Ebook: Global Telehealth 2015: Integrating Technology and Information for Better Healthcare

Global Telehealth 2015 (GT2015) was hosted by COACH: Canada's Health Informatics Association, taking place in Toronto, Canada during May 29–30, 2015. This was the 4th International Conference in the series, which was initiated in 2010 by the Australasian Telehealth Society. The conference series has now matured to the point where it has become an annual event from this year, and a precedent has been set of locating the conference in alternate hemispheres. A total of 25 full length technical papers were accepted for publication in this volume from those originally submitted, as the highest ranked by an international expert reviewer panel of 21 Health Informatics academics and practitioners from 7 countries. We trust this compilation will prove informative and useful in both the Telehealth and wider eHealth domains.

Developments in Telehealth in the recent months and years have demonstrated a growth in adoption, a diversification in service delivery and a broadening of access, all pushing the boundaries of traditional healthcare. The cultural and socio-economic factors are progressively aligning to support successful clinical adoption. Technologies for delivery of Telehealth are increasingly well established and diverse, whether in the form of instantaneous interpersonal communications, or as captured information transmitted for later attention. Workflows and models of care incorporating Telehealth are widely developed and successfully demonstrated in numerous rural, remote and urban healthcare settings around the world.

Additionally, we see some prominent new elements arising in Telehealth today, which offer the potential to further the broadening and integrating of the application of Telehealth. The strongest related trend is the growth of Mobile Health (mHealth), with pervasive access to information and communication services now achievable through personal devices such as tablet computers and smartphones. Closely related is the explosion in the personal and home health monitoring market, enabling the monitoring and tracking of individuals to achieve a “quantified self”, providing value added and enriched datastreams for preventive health and chronic disease management.

Another interesting trend impacting on the future of Telehealth is the emergence of “virtual healthcare” services, using online interactive environments to engage with the subject of care which remotely enable or mimic the desired patient-clinician direct relationship. These can be variously provided by virtual clinics, by anonymous interactions or by agents such as dialogue engines or avatars. In areas where patient personal sensitivity may compromise access to conventional care, such as mental health or youth social issues, provision of these types of services via health portals is increasingly gaining traction.

These new and integrated realms of mobile, personal and virtual are opening up the Telehealth worlds, to serve the patient's health and care while ensuring the evidence of clinical benefits and business efficiencies are well established. The factors that support such adoption in our countries, the technologies that are at the cutting edge and the use of Telehealth to extend the reach of health care, collectively reinforce the Global Telehealth 2015 theme of “Serving the Underserved: Integrating Technology & Information for Better Healthcare.” Our global healthcare community, through the leadership and knowledge reflected in these papers, will benefit in the equity of access and uniform provision of healthcare services and influence health policy and strategy decisions worldwide.

Telehealth, in the integrated and broad sense identified above, will continue to contribute directly and comprehensively towards achieving these ideals. In settings where very diverse demographics and population distribution occur, Telehealth has played a leading role in addressing such needs, and the GT2015 host country Canada provides numerous benchmark examples of how such goals can be attained. On behalf of COACH and our Canadian Telehealth Forum we hope that the knowledge shared at GT2015 and this Canadian and international leading thinking will further the discussions and collaboration and lead to breakthroughs in serving the underserved and integrating technology and information for better healthcare.

Don Newsham and Grant Gillis

COACH: Canada's Health Informatics Association, Canada

Anthony J. Maeder

University of Western Sydney, Australia

Over the past 50 years, survival for children in high-income countries has increased from 30% to over 80%, compared to 10-30% in low and middle income countries (LMIC). Given this gap in survival, established paediatric cancer treatment centres, such as The Hospital for Sick Children (SickKids) are well positioned to share clinical expertise. Through the SickKids Centre for Global Child Health, the SickKids-Caribbean Initiative (SCI) was launched in March 2013 to improve the outcomes and quality of life for children with cancer and blood disorders in the Caribbean. The six participating Caribbean countries are among those defined by the United Nations as Small Island Developing States, due to their small size, remote location and limited accessibility. Telemedicine presents an opportunity to increase their accessibility to health care services and has been used by SCI to facilitate two series of interprofessional rounds. Case Consultation Review Rounds are a forum for learning about diagnostic work-up, management challenges and treatment recommendations for these diseases. To date, 54 cases have been reviewed by SickKids staff, of which 35 have been presented in monthly rounds. Patient Care Education Rounds provide nurses and other staff with the knowledge base needed to safely care for children and adolescents receiving treatment. Five of these rounds have taken place to date, with over 200 attendees. Utilized by SCI for both clinical and non-clinical meetings, telemedicine has enhanced opportunities for collaboration within the Caribbean region. By building capacity and nurturing expert knowledge through education, SCI hopes to contribute to closing the gap in childhood survival between high and low-resource settings.

Cardiac rehabilitation programs (CRP) are medically supervised, multidisciplinary programs that provide secondary prevention aimed at addressing risk factors and improving lifestyle behaviours for patients following an acute cardiac event. CRPs have been demonstrated to be a cost-effective and evidence-based mechanism to improve patient outcomes, but despite the known benefits of these programs, uptake remains poor. Poor attendance has been linked to many factors, but geographical accessibility is a key concern, since many CRPs are limited to hospitals in urban areas. The widespread availability of the Internet has made it possible to provide virtual health services to populations that may have previously been hard to access. This paper examines the qualitative findings from a 16-month mixed methods randomized controlled trial examining the impact of a virtual CRP (vCRP). The vCRP was revealed to be an accessible, appropriate, convenient and effective way to deliver cardiac rehabilitation services, with patients experiencing both clinical improvements and a high level of satisfaction. To understand the experience of patients undertaking the vCRP, semi-structured interviews were undertaken with a purposive sample of 22 participants. An analysis of the qualitative interviews revealed that the vCRP improved participants' access to healthcare professionals, supported them to make healthy choices, and enhanced feelings of accountability due to greater surveillance. Barriers to participation, such as computer literacy, and general perceptions of a vCRP were also examined. Further investigation into the use and long-term effectiveness of virtual programs across a broader range of healthcare settings is warranted, particularly in those with multiple chronic diseases and those located in rural and remote communities.

Chronic pain is a prevalent and serious problem in the province of Ontario. Frontline primary care providers (PCPs) manage the majority of chronic pain patients, yet receive minimal training in chronic pain. ECHO (Extension for Community Healthcare Outcomes) Ontario Chronic Pain & Opioid Stewardship aims to address the problem of chronic pain management in Ontario. This paper describes the development, operation, and evaluation of the ECHO Ontario Chronic Pain project. We discuss how ECHO increases PCP access and capacity to manage chronic pain, the development of a community of practice, as well as the limitations of our approach. The ECHO model is a promising approach for healthcare system improvement. ECHO's strength lies in its simplicity, adaptability, and use of existing telemedicine infrastructure to increase both access and capacity of PCPs in underserviced, rural, and remote communities.

Evidence supporting the use of remote patient monitoring (RPM) as a cost-effective means of keeping patients from being re-admitted to hospitals or making repeated emergency department visits is growing, especially for the treatment of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). A recent study funded by Canada Health Infoway, titled Connecting Patients with Providers: A Pan-Canadian Study on Remote Patient Monitoring, aimed to assess the current state of RPM solutions; to examine the evidence for patient and health system benefits achieved both in Canada and internationally; and to determine the critical success factors needed to support further investment and scaling-up of RPM solutions across the Canadian health care system. Break-even analysis of four different implementations reviewed in this study demonstrated that RPM programs can be viable and sustainable for large and small jurisdictions; however, more evidence is needed with regards to a number of potential applications for RPM beyond the management of COPD and CHF.

In this case study, based on six criteria, four Chinese hospitals were chosen from a national sample to showcase, through content analysis and in-depth interviews, the best practices of serving patients online. The extensive findings have addressed the following three questions: what these hospitals have in common in their Web development, what problems and challenges they are facing, and how they have excelled in serving their patients online. The study concludes that, like larger hospitals, smaller hospitals can also excel in creating an outstanding Web site to serve their patients so long as they truly care about their patients, have a clear vision and strong expertise in IT development. The study also concludes that Chinese private hospitals can learn from these state-owned hospitals in establishing a good reputation through professional and responsible interaction with patients. The four hospitals studied may shed light on the Web development in many other Chinese hospitals that are going through the same healthcare new media adoption. The findings from this study can also help Chinese hospitals form their visions in serving patients online.

Electronic consultation can improve access to specialist care. However, specialists have been identified as less likely to adopt electronic solutions in clinical settings. We conducted an online survey to explore the perspectives of specialists who use the Champlain BASE eConsult service in Eastern Ontario, Canada. Specialists were asked their opinions on experience with the service, their current consult/referral practices, recommendations for change and expansion of the service, and compensation models. We tabulated descriptive statistics from the multiple choice and Likert scale responses and performed a content analysis with an emergent code strategy for open-text responses. Specialists (n=34, 77% response rate) agreed that the Champlain BASE eConsult service is a feasible way to improve access to specialist care (94%), improves communication between specialists and primary care providers (PCPs) (94%), has educational value for PCPs (91%), and is user friendly (82%). A majority of specialists (88%) felt the service should be expanded provincially and 67% felt it should allow specialist-to-specialist consultation. 88% of specialists agreed that the current compensation process is best. This study provides an in-depth look at the perspective of the specialist physicians who use the Champlain BASE eConsult service. Specialists stated specific recommendations for change that will allow us to ensure the service remains sustainable.

Decades of war, social problems and poverty, have led large number of Afghan youth aged between 18-25 years suffering from mental health problems. Other important contributing factors include extreme poverty, insecurity, and violence and gender disparities, contributing to worsening mental and emotional health conditions in the country. The reported project is designed to strengthen the health system for improving mental health services in the province of Badakshan by improving awareness in the community and empowering frontline health workers. The project uses technological innovations, in combination with traditional approaches, to reduce stigma, enhance capacity of health providers and improve access to the specialist. The project also focuses on skills development of health providers, and empowering them to provide quality mental health services through access to interactive protocols, Management Information system and telemedicine.

This paper addresses the role of international telemedicine services in supporting the evacuation procedures from Cape Verde to Portugal, enabling better quality and cost reductions in the management of the global health system. The Cape Verde, as other African countries, health system lacks many medical specialists, like pediatric cardiologists, neurosurgery, etc. In this study, tele-cardiology shows good results as diagnostic support to the evacuation decision. Telemedicine services show benefits while monitoring patients in post-evacuation, helping to address the lack of responsive care in some specialties whose actual use will help save resources both in provision and in management of the evacuation procedures. Additionally, with tele-cardiology collaborative service many evacuations can be avoided whereas many cases will be treated and followed locally in Cape Verde with remote technical support from Portugal. This international telemedicine service enabled more efficient evacuations, by reducing expenses in travel and housing, and therefore contributed to the health system's improvement. This study provides some evidence of how important telemedicine really is to cope with both the geography and the shortage of physicians.

Cardiac rehabilitation (CR) is essential for secondary prevention, yet only 10%-30% of eligible patients attend as geographical proximity is a major barrier. We evaluated a ‘virtual’ CR program (vCRP) delivered by the Internet to patients in small urban and rural areas. In our study, in-patients (n=78) with acute coronary syndrome or post-revascularization were randomized to usual care (UC) or vCRP. The vCRP was a four-month program that included heart rate monitoring; physiologic data capture; education sessions; ask-an-expert sessions; and chat sessions with a nurse, exercise specialist and dietitian. Participants were assessed at baseline and four months, and followed for another 12 months. The primary outcome was change in maximal time on the treadmill stress test (MTT) between groups adjusted for age, sex, diabetes status and Internet use for health information. The vCRP resulted in a greater increase in MTT by 45.7 seconds (95% CI: 1.0, 90.5) compared to usual care (p=0.045). Cholesterol levels and dietary quality improved in the vCRP compared to the UC group. Participants perceived the vCRP to be an accessible, convenient and effective way to received healthcare. Eleven (30%) and 6 (18%) participants in the UC and vCRP groups, respectively, had cardiovascular-related events (p=0.275). In conclusion, the vCRP was safe and effective and resulted in sustainable risk reduction without the requirement of face-to-face visits and directly monitored exercise.

Excessive wait times and poor access to care are among the most significant problems facing health care service delivery in Canada and beyond. We implemented the Champlain BASE eConsult service in the region of Ottawa, Canada to increase access to specialist care. We have collected ongoing utilization data and provider surveys over a three year period, providing a unique opportunity to explore the economic aspects of this multispecialty eConsult service. This is an economic evaluation from the perspective of the payer: the Ministry of Health and Long-Term Care of Ontario. All eConsults submitted during April 1, 2011 to March 31, 2014 were included. We attributed cost savings only to those cases where an eConsult led to the avoidance of a face-to-face specialist visit. A total of 2606 eConsults directed to 27 different speciality groups were included. In 40.3% (n=1051) of cases processed, a face-to-face specialist visit was originally planned but avoided as a result of eConsult, while 29% led to a referral. The estimated cost per eConsult for Years 1, 2, and 3 were $131.05, $10.34, and $6.45 respectively. Results from a sensitivity analysis project that the eConsult service will break even once we reach 7818 eConsults. This is one of the first studies to examine costs across a multispecialty eConsult service. We saw a marked decrease in the cost per eConsult over each annual period. Future research is needed to identify and examine similar outcomes that may lead to cost savings.

Access to specialist care is a point of concern for patients, primary care providers, and specialists in Canada. Innovative e-health platforms such as electronic consultation (eConsultation) and referral (eReferral) can improve access to specialist care. These systems allow physicians to communicate asynchronously and could reduce the number of unnecessary referrals that clog wait lists, provide a record of the patient's journey through the referral system, and lead to more efficient visits. Little is known about the current state of eConsultation and eReferral in Canada. The purpose of this work was to identify current systems and gain insight into the design and implementation process of existing systems. An environmental scan approach was used, consisting of a systematic and grey literature review, and targeted semi-structured key informant interviews. Only three eConsultation/eReferral systems are currently in operation in Canada. Four themes emerged from the interviews: eReferral is an end goal for those provinces without an active eReferral system, re-organization of the referral process is a necessity prior to automation, engaging the end-user is essential, and technological incompatibilities are major impediments to progress. Despite the acknowledged need to improve the referral system and increase government spending on health information technology, eConsultation and eReferral systems remain scarce as Canada lags behind the rest of the developed world.

Telehealth pilot projects and trial implementations are numerous but are often not fully evaluated, preventing construction of a sound evidence base and so limiting their adoption. We describe the need for a generic Telehealth project evaluation framework, within which evaluation is undertaken based on existing health systems performance indicators, using appropriately chosen measures. We provide two case studies explaining how this approach could be applied, in Australian and Canadian settings. It is argued that this framework type of approach to evaluation offers better potential for incorporating the learnings from resultant evaluations into business decisions by “learning organisations”, through alignment with organisational performance considerations.

Telehealth and telemedicine are increasingly becoming accepted practices in Asia, but challenges remain in deploying these services to the farthest areas of many developing countries. With the increasing popularity of universal health coverage, there is a resurgence in promoting telehealth services. But while telehealth that reaches the remotest part of a nation is the ideal endpoint, such goals are burdened by various constraints ranging from governance to funding to infrastructure and operational efficiency.

Objectives: enumerate the public funded national telehealth programs in Asia and determine the state of their governance and management.

Method: Review of literature, review of official program websites and request for information from key informants.

Conclusions: While there are national telehealth programs already in operation in Asia, most experience challenges with governance and subsequently, with management and sustainability of operations. It is important to learn from successful programs that have built and maintained their services over time. An IT governance framework may assist countries to achieve success in offering telehealth and telemedicine to their citizens.

Background: The Ontario Telemedicine Network's Telehomecare initiative brings together specially trained clinicians and technology to coach patients with COPD and/or heart failure to monitor vital signs and manage their health at home.

Objectives: To evaluate pre- and post-enrollment and post discharge data captured by Telehomecare host William Osler Health System (WOHS).

Outcomes: Results demonstrate a 46% reduction in emergency department use and a 53% reduction in hospitalizations post-enrollment compared to pre-enrollment. Average length of stay (LOS) dropped by 25% of a day compared to pre-enrollment. In addition, six months after Telehomecare discharge, inpatient admissions and emergency department visits continued to decline, by 65% and 57% respectively, compared to pre-enrollment. While average LOS increased between pre-enrollment and post-discharge, the reduction in acute inpatient episodes created a net reduction in accumulated inpatient days of 563.16 days (63% reduction).

Conclusions: The WOHS Telehomecare results strongly support the positive influence of the program on health system utilization and the development of effective long-term self-management skills. Next steps could include reviewing, more closely, the reasons for hospital utilization and undertaking a cost-benefit analysis to support further expansion of the program to address other chronic illness and care needs.

While occupational health is a significant driver of population health, productivity, and well-being in Canadian society, most workers do not currently have adequate access to qualified occupational health services. A case study is used to demonstrate the utility of a telehealth approach to service delivery.

Patients presenting to a rural emergency department (ED) with mental health symptoms have difficulty accessing services of mental health professionals [1,2]. Videoconferencing (VC) has been found to improve patient access to health services that require specialist care in rural EDs [3,4,5]. Although previous studies highlight the benefit of using VC for patients presenting with mental health emergencies, no study has investigated the current views and use of VC for mental health emergencies in EDs in Southwestern Ontario [3,5,6]. To explore the views of ED staff regarding the use of VC in mental health emergencies, structured telephone interviews were conducted with representatives from EDs in the Erie St. Clair and Southwest Local Health Integration Networks (LHIN). Participants noted that using VC for mental health emergencies may improve patient experience and benefit crisis response teams. VC was perceived by some participants as a means to expedite the direct assessment of a patient presenting with a mental health emergency by a mental health specialist. However several participants stated that using VC for mental health emergencies strains ED resources. Lack of use and difficulty accessing a psychiatrist were identified as potential barriers to implementing the use of VC for mental health emergencies.

Despite decades of international experience with the use of information and communication technologies in healthcare delivery, widespread telehealth adoption remains limited and progress slow. Escalating health system challenges related to access, cost and quality currently coincide with rapid advancement of affordable and reliable internet based communication technologies creating unprecedented opportunities and incentives for telehealth. In this paper, we will describe how Human Factors Engineering (HFE) and user-centric elements have been incorporated into the establishment of telehealth within a large academic medical center to increase acceptance and sustainability. Through examples and lessons learned we wish to increase awareness of HFE and its importance in the successful implementation, innovation and growth of telehealth programs.

Isolated communities in remote regions of Afghanistan, Kyrgyz Republic, Pakistan and Tajikistan lack access to high-quality, low-cost health care services, forcing them to travel to distant parts of the country, bearing an unnecessary financial burden. The eHealth Programme under Central Asia Health Systems Strengthening (CAHSS) Project, a joint initiative between the Aga Khan Foundation, Canada and the Government of Canada, was initiated in 2013 with the aim to utilize Information and Communication Technologies to link health care institutions and providers with rural communities to provide comprehensive and coordinated care, helping minimize the barriers of distance and time. Under the CAHSS Project, access to low-cost, quality health care is provided through a regional hub and spoke teleconsultation network of government and non-government health facilities. In addition, capacity building initiatives are offered to health professionals. By 2017, the network is expected to connect seven Tier 1 tertiary care facilities with 14 Tier 2 secondary care facilities for teleconsultation and eLearning. From April 2013 to September 2014, 6140 teleconsultations have been provided across the project sites. Additionally, 52 new eLearning sessions have been developed and 2020 staff members have benefitted from eLearning sessions. Ethics and patient rights are respected during project implementation.

Community Health Nursing (N456) is a required senior clinical course in the undergraduate nursing curriculum at the University of Michigan in which students learn to assess and address the health of populations and communities. In 2012, we began our efforts to internationalize the curriculum using a globally engaged nursing education framework. Our goal is for all students to have an intercultural learning experience understanding that all students are unable to travel internationally. Therefore, this intercultural learning was implemented through a range of experiences including actual immersion, virtual activities (videoconferencing) and interventions with local vulnerable populations. Grants were obtained to provide immersion experiences in Quito, Ecuador and New Delhi, India. Several technologies were initiated with partner nursing schools in Leogane, Haiti and New Delhi, India. Weekly videoconferencing utilizing BlueJeans software and exchange of knowledge through the Knowledge Gateway facilitated intercultural exchange of knowledge and culture. Local clinical groups work with a variety of vulnerable populations. A private blog was developed for all sections to share community assessment data from local and international communities. Qualitative evaluation data was collected for local and international students to begin to assess cultural competence and student learning. Analysis of data documented increased awareness of culture and identified the many positive benefits of interaction with a global partner.

Strokes account for 1 of every 18 deaths in North America, and remain a major burden cost-wise and clinically for societies globally. Quicker and more clinically astute care for stroke leads to improved outcomes for the patient, families and the healthcare system at large. The intervention shared illustrates how a locally-programmable EMR with inherent community-wide communications capabilities leads to proven better outcomes for all. The impacts range from initial hospital encounter through acute-care treatment, and then more broadly into post-discharge care community-wide. Implications for all healthcare communities are established.

The power of interoperable systems with data/information integration, central to achieving the goals of Telehealth, is illustrated through mutually beneficial sharing between Labor & Delivery (L&D) and Obstetrics (OBs) Clinics. Data shared between L&D and OB brought improved practice patterns and outcomes, and increased satisfaction at both. Staffing and skillsets were significantly improved by knowing complications arriving and anticipated volumes. OBs increased clinic efficiencies and improved patient-direct care time with improved clinical and cost outcomes.

This project evaluated the effect of a telehealth follow-up intervention on readmission rates for patients discharged from the Saskatoon Health Region cardiology units with ACS or HF. 1-year readmission rates for ACS patients were 27.4% (95% CI: [26%, 29%]) before telehealth implementation and 25.2% (95% CI: [24%, 27%]) after, producing an insignificant hazard ratio of 1.07 (95% CI: [0.97, 1.18], P=0.1899). For HF 50.3% (95% CI: [44%, 56%]) of pre-implementation and 47.9% (95% CI: [43%, 53%]) of post-implementation patients had a 1-year readmission, producing a HR of 1.04 (95% CI: [0.83, 1.26], P=0.6882). This analysis found no significant effect of telehealth on readmission rates for ACS or HF patients.

Driven by the diverse needs for exchanging patient, other healthcare and health system data with the aim to improve the overall quality and efficiency of healthcare provision, regions and countries globally have been developing electronic platforms to gather and exchange such data. Based on an initial sample of more than 50 potential cases, eight such platforms were analysed in detail. This covered issues like core public health policy goals pursued, and major patient and other healthcare data access and exchange characteristics driving the platforms surveyed. This allows for arriving at an initial, pragmatic typology of such platforms. It provides for a better understanding of the main objective(s) and the major thrust of the underlying national (or district-related) health policy to develop and implement such infrastructures.

To better enable cross-border healthcare delivery, particularly the exchange of ePrescriptions, this global undertaking advances the unique identification of medicinal products (MPs) and patient safety in cross-border settings. Major stakeholders harmonise their respective efforts to deliver

• common data models for prescribed MPs

• a common vocabulary for unambiguous definition, description, and identification of MPs

• rules to harmonise practices of therapeutic and economic substitution

• a global roadmap for post-project actions and implementations

Based on earlier activities of standard development organisations (SDOs), use case scenarios are developed, where the identification of an MP is an issue, including pharmacological and pharmacokinetic attributes, clinical indications, and risks to be considered. Next, the univocal identification of MPs is addressed, for standard pre-packed ones as well as for special cases like MPs with multi-components, biologics, or special packaging. Impacts will be considerable for global healthcare services and systems as well as – through simplifying and speeding up the registration of new products and afterwards pharmacovigilance – for national and international regulatory agencies, the MPs industry, and, in particular, patients.