Cite as: Noorani H, Picot J. Assessment of videoconferencing in telehealth in Canada. Ottawa: Canadian Coordinating Office for Health Technology Assessment (CCOHTA); 2001. Technology report no 14.
This study is intended (1) to provide decision makers within the Canadian health care system with broad-based information about the collective experience of eight telehealth videoconferencing (VC) programs, (2) to provide decision makers with evidence regarding outcomes from the use of VC technology in terms of patient care, distance education and training, user and provider satisfaction and communication patterns, and; (3) to suggest directions for the future through a retrospective view of what has occurred, or not occurred, in VC in telehealth in Canada over the past two decades.
Telehealth is increasingly evident in every Canadian province and territory. Factors contributing to the growth of telehealth in Canada include increasing technological capacity, the perceived need to deliver specialty services to rural and remote communities, and the need to reduce the isolation of health professionals in remote areas through continuing health and medical education. A number of barriers, however, continue to inhibit the widespread adoption and implementation of telehealth including an insufficient infrastructure, and a lack of standards.
This study is a synthesis of survey responses and project evaluation reports from eight telehealth programs across Canada where VC is used to provide health care and continuing health and medical education at a distance. The telehealth programs were identified according to pre-defined criteria by representatives from the participating health care agencies and federal, provincial and territorial governments, and consist of six provincial programs (Alberta, Newfoundland, Nova Scotia, Ontario, Quebec, Saskatchewan) and two programs from the territories (Northwest Territories, Nunavut). In addition, a literature review from 1998 to present was performed to evaluate the efficacy of VC from research studies.
On the basis of the survey results, VC for telehealth applications in Canada is in a state of transition between pilot project and program status. Most programs are undergoing expansion and enlargement. The eight programs in total reach out to approximately 150 sites across Canada.
Network transmission methods and bandwidth are generally similar among programs. Seven programs use VC for both patient-related sessions and education sessions. One program uses VC only for education sessions. Cost estimates for VC equipment, telecommunications, and staff time vary by the number of sites within the programs (which range from 3 to 61 sites) and type of application. One program evaluation reports VC having a positive impact on utilization of face-to-face (FTF) assessments with fewer FTF visits needed, and two other programs report VC having a positive impact on timeliness of care.
Each program responding to the survey seems to have chosen its own path to implementation. Needs assessments, program evaluation results or historical experiences were used to guide program implementation. All programs indicated that training of staff was provided at a practical, technical, or "how-to" level.
Three programs have addressed issues around physician reimbursement. That is, physicians are being paid through their provincial medical reimbursement schemes for telehealth consultations and services to patients. Four programs responded that they are dealing with reimbursement issues using a variety of mechanisms ranging from the use of research budgets to project funding. There are a number of unresolved issues related to health professionals. Some programs have implemented solutions, while others are still negotiating and searching for resolutions to the issues raised.
The literature search yielded over 270 articles and reports. Forty were identified as primary outcome studies. Such topics include mental health, dermatology, education and training of health professionals, and patient satisfaction and communication patterns between the two modes of health care delivery, FTF and VC. Only two studies were of Canadian origin and included evaluation results from two of the provincial programs identified for this project. A majority of the studies reviewed suffered from methodological problems. The six studies related to distance education by VC, albeit limited by their small number and sample size, report the usefulness of VC, especially with respect to surgical training. In general, high levels of patient satisfaction with telehealth are reported in the literature. The costs of teleconsultation were found to decrease as the frequency of its use, and the amount of patient travel time increased.
Given the size and population of Canada, the number of sites covered by VC and the number of patients seen by VC in telehealth is very small. Establishing systems for patient care using VC technology is feasible. However, there is little evidence from the literature of either its clinical or economic benefit, especially regarding its cost-effectiveness when compared to FTF care. All the programs surveyed reported some positive results using VC. This includes improved communications between colleagues, better access to care, and a high level of patient satisfaction.
There are many important issues that remain to be resolved in the use of VC. Reimbursement of practitioners is still a pending issue within some programs. The surveyed programs have added new staff positions, but there are no nationally approved standards for training, and education of operators or site coordinators. The use of VC in telehealth in Canada faces its greatest challenges within the areas of organizational change and medico-legal issues.
VC in telehealth in Canada has a tenuous position within the health care system. Sustainable long-term funding is in place in only two of the programs surveyed. In spite of these difficulties, most programs reported having met their objectives. All plan to expand the programs in the future. Survey respondents report a growing acceptance of telehealth practices by practitioners and patients. This acceptance comes from the desire to improve access to care, particularly for patients in remote locations, newer generations of user-friendly technologies, and the expanding number of applications for telehealth.
This report offers some suggestions regarding future considerations for VC programs in telehealth in Canada. These include the need for quality outcome studies regarding clinical effectiveness and cost effectiveness, and the need for guidelines for planning and implementation, user training, and program sustainability over the long-term.
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