As in Ontario and Quebec, Manitoba is also using its telehealth network to lessen administrative burdens and to provide educational opportunities for its remote care-givers. Though it only uses up a small portion of network time, Loewen says the most heart-warming telehealth service her organization provides is its tele-visitation service: “We treat a lot of patients who are flown in from Nunavut in the far north. There’s actually a residential centre for them here in Winnipeg. So we have worked with Nunavut to put telehealth in that residence so patients can connect back home either to their primary care provider and to family and friends. And that’s hugely helpful, not only psychologically but when important decisions have to be made about their care, they need the support and wisdom of those back home.”