THROUGH THE CROSS-JURISDICTIONAL LOOKING GLASS: MEASURING CONSUMER, PROVIDER, AND HEALTH SYSTEM IMPACTS OF E- HEALTH IN REMOTE AND ISOLATED FIRST NATIONS PRESENTATION TO COACH OTTAWA, ONTARIO MAY 28, 2013 PENNY CARPENTER AND ORPAH MCKENZIE

INTRODUCTION

PURPOSE OF PRESENTATION First Nations OTN Provincial government- MOHLTC/NW LHIN 14/province health services Federal government-FNIHB to describe KO eHealth’s efforts to measure and report telemedicine impacts to diverse partners

OVERVIEW OF PRESENTATION First Nations in Northern Ontario KO/Knet (Kuh ke Nuh) Network KO eHealth Services and the role of the Community Telemedicine Coordinator Methodology/Approach Findings/Results Recommendations and Conclusions

Section 1 FIRST NATIONS IN NORTHERN ONTARIO

REMOTE AND RURAL FIRST NATIONS IN THE SIOUX LOOKOUT AREA 25 First Nations are either remote or rural Limited access to health Limited access to educational services Limited access to opportunities First Nations members who need medical procedures or higher education are often required to leave their communities to have access to schools and medical facilities in urban centres

In the Beginning……. In the early 1990’s, Sioux Lookout area First Nations (SLAFN) had no broadband connection and had to rely on slow dial up systems via telephone lines to receive any both in the health centre and the community. The Keewaytinook Okimakanak Chiefs, identified broadband as a need for their 5 communities and by 2000 received funding from a IC SMART Communities project to build broadband. One objective of the SMART project was to develop telemedicine in 5 remote First Nations, by 2004 and after the end of the project, telemedicine expanded to 25 remote First Nations in Northern Ontario

BROADBAND IN THE SIOUX LOOKOUT AREA All the First Nation communities in the Sioux Lookout area are connected to KO-KNET’s broadband services 25 sites have access to KO Telemedicine (health and wellness services delivered via videoconference) Keewaytinook Internet High School, among other broadband-enabled services.

KO-KNET BROADBAND SITES

KNET TECHNICIANS

KO TELEMEDICINE SITES

PARTNER CONTRIBUTIONS- FIRST NATIONS Each FN has an agreement with KO to provide office space in the health clinic/nursing station FN is responsible for hiring a Community Telemedicine Coordinator KO eHealth also supports 10 off-reserve First Nations provider sites, e.g. the Sioux Lookout Diabetes Program, Sioux Lookout First Nations Health Authority, Shibogama FN Council to name a few

PARTNER CONTRIBUTIONS-OTN KO eHealth maintains a partnering agreement with the Ontario Telemedicine Network, is fully integrated with the provincial telemedicine service management system and maintains linkages to more than 500 additional points-of- care

PARTNER CONTRIBUTIONS-FNIHB Health Canada’s First Nations and Inuit Health Branch provides approximately $2.9M annually to support KO eHealth operations Funding provides salaries, broadband connectivity and program costs

COMMUNITY TELEMEDICINE COORDINATOR The CTC is the person in the community responsible for ensuring that telemedicine events are conducted from the initial referral stage to the completion of the event CTCs also are the point of contact in the community for telemedicine

TELEBABIES CTCs also have leveraged telemedicine to assist in emergency deliveries.

CURRENT KO TELEMEDICINE ACTIVITY

WHY STUDY THE IMPACTS OF KO TELEMEDICINE? It is important to document how users of telemedicine use this service If designed to meet the needs of First Nations, impacts should teach First Nations about community health needs for health planning. Provides evidence to funders for future program development and funding

METHODOLOGY AND APPROACH OTN data collection process: All appointments are entered into the Telemedicine Service Manager (TSM) by the Schedulers Monthly reports are produced by OTN and sent to KO eHealth for our review and assessment KO eHealth keeps track of the clinical activity of all sites and provides information to each site as requested or needed This information also helps us determine which sites are in need of assistance

METHODOLOGY AND APPROACH FNIHB data collection process: Handwritten activity logs are faxed by the CTC to the main office after a consult is completed The logs are faxed to the NIHB office to be assessed as to whether the consult has saved $ in travel and to assess the value of the saving The form is considered ineligible if it has missing information or if it is not eligible under NIHB This information is also entered into a spreadsheet by our staff and used as a backup to confirm assessments by NIHB office

RESULTS/FINDINGS 1.Internal Audit As part of a strategic service review, an audit of how eligible consult data was collected, processed and interpreted 2.FNIHB 2007/08 – 2011/12 five year evaluation plan

RESULTS/FINDINGS  During the five year evaluation period KOeHealth o Annually delivered access to more than 70 therapeutic areas of care o Coordinated 26,661 telemedicine events  70% of all events resulted in the delivery of a clinical service at a First Nation point-of-care  more than 8,000 events supported a health education or administrative function o Engaged more than 400 unique health professionals o Delivered a valued community-based health service o Provided timely access. Wait times compare favorably to national and provincial standards; the average elapsed time from placing a referral to a telemedicine appointment was less than 48 days

RECOMMENDATIONS Specific recommendations to streamline business processes Introduce a more collaborative and managed approach with health service providers Five years of historical consult data has shown us how to adapt specific business processes and to more effectively assess the impact of the eligibility metrics e.g. more than 60% of our consults are considered ineligible by NIHB

RECOMMENDATIONS The need to identify a source of capital funding to support telemedicine technology upgrades and replacement Development of a virtual trauma care service for Isolated First Nations in the Sioux Lookout Zone Expansion of the KO eHealth Telemedicine service model to all isolated and remote First Nations in Ontario

Referral and Data Collection Processes Challenges A recent analysis of this manual logging process has identified a number of pain points at which productivity (staff time) and data integrity (incomplete, missing or erroneous information) are impacted. Errors are introduced by faxing, correcting, and refaxing logging sheets Automated error checking and quality control processes are not possible because KOTM & NIHB staff must complete and review logging sheets by hand KOTM and NIHB staff each manually transfer the same hand-written information from the logging sheets to Excel workbooks. Results of the NIHB event tracking, eligibility assessment and financial valuation process do not accurately represent services delivered

Referral and Data Collection Processes Challenges The logging/referral sheet is the primary tool by which service volumes are documented by KOTM and assessed for eligibility and financial value by NIHB (non insured health branch) Logging is a wholly manual process, with as many as 5000 sheets being faxed and re-faxed in a given fiscal year

E-FORM DEVELOPMENT –PAIN POINTS 1.Loss of productivity – staff time for manual systems – staff from both NIHB and KOTM reviewing forms and logging sheets by hand to excel spreedsheet 2.Data Integrity – incomplete forms, missing or erroneous information 3.Non standard eligibility assessment and financial valuation process

E-FORM DEVELOPMENT FUTURE STATE KOTM is proposing an eHealth-enabled logging/referral template and workflow The e-logging project has 3 objectives:  Integration – NIHB logging e-Form will be part and parcel of KOTM’s scheduling workflow  Efficiency – NIHB logging e-Form will reduce staff time required to complete, check, track and transfer information  Scalability – NIHB logging e-Form will be scalable to other point of care telemedicine services

CONCLUSIONS Concluded that KO eHealth provides a highly valued and cost effective service and directly contributes to improved access to health and wellness services for remote and isolated First Nations in Ontario. KO eHealth will continue to work with First Nations to develop ehealth solutions to complement community health services.

THANKS! MERCI! MIIKWEHC! Acknowledgment to the communities and people of the KO Telemedicine served First Nation Communities For further information, please contact