Lessons learned from early telehealth deployments

Since many initiatives in the early days of telehealth didn't survive after financing ran out - a hard lesson that telehealth enthusiasts have learned - its proponents have had to revise their approach to implementing telehealth."We have had many telehealth projects," says Patricia Dwyer, a registered nurse and program manager for telehealth at the Newfoundland Centre for Health Information in St. John's NL. "Most of the projects were supported through research funding. Projects received a set amount of dollars, and dollars were finite. There was a lot of start and stop with projects."Earlier this year, Dwyer delivered the keynote address at Telehealth 2007, a conference organized by the International Association of Science and Technology for Development. In a subsequent interview with Network Letter, she described Newfoundland and Labrador's current experience with telehealth, its history in the province, and the current telehealth landscape in Canada."Everyone had sustainability attached to what they were doing," says Dwyer. "For all of those projects, a component of what they were doing was that they were supposed to be sustainable. We know that a number of those projects ended when the funding ran out."Dwyer says actors in telehealth across the globe have found common ground in sharing experiences in the pioneering years in telehealth or telemedicine. Most telehealth initiatives began as research pilot projects that were dependent on special financing from ad hoc organizations. Part of the mandate of the projects was that they become sustainable through finding permanent funding sources beyond the life of their pilot stage.Newfoundland and Labrador has a rich telehealth history, including the use of distance health education using microwave technology in 1976 and a teleradiology trial in 1980 using slowscan television. In the 1990s, the province launched the Hibernia Offshore Telemedicine Project."We had to find ways to move the projects forward, so that they part and parcel of the healthcare process," notes Dwyer. "We can now implement telehealth within the regions of the province. Telehealth is now integrated into everyday practice."What planted the seeds of telehealth in Canada and internationally were projects in areas such as the military or space travel, where great minds were experimenting with technology to provide healthcare in very remote places, she explains."Part of the goal of developing telehealth in specialized areas such as space travel was to transfer the knowledge into everyday activity in healthcare," says Dwyer. "The initial experiments involved places far more remote than what we are focused on in Canada."The birth of the Newfoundland Centre for Health Information saw the development of a governance model for telehealth to ensure it was implemented across the province in a coordinated manner, through the enhancement and expansion of existing services, and deployment of new telehealth applications. The centre was given a mandate to oversee the advancement of telehealth in the province in conjunction with regional health authorities. A strategy was developed in 2005 with a focus on chronic disease management and access to specialists and specialty services. Oncology, mental health, nephrology, neurology, and diabetes prevention are now available through telehealth in the province. The federal government began to show its long-term commitment to telehealth by creating Canada Health Infoway (CHI), an agency with a mission to fund sustainable telehealth projects and oversee the development and expansion of the electronic health record throughout the country. Consequently, the actors in telehealth now can turn to the federal government, through a source such as CHI, and secure matching funds from their provincial government.Still, proponents of telehealth in Canada have had to overcome other obstacles apart from obtaining startup and operating funds to move telehealth forward. Those obstacles have included reimbursement, the existence of adequate telecommunications infrastructure, as well as privacy, confidentiality, and security, notes Dwyer. However, the obstacles aren't unique to Canada, but they have existed in other countries that have attempted to implement telehealth, adds Dwyer.The Canadian Medical Protective Association (CMPA), which provides legal defence for 95% of physicians in Canada, has required that physicians need a licence in the province where the patient is situated when providing telehealth. For instance, a physician in Newfoundland performing a telehealth consultation with a patient in Ontario requires an Ontario medical license to practice. With the goal of advancing telehealth, advocates have worked with the CMPA to develop restricted medical licenses for the purposes of physicians able to provide telehealth consultations between provinces, according to Dwyer. "Privacy health assessments will have to be ongoing," she says. "We will have to look at the risks with access to information." Future goals of the telehealth program in Newfoundland include integrating telehealth in primary care and expanding the use of the electronic health record in the province. One of the major successes with telehealth in Newfoundland includes the Picture Archiving Communications Systems (PACS). Implemented about five years ago, PACS involves computerized management and distribution of diagnostic images such as x-rays, computerized tomography, and magnetic resonance imaging. Diagnostic images are incorporated into PACS in either one of two ways: digital-ready diagnostic imaging equipment directly creates a digital image; or, images are produced in the traditional manner and converted to a digital format by scanning. For example, conventional x-ray equipment produces pictures that are later scanned into digital format and incorporated in the PACS. The technology greatly improves access to diagnostic imaging services in rural areas by sending the images electronically to principal sites where a radiologist is present, notes Dwyer. "Everyone knows what the PACS system is and how it works. To expand a program like PACS, we need to ensure the bandwidth is there," she adds. Improved telehealth services with greater availability allow a patient to avoid travel, particularly distances, and participate in a telehealth consultation. "What we are finding is that it's the patient's preference not to travel," says Dwyer. "With telehealth more integrated in practice, a rapport that exists in a face-to-face environment can be developed in a telehealth setting."The implementation of multi-disciplinary care is a facet of telehealth, so that it isn't a strictly physician-driven model. The result is more cohesion in its delivery to patients, stresses Dwyer. "We can't just focus on the physicians," she says. "We have built relationships with pharmacists, nurses, rehabilitation specialists, and others, so that there is a collaborative work environment and team work is a guiding principle."

Lessons learned from early telehealth deployments

News | July 6, 2007

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