Appendix 6 Telemedicine Services on PEI

Introduction

This virtual case study was carried out as part of the Knowledge Assessment Methodology Project in Prince Edward Island. As one element of that methodology, virtual case studies are used to explore the weaknesses and strengths of PEI's knowledge economy, using as a vehicle the planning of a hypothetical, knowledge-based enterprise in an area of comparative advantage that is affected by technical change. It is emphasized that this report is almost entirely drawn from the expertise and experience of the participants, and is not intended to propose that such an enterprise actually be established on PEI.

The virtual case study on telemedicine took place on the campus of the University of Prince Edward Island on May 15, 1998. Participants included representatives of the Department of Health and Social Services, Holland College, the Department of Veterans Affairs, Island Tel, the University of Prince Edward Island, regional hospitals, and the private sector. The U.S. National Research Council was represented by Pamela Whitten, director of the Kansas State telemedicine system; Doug Perednia, head of the Oregon program and president of the Association of Telemedicine Service Providers; and Michael Greene, Director of International Development Programs at the NRC.

Background

A 1996 report by the Institute of Medicine of the National Academy of Sciences defined telemedicine as the use of electronic information and communica-



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--> Appendix 6 Telemedicine Services on PEI Introduction This virtual case study was carried out as part of the Knowledge Assessment Methodology Project in Prince Edward Island. As one element of that methodology, virtual case studies are used to explore the weaknesses and strengths of PEI's knowledge economy, using as a vehicle the planning of a hypothetical, knowledge-based enterprise in an area of comparative advantage that is affected by technical change. It is emphasized that this report is almost entirely drawn from the expertise and experience of the participants, and is not intended to propose that such an enterprise actually be established on PEI. The virtual case study on telemedicine took place on the campus of the University of Prince Edward Island on May 15, 1998. Participants included representatives of the Department of Health and Social Services, Holland College, the Department of Veterans Affairs, Island Tel, the University of Prince Edward Island, regional hospitals, and the private sector. The U.S. National Research Council was represented by Pamela Whitten, director of the Kansas State telemedicine system; Doug Perednia, head of the Oregon program and president of the Association of Telemedicine Service Providers; and Michael Greene, Director of International Development Programs at the NRC. Background A 1996 report by the Institute of Medicine of the National Academy of Sciences defined telemedicine as the use of electronic information and communica-

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--> tions technologies to provide and support health care when distance separates the participants. It has recently gained widely in popularity because of dramatic advances in the information and telecommunications technologies, but it has been used since the 1950s in selected fields, such as remote psychiatry. There are still several different levels within telemedicine: Seeing and hearing through remote real-time audio and video technology; Transferring data, such as radiology, pathology, etc.; Remote manipulation, including surgery, through the use of robotics. The first two levels have been widely implemented, beginning about 1992 at the University of Kansas and a few other places. Now there are over 70 medical services worldwide that routinely make use of telemedicine technology, and there is an explosive growth in linkages and services available. The third level is still in a developmental stage, and today is primarily of interest to the military. The situation in Kansas in the early 1990s was roughly analogous to that of PEI, although on a somewhat larger scale. There were remote counties with no physicians, and there was a clear demand for equal access to health care. In 1992, the problem was put in the hands of the medical school at the University of Kansas, and a retired general familiar with military telemedicine applications was put in charge. The state telephone company put in a LAN-based structure with a fractional T1 bandwidth, and equipment was purchased for the university and the potential remote sites. But there was an initial error of focusing heavily on technology and not embedding the telemedicine service within the formal health delivery system, and the service was not fully utilized. In 1995, the university began to create a needs-based service, beginning with an assessment of needs in rural areas, and technology services were placed in the context of clinical and educational programs. In the clinical program, patients now see the physicians in one of three modes: on an as-needed basis, in an emergency or when a rare subspecialty is required, as they would in the normal practice of medicine; on fee-for-service contracts for specific services requested by the rural center; and at regularly scheduled subspecialty clinics. For example, there might be an oncology clinic on a given day of the month, cardiology on a different day; other specialties might be dermatology, psychiatry, and rheumatology. A scheduler at each rural center arranges appointments for patients. In all cases, the specialist receives x-rays and other data at the patient's appointment time, and he or she can examine and interact with the patient privately through an interactive audio-video (ITV) hookup, assisted by a nurse specially trained on use

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--> of the equipment. There is special peripheral equipment for the ITV, including stethoscope, otoscope, etc., that directly transmit diagnostic data. The educational program provides the special training for the nurses who present patients via telemedicine. It also makes available continuing education for physicians, nurses, and allied health care providers to allow them to maintain their licenses and, incidentally, to relieve the isolation. There is an ITV guide, with a menu of lectures and courses presented to several sites at once to encourage class participation. There are also programs for patient education, such as a series on diabetes, weight loss, smoking cessation, and the care of relatives with Alzheimer's disease. The rural sites pay for their own equipment and phone charges. The university charges health care providers for courses taken for credit, and provides the patient education courses free. Patients in Kansas now accept telemedicine as a normal part of the health care system. Often they would prefer a live consultation, but the eight-hour drive across the state and the cost are deterrents. At the same time, telemedicine is credited with keeping rural hospitals open by making necessary services available locally through them. The technology used in Kansas is room-based interactive video with a bandwidth of 384 kHz, used in 28 rural hospitals. There is now also a PC-based rural medicine option, requiring only a PC plus a camera at 128 kHz, useful particularly for telepsychiatry. At lower bandwidth, and therefore lower cost, there are POTS-based (Plain Old Telephone Service) solutions, using a phone and a TV, and World-wide Web based technologies, but these are not popular with physicians. The greatest jump in quality comes between POTS and PC. In Kansas, telemedicine is now integrated into the health care service, and it has been extended to new contexts. The normal telemedicine service is hospital to hospital. Newer initiatives are based in elementary schools in the inner city, where children who never see a doctor can be linked to pediatricians through the local hospital scheduler. There is also a program in psychiatry for prison inmates, and a home-service, using POTS-based equipment, for geriatric and hospice care. Oregon's telemedicine program, focused on emergency services, demonstrates another promising approach. Studies throughout the state identified that morbidity and mortality in emergency room cases varied by up to a factor of ten between some rural hospitals and large urban centers. A firm, Life Corn Inc. of Portland, Oregon, has developed a protocol-based system of network operating centers (NOCs). The NOCs, which are staffed by physicians, operate as telementors or expert systems supporting emergency rooms in rural hospitals. Protocols have been developed using a system of screens to ensure rapid diagnosis and optimum treatment for over 200 emergency situations. The system is aimed at helping the emergency rooms carry out triage to minimize morbidity and mortality by deciding quickly on whether to discharge the patient, admit locally, or transfer to a larger hospital. This system is credited with significant improvements in morbidity and mortality, and substantial relief and support to the rural

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--> physicians carrying out emergency medicine. The protocols themselves are a knowledge-based product, which the firm is now selling separately. To evaluate the potential of telemedicine in PEI, with its limited distances and high hospital/population ratio, costs must be considered carefully. The cost of transmission in PEI effectively depends only on band width, with additional tariffs for off-island communications. In the future, it is likely that satellite-based technologies will make costs completely independent of distance. Meanwhile the cost of telecommunications is falling, and the cost of health care is rising. The cost of seeing patients in person is rising with it, when salaries, transport, parking, reception, and overhead are taken into account. In Prince Edward Island, most of the specialists are located in Charlottetown and Summerside, and patients must come in from rural areas to see them. Points of Presence (POP) sites dedicated to health care can be established, perhaps at the seven hospitals, and the telecommunications links can be set up. The POP will have a room with telecommunications equipment staffed by a nurse or a trained layperson. Patients referred to a specialist will have the choice of a drive to Charlottetown or to a POP for a regularly scheduled clinic. For specialties for which there may be no one practicing in the province, the system can communicate with other sites off-Island. Continuing medical education can be similarly included. An added bonus is that it may be possible to provide access to French or Japanese-speaking care providers for tourists; the latter can be referred to the Nippon Medical Clinic in Los Angeles for a fee. For emergency services, in order to relieve the pressures on local physicians, the potential for a system such as the LifeCom network in Oregon could be explored. The Enterprise The telemedicine service selected for the case study would establish points of presence at the seven hospitals in PEI, and provide clinical consultation service and continuing medical education. Other sites and other services are possible in PEI, but this model reveals the essential issues. Statement of Purpose The enterprise would enhance the quality of health care for residents and visitors in rural areas of PEI by providing access to medical education and specialty consultation services at established points of presence throughout the province. What is the service? Regularly scheduled consultation clinics in rural areas in selected specialties, such as cardiology, dermatology, allergy, endocrinology, and psychiatry, plus a

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--> series of medical education courses made available to doctors, nurses, and allied health professionals, and lectures for patient education on diabetes, weight loss, smoking addiction, and other topics. Before setting up the system it will be necessary to analyze the disease burden of PEI and clinical outcomes, and compare different sites on the Island. The telemedicine program should concentrate on strengthening the services and specialties that will have the greatest impact on outcomes. Who are the customers? The customers are health care providers and patients in rural areas of PEI. What is the competition ? The ''competition" is the drive to Charlottetown or, for specialists, circuit riding to visit the rural hospitals. What technologies will be used? The technologies would include: Interactive video with store-and-forward capability, or PC-based facilities, and electronic stethoscope and other suitable peripherals. Bandwidth of 384K connection or higher, depending on services desired. A program for coordination of services and protocols for consultations, providing standard operating procedures for consistent quality care. What is the core competency of PEI that makes telemedicine service appropriate ? PEI is an island community with a relatively large rural population and a limited number of specialists. A high speed telecommunications infrastructure is being put in place throughout PEI. The Canadian health care system provides an inclusive network of referrals. Service Requirements In the absence of a geographically based study of health outcomes compared to care availability, for the purposes of the case study, it will be assumed that the telemedicine POP sites will be sited in the seven hospitals. Public expectations would likely dictate that all hospitals be included in the program. Broad band connectivity is present in all schools and can be installed within one week at the hospitals. An agreement between Island Tel and the Provincial Government speci-

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--> fies a 25% discount on usage fees. Connections of 128K, 512K, and T1 (1.5 M) are available. The school rate for 128K is C$250 per month, with unlimited use. Thus, connectivity will not be a problem. In each site, the facilities required will be a multipurpose room, with removable seating for about a dozen people, and a place to present a patient for consultations. It should have good lighting; blue walls are somehow considered appropriate for telemedicine. The equipment can either be PC-based or room based ITV. Since the capital cost must be paid up front, the choice will depend on the funds available. An ITV will cost up to C$50,000; the PC will cost much less and can be used for other purposes as well. A PC-based system at 384K bandwidth with ISDN digital transmission will permit transmission of medical records, and with peripherals it can transmit x-rays and EKG. It would not be sufficient for diagnostic radiology, but there are no CT scan facilities in the rural areas anyhow. (That would require a T1 at 10M or delayed transmission.) A large monitor would increase patient comfort, and a good camera will be necessary to show the patient's appearance and full length image as well as close-ups. There has been no good cost-benefit research on telemedicine published yet. There is a feeling among some PEI physicians that at present the system provides consistent care throughout the province once the patient presents for treatment, but experience in other places shows this perception to be unreliable. Information on mortality and morbidity and a study of outcomes are required to accurately calculate the potential improvement in service and the savings. The telemedicine system would be picking up the cost of transport, now paid by the patients, but it may save in transmitting films and records. For consultations off the Island, the system would be absorbing the patients' much higher cost in travel. Under the Canadian system, inter-province consultations are payable on a province-to-province basis, and a new accounting system must be developed to register telemedicine consultations. A similar modified system must be put in place for physicians within the Island. Presently, under Canada's one-payer system, physicians receive a fee for service, with an annual cap on fees, and service is defined as a face-to-face visit with a patient. The system must be adapted to count telemedicine consultations under the fee structure, but since there are telemedicine services operating in other provinces, there are probably existing solutions that could be put in place in PEI. A new hospital will shortly be put in service in Summerside, and the telemedicine services could be made a part of it, introducing a new culture and new expectations without having to retrofit old habits. Medical licensing may be an issue. Must a physician in New Brunswick be licensed in PEI to treat a patient from PEI? Probably not if the patient travels to the other province, but suppose the physician offers his services inside PEI by telemedicine? This will have to be explored. There will be some ancillary services that will not be maintained within the telemedicine system but must be outsourced to contractors. One of these is tech-

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--> nical support for system maintenance and technology problems through a telephone help desk. Island Tel may be able to set up or find an appropriate contractor. Another required service will be access to health information and patient records. The provincial government is currently developing an integrated health information system, the Island Health Information System (IHIS). The system will provide patients' medical records on-line to those with a need to know. As one component of IHIS, there will also be a Pharmaceutical Information System (PHIP) that will contain the patients' pharmaceutical record, plus information on counter-indications for each prescription drug. It may be necessary to have a second, separate PC on a separate line in the telemedicine site at the providers' end to access these before or during a consultation. Telemedicine provides an opportunity to establish a quality case management system. It would be necessary to establish goals, create the necessary infrastructure, and design the treatment protocols. An on-line expert system would confirm diagnoses and make treatment recommendations, but it would be up to the primary care physician to implement them or not. Preparing the protocols for a telemedicine-based case management system could probably be outsourced, perhaps by adopting the protocols for an established system like Kansas, Texas, or LifeCom, or consulting the Canadian Medical Association. The protocols should be focused on telemedicine consultations, but they should be general enough to embrace all medical procedures, designated by area: oncology, pediatrics, etc. Strictly speaking, these protocols are not part of the telemedicine system, but introducing a new methodology is an opportunity to add value and upgrade the entire system. Aside from the physicians, few people are required to manage the telemedicine system. Most important is the nurse/scheduler at each site, trained to operate the equipment and to present a patient using the camera, peripherals, and other resources. The nurse should also be trained to prepare the patient psychologically for the telemedicine experience and assist in presenting the patient. There must also be a technical specialist to trouble-shoot the system. For most problems, this can be handled by phone by a help desk, provided by a subcontractor. The equipment and bandwidth at each site would have to be of equivalent or higher capability as that in the central medical centers. High bandwidth connections exist between universities through the Canarie system, funded by the government, so that Dalhousie Medical School will have access to it. For remote consultations, the PEI telemedicine system would connect with Canarie through a fiber leg between Queen Elizabeth Hospital and Holland College. Billings should be treated like a normal consultation, face-to-face, with the cost of the telecommunications connection, if any, added on. The liability issue is the same as face-to-face, and the same insurers would likely cover the physicians. No new liability issues have as yet arisen for telemedicine consultations. (It is sometimes said that the two best indicators of the

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--> probability of a lawsuit are whether the patient thought the doctor listened and whether the doctor smiled. The doctor's face may not always be visible to the patient during a telemedicine session, but the nurse may listen, smile, and demonstrate concern. In any case, experience shows no higher incidence of lawsuits for telemedicine consultations.) Marketing will be an important factor in the success of the telemedicine system. There will be marketing to the public, to patients, and to the medical community. Inevitably, however, there will be opposition, with some people seeing not the cost savings and higher quality service, but only the expenditures, and they will measure them by the number of beds that could have been added to the rural hospitals for the same cost. Marketing and education will be very important for gaining public support. In Kansas, telemedicine enabled rural hospitals to remain open, and this was an important selling point for the rural communities. But people are resistant to change, and it will only come about if the medical community supports it. It should help to reduce the workload of the rural doctors by letting them cover for each other in different centers, especially in emergency room services; it would also expand the reach of the subspecialists. The doctors should be helped to see what's in it for them, and it would help if the Medical Association were positively involved. The continuing education aspect might appeal to the association that supports the licensing regulations. In the United States, physicians may be motivated by money, time savings, or mandatory requirements. The latter would seem to be out of the question in PEI, as the Cabinet would need to be persuaded that the doctors were in favor before promoting a telemedicine service. The other incentives likewise are hard to mobilize under the Canadian system, since doctors already see as many patients as they can handle and the patients are not permitted to pay out of pocket. But the doctors may have a genuine desire not to be leaving some segment of the population underserved, and telemedicine would enable them to extend high quality coverage throughout the Island. Alternatively, the doctors could be shareholders and share in some of the savings of the system. Marketing to the public presents a different problem, and this can be done very effectively. The Association of Telemedicine Service Providers provides one model. In an early survey, it was found that most people (including doctors) had never heard of telemedicine, or confused it with telemarketing. Telemedicine is useful only where there is a mismatch between the location of patients and the availability of live care. Measurements must be made of where people are not being served in certain specialties, like cardiology. On a regional basis, the population data can be combined with morbidity and mortality data to estimate telemedicine needs, in terms of time and bandwidth. The community is likely to react to learning the number of cases expected and the care needed in various specialties. The method can be refined by preparing maps that compare the costs of care,

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--> depending on distance: the distance to the care provider versus the cost of telecommunications. These maps can be overlaid by maps of provider locations, maps of population, and maps of adverse outcomes from particular diseases. They can be linked to a geographical information system for an elegant presentation and put in the public domain or on the Internet. It will show the government the location of the nearest point of service for each specialty: oncology, cardiology, emergency room service, etc., and compare with the distribution of the population at risk. These maps can be prepared as a planning tool for government officials. In the U.S. private health care system, this approach has also proven successful in building public support for telemedicine. If the public can be convinced, the money could be available from ACOA, from Island Tel, and from the Province, but the project might falter if the medical community does not fully accept telemedicine. Implementation Requirements Leaders in each rural community should be identified and convened to create a strategic plan. They should encourage the local physicians to clarify their positions with regard to telemedicine. The data gathering and mapping should be initiated to determine and demonstrate the intensity of the need. A rough cost estimate (in Canadian dollars) includes the following: About $40,000 might be needed to install the necessary lines as a onetime expense. For each of the seven proposed sites, equipment costs for a PC-based system with the necessary peripheral equipment would be close to $35,000. Up to another $10,000 would be required at each site for the physical facilities: room, furniture, paint, etc. Connection costs are estimated at about $1,200 per year per site. Operating costs would average $500 per month or less per site, including maintenance, licensing, and help desk services. As with any endeavor, a full time coordinator or change agent will be required to set up the system, and much will depend on the energy and effectiveness of that individual. At each site, a part-time coordinator can be selected to start, and the training of nurses begun. The training will consume about 3 months to learn the whole system, including the computer and telecommunications technology and the practice of delivering health care in a new way. There would be practical exercises in presenting patients for each specialty. As described above, one of the most valuable benefits of establishing a new telemedicine system is the opportunity to establish protocol-based procedures at the same time. Possibly telemedicine might provide the motivation for this change, but the protocol-based care would in the long term do more for health

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--> care than the telemedicine itself. It is important that the protocols be licensed or developed at the same time that the telemedicine procedures are installed and not be imposed as an afterthought. The Association of Telemedicine Service Providers can provide guidance for testing and evaluation of protocols. There are several alternatives for funding. ACOA has funds to support information technology initiatives. Human Resources Development Canada may have funds available for training. There may also be a buy-in from Island Tel that would encourage others to join and would leverage matching funds from other partners. The Atlantic Center for the Study of Human Health might be interested in participating in the health care providers' training element. For partners, there are several groups to approach. Number one should be the physicians, through the Medical Association, and the nurses and other professional groups' representation. Island Tel, the Department of Health, and the Department of Veterans Affairs would represent the service providers and the funders. Finally the consumers' groups and the disease advocacy groups could provide useful public support.