It’s still far from routine, but telemedicine is quietly growing across Canada. Last year, a pilot project with a portable robot was launched in Saskatchewan. And telemedicine programs in Ontario have been growing by around 30% per year for the last several years, according to David Jensen, spokesperson for the Ministry of Health.
Telemedicine can involve a health worker speaking to a patient through videoconference, telephone or gionviewing aspects of a patient’s history and physical examination remotely. As these four examples show, telemedicine can result in reduced wait times and decrease travel costs, thereby improving access and outcomes. “Telemedicine reduces hospitalizations,” says Ed Brown, chief executive officer of Ontario Telemedicine Network, a not-for-profit telemedicine hub that’s funded by the government of Ontario. A 2014 review of telemonitoring services for congestive heart failure, stroke and chronic obstructive pulmonary disease found that the majority of services reduced hospital admissions.
But there are challenges to scaling up telemedicine, and chief among them is resources. Ontario has “one of the largest telemedicine programs in the world,” says Jensen, but it still accounts for far less than 0.1% of the health budget. These four programs around Canada highlight the great potential and barriers to expanding telemedicine.
Remote Medicine Program, Pelican Narrows, Saskatchewan
When patients in Pelican Narrows urgently needed to see a specialist, they would often be driven six hours by ambulance or airlifted to Saskatoon. The Angelique Canada Health Centre in the community of 3,000 is staffed by nurses and, intermittently, a physician.
Since a pilot program was launched last year, however, there’s another option. Rachel Johnson, a telemedicine nurse stationed in Pelican Narrows can video-in doctors at the Royal University Hospital in Saskatoon. With the help of a Remote Presence-7 (RP-7) robot, which is equipped with a stethoscope, ultrasound, dermatoscope (to see a magnified view of the skin), ophthamoloscope (to look into the eye) and otoscope (to look into the ear), Johnson can perform various tests with the guidance of the doctor appearing over the robot’s video screen. The doctor can then view the video, images and graphs in real time on a computer screen. (The robot and nurses at Pelican Narrows are pictured.)
Since the pilot project’s launch, 17 patients who would have otherwise been airlifted, at a cost of about $10,000 each, have been treated remotely, explains Ivar Mendez, a Saskatoon-based neurosurgeon overseeing the program. For example, when a child came in who was struggling to breathe, Johnson used a stethoscope so she and Tanya Holt, a pediatric intensive care doctor in Saskatoon, could listen to the boy’s lungs. Johnson then attached a small probe to the child’s finger, so the doctor could see how much oxygen he was taking in. Based on these tests, Holt diagnosed the child with common croup that could be managed with inhaled medication. Previously, says Mendez, the child would have been evacuated, but with the telemedicine program “he was able to breathe normally after that and recovered in the community.”
In addition to the benefit of patients getting earlier access to specialists and staying in the community, Johnson says, “as nurses, we’re also getting the mentorship to help us manage similar cases in the future.” Johnson says she and other nurses use the RP-7 robot a dozen or so times a month (the use varies widely depending on the need). Through consultations with Dr. Holt, she has become better able to recognize “the red flags that indicate when patients should be hospitalized versus symptoms that we’re able to manage in the community.”
The Pelican Narrows Telehealth Pilot is funded by Saskatchewan’s Ministry of Health and is part of a larger remote medicine program being run by Mendez out of the University of Saskatchewan. Mendez expects the remote monitoring technology will be scaled up to other sites in northern Saskatchewan over the next few years.
Telemedicine Program, Champlain region, Ontario
In the last two years, telemedicine has “exploded” in the Champlain Local Health Integration Network (LHIN), says Paula Archambault, clinical telemedicine program coordinator at The Ottawa Hospital. According to the OTN, the Champlain LHIN has the most participating telemedicine sites in the province. Through the program, pediatricians, kidney specialists, cardiologists, psychiatrists and dozens of other specialists see patients through teleconference with the help of 17 nurses, who are funded by the LHIN and OTN. In the fiscal year 2014-2015, these nurses facilitated 34,000 telemedicine appointments in the southeast Ontario region, which has a population of around 1.2 million. That’s a 29% increase from the year before, says Kevin Barclay, a telemedicine specialist at the Champlain LHIN.
Cindy McCaughan, one of these nurses stationed at Pembroke Regional Hospital, says she will sit with each patient in a telemedicine room and perform various assessments before and during the video consult with a specialist. When McCaughan runs a stethoscope along a patient’s chest, the specialist she’s consulting from one of the region’s larger hospitals can hear the patient’s heart and lung sounds through their own, connected stethoscope.
Telemedicine nurses and a video-connected specialist will see everyone from a thrombosis patient to find out how they’re doing on a blood thinner medication to a cancer patient to discuss side effects of chemotherapy. McCaughan says an added advantage of telemedicine is that because she sits with the patients, she can take notes and explain the specialist’s instructions if the patient has questions after the specialist has signed off.
Telemedicine has reduced wait times, says Archambault. For example, wait times to get Hepatitis C treatment decreased from several months to two weeks once telemedicine was introduced. The hospital was able to offer additional appointments because telemedicine made it possible to do so without increasing the waiting room and receptionist space – which the hospital doesn’t have.
Patients have been overwhelmingly positive about the telemedicine program, with 98.6% of almost 900 patients surveyed at The Ottawa Hopsital saying they were satisfied with the services. No longer do patients have to “travel two hours for a short follow up appointment,” explains Archambaut. Now, the LHIN’s telemedicine program is limited only by personnel. Hospital-based physicians could see more patients through telemedicine if resources were available to hire more telemedicine nurses, explains Archambaut.
Teleophthalmology and Teledermatology, Ontario
Certain eye and skin conditions can easily be diagnosed by examining high-quality photos, which is why teleophthalmology and teledermatology are two of the biggest programs at OTN.
Between April 2014 to March 2015, 1,473 patients were seen virtually by ophthalmologists. Most of them were persons with diabetes who should be screened every two years for diabetic retinopathy but live in remote northern or rural areas. “There are probably about a million diabetics in Ontario and roughly a third of them have not had appropriate screening of their retina,” explains Brown. The costs of travelling are chief among the barriers to screening. For many northern patients, the closest ophthalmologist is several hours away.
In teleophthalmology , a technician in a health centre takes photos of a patient’s eye with a special camera that shows the deep blood vessels. A teleophthalmologist like Steven Kosar, based in Sudbury, Ontario, then views the photos and decides whether the patient needs to come in for treatment. According to Kosar, only about one in 12 patients with diabetes will have diabetic eye disease, “so you save a whole lot of people from having to travel, and you can identify the ones that need to travel.”
Even more patients are served by the teledermatology program. Last year, there were 9,651 teledermatology referrals, according to Brown.
Melinda Gooderham, a dermatologist in Peterborough, looks over photos and notes in the early morning and evening, outside of her regular, in-person clinic hours. “I see everything, including moles, new lesions, itchy rashes and psoriasis,” says Gooderham. Most of the patients can be managed remotely, while the remainder Gooderham will recommend come and see her in person. About 10% of the time, however, technical issues with the photos sent mean that a diagnosis isn’t possible, according to the OTN.
A major challenge to the work is reimbursement. Last year, the Ministry of Health of Ontario cut the telemedicine consulting fee to 60% of that of an in-person consult. The justification was that making diagnoses based on photos and texts takes less time than seeing a patient in one’s office. But Gooderham points out she doesn’t receive enough telemedicine consults to justify cutting back on her in-person clinic’s hours and therefore she still needs to see patients in person from nine to five. She says she may stop providing teledermatology programs – though she’s impressed with how the program improves access for patients – because she’s not sure the reimbursement is enough.
Psychiatry services “have been one of the most common applications for telehealth internationally,” says Doug Urness, a Ponoka, Alberta-based telepsychiatrist. His province saw the opportunity to provide psychiatry care via videoconferencing between patients and doctors back in 1996, when the province’s program was launched. Since then, telepsychiatry has continually expanded. In the 2014-2015 year, there were 2,775 sessions held in the province, up from 2,263 two years before.
Most often, a videoconference with a telepsychiatrist will be arranged by a family doctor in a rural or remote area who wants the help of a psychiatrist in diagnosing and managing common mental health disorders such as bipolar depression or attention deficit and hyperactive disorder. The psychiatrist can suggest a treatment plan, prescribe medication when required and make follow-up video appointments with patients to assess how the patient is doing. “Most routine mental health visits can be carried out successfully using telemedicine,” says Urness.
Telepsychiatrists in Alberta are careful to support, rather than usurp, the role of local doctors and counsellors, says Urness. When a telepsychiatrist thinks a patient will benefit from counselling services, he or she will refer the patient to local counsellors before doing counselling themselves, Urness explains.
The future of telemedicine
Telemedicine programs in Canada have demonstrated cost savings, improved patient outcomes and improved access. Given that rural and northern Canadians generally have poorer access to health services and suffer more health problems, telemedicine may be a method of reducing disparities in health. But many barriers remain.
Reimbursement for telemedicine in the country remains patchy, with the specific telemedicine services covered varying by jurisdiction, says Omid Shabestari, a professor at the Institute of Health Policy, Management and Evaluation at the University of Toronto. Meanwhile, funding needs to be made available for equipment, mass training of health workers and increasing internet bandwidth to support videoconferencing – all before the cost savings of telemedicine affect is felt.
Health practitioners also need to be convinced to try a new mode of health care delivery. Shabestari, who has studied the implementation of telemedicine in Europe, says that reimbursements “even at rates higher than in-person visits” are often necessary in the initial stages to encourage health practitioners to deliver telemedicine.
As health practitioners become more comfortable with the technology, however, more telemedicine projects may be driven by health workers themselves, like Mendez. “The next generation of young doctors coming out of medical schools are more comfortable using these kinds of technologies,” says Shabestari.