The Effects of Telehealth on Canadian Health Workforce: Where is the Evidence

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The Effects of Telehealth on Canadian Health
Workforce Where is the Evidence?

• Jennett P, Person V, Watson M, Watanabe M
• Health Telematics Unit, Faculty of Medicine,
  University of Calgary, Calgary, AB

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Rationale

• Telehealth has been proposed to assist with
  health workforce concerns, and has the potential
  to dramatically influence the health workforce,
  yet there is very little published evidence -
  especially Canadian - to support and substantiate
  this commonly held belief.
• Canada and other countries with wide geographical
  dispersion of health professionals face serious
  concerns and challenges regarding equitable
  access to specialized health services.

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• National and provincial governments projected
  that telehealth could help equalize both rural
  and urban access to specialized health services
• Health care administrators proposed that
  telehealth could address long-standing health
  workforce issues such as problems of recruitment
  and retention of health care providers, and more
  appropriate use of limited health resources and
• Physicians and other health care professionals
  enthused that telehealth could alleviate such
  issues as feelings of professional isolation and
  "burn out".

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• As telehealth moves from pilot studies to full
  implementation, these factors hold the potential
  to have a substantial impact on issues highly
  relevant to planning for the health workforce
  such as
• The numbers and kinds of health care
  professionals
• Delivery approaches to health care
• Traditional roles, responsibilities, and
  skill-sets
• Changes due to clinical support
• Continuing education opportunities along with
• Improved morale and workloads.

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Methodology

• The Initiatives
• One initiative from each of Canadas ten
  provinces and two territories.
• Telehealth initiatives in the study included
• Consultative,
• Information/administrative, and
• Community-based telehealth activities.

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I. Consultative

• Eight initiatives with an emphasis on delivering
  consultation (or planning to deliver) services to
  rural and remote communities in diverse or
  various health fields were included.
• These were the
• Alberta Telepsychiatry Project (AB),
• Saskatchewan NorthEast Health District Telehealth
  Satellite Initiative (SK),
• Manitoba Speech Therapy on the Web (MN), (in beta
  phase)
• Hospital for Sick Children Telehealth Program
  (ON),
• Quebec Neo-Natal Tele-Echocardiography Project
  (PQ),
• The Telemedicine and Educational Technology
  Resources Agency (NF),
• WestNet/BaffinNet (NWT), and
• Yukon Telehealth Project (YT) - (in planning
  stage).

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II. Information Systems and Administration

• Provincial and federal health information systems
  designed to support decision-making by health
  professionals, managers and policy makers are
  emerging across Canada. The two initiatives in
  the survey -both in the early implementation
  phase- which focused on information management,
  were
• British Columbia Clinical Laboratory Support
  Project (BC) and
• Prince Edward Island - Island Health Information
  System (PEI).

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III. Community-based Programs

• Two other initiatives dealt with information, but
  with a somewhat different focus, and had shared
  objectives to support patients outside of
  traditional healthcare facilities and to direct
  care in the most appropriate venue.
• New Brunswick Tele-Care (NB) - full
  implementation, and
• Nova Scotia Home Care System (NS) - full
  implementation in 1999.

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The Questionnaire

• A questionnaire was developed with ten
  semi-structured, open-ended questions aimed at
  exploring
• the effect of each telehealth initiative on the
  distribution of expertise of health
  professionals,
• alterations in roles of health professionals,
• effect on skills base,
• recruitment and retention of health
  professionals,
• staffing of telehealth initiatives and
• the appropriate use of health care resources.

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The Interviews

• Initial telephone interviews with individuals
  involved in the telehealth projects, primarily
  project managers.
• Second telephone interview, six months following
  the initial interview, to confirm findings from
  the previous interview, and to provide any
  additional comments related to workforce issues.

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Results

• General Telehealth Workforce Outcomes
• Observed or Expected by Canadian Telehealth
• Project Managers

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General Telehealth Workforce Outcomes Observed or
Expected by Canadian Telehealth Project Managers

• Distribution of Expertise of Health Professionals
  
• Enhanced access to local expertise
• Improved care within the community
• Expanded access to Continuing Professional
  Education and Increased Skills Building for Local
  Providers
• Altered or Enhanced Roles of Health Professionals
  or Expanded Skills Base
• Newly acquired skill-sets and role sharing
• Enhanced multi-disciplinary care provision
• Positive Effects on Recruitment and Retention of
  Health Professionals
• Improved morale of local providers
• Increased access to clinical support

• Staffing of Telehealth Initiatives
• Project champion required for telehealth
  initiatives
• Integration into existing staff
• Additional staff and IT expertise
• Appropriate Use of Resources
• Increased volume of services provided locally
  alternative interventions to hospitalization
• Improved case management
• Allocation of provider time.
• Increased Productivity and Proficiency of health
  professionals
• Overcoming Limitations for Service
• Improved Co-ordination of Care Innovative
  Approaches to Care
• Additional Outcomes
• Training issues with the introduction of
  telehealth
• Informal telehealth networks.

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I. Distribution of Expertise of
Health Professionals

• In health care settings outside major urban
  centres especially rural, remote and isolated
  areas a mal-distribution of expertise has been
  documented. Primary health services are
  provided, but there is often a lack of specialist
  expertise to effectively address and manage
  advanced clinical demands.
• Patients must be transported to major centres to
  obtain consultation and care.
• Patient transfers can also create a discontinuity
  of care.
• Project managers report that telehealth provides
• Enhanced access to local expertise
• Improved care within the community
• Continuing Professional Education and Skill
  Building for Local Providers

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II. Altered or Enhanced Roles of
Health Professionals or Expanded Skills Base

• Telehealth has encouraged
• a move toward a multi-disciplinary approach to
  providing care,
• expanded opportunities for health care
  professionals to challenge themselves and fully
  explore their scope of practice.

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III. Recruitment and Retention of Health
Professionals

• Factors contributing to the recruitment and
  retention of health care professionals have been
  cited in the literature as including
• access to colleagues,
• opportunities for professional networking and
• continuing professional education.
• Project managers reported
• positive effects on the inter-disciplinary nature
  of telehealth in building rapport with
  specialists,
• an improvement in at least one of the factors in
  this area due to telehealth,
• improved professional relationships, and
• enhanced peer networking and support.

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IV. Staffing of Telehealth Initiatives

• The implementation of telehealth initiatives can
  produce many changes both subtle and overt on
  the available workforce.
• Staffing changes
• Project champion required
• Additional staff and IT expertise This may
  include the addition of one or more director,
  manager/co-ordinator, computer consultant,
  technical consultant, research/training
  consultant, administrative assistant, secretary,
  or receptionist.
• Integration into existing staff
• Training changes
• The training of people to use the system
  effectively is also relevant.

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V. Appropriate Use of Resources

• Telehealth has been vigourously promoted in its
  potential to streamline care and encourage the
  appropriate use of health resources. This
  appropriate use is intimately related to informed
  timely decisions.
• Increased volume of services provided locally
• Improved case management
• Allocation of provider time.
• Productivity of health professionals
• Overcoming Limitations for Service
• Improved Co-ordination of Care Innovative
  Approaches to Care

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VI. Additional Outcomes

• Other unexpected topics arose that were relevant
  to workforce issues. Most noteworthy was the one
  addressing the need for training and telehealth
  networks.
• Training issues with the introduction of
  telehealth
• Informal telehealth networks.

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Analysis

• Projects Stage of Implementation
• Eight of the telehealth projects (66.7) were in
  the implementation phase,
• Four were either in beta (BC, MN, NS) or planning
  (YT).

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• Coding of emerging themes
• distribution of expertise of health
  professionals,
• alterations in roles of health professionals,
• effect on skills base,
• recruitment and retention of health
  professionals,
• staffing of telehealth initiatives, and
• the appropriate use of health care resources.
• When data collection was complete all coding was
  verified for interpretation and consistency by
  two of the authors (PJ, MW). Specific quotes
  were captured to illustrate specific points.

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Discussion and Conclusions

• Until telehealth is more widely diffused, the
  total impact on workforce issues will not be
  known.
• Operational system integration across
  jurisdictions and disciplines, including public
  and preventative health, is essential for
  detailed answers.
• Implementation policy challenges remain.
• Quality proof of concept evaluation projects,
  based on operational networked applications with
  in the health system, are required to answer many
  outstanding questions specific to workforce
  areas.

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• Responses affirm findings from the literature.
• For example, that telehealth can assist in
  workforce areas such as
• improved distribution of expertise of health
  professionals
• improved care within the community
• improved morale of local providers
• expanded access to continuing professional
  education
• increased skills building for local providers
• altered and/or enhanced roles for health
  professionals
• newly acquired skill-sets and role sharing

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• positive effects on recruitment and retention of
  health professionals
• multi-disciplinary care provision
• increased productivity and proficiency
• increased access to clinical support
• reduced travel time for providers
• increased volume of care provided locally
• improved case management, and
• the fostering of innovative approaches to care.

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• Issues such as the need for training and
  telehealth networks require consideration.
• Lastly, the stage of telehealth implementation is
  closely associated with the impact on workforce
  requirements.
• We look to the future to guide us and for
  continued creative telehealth solutions to
  workforce concerns.

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References

• Please see handout

Acknowledgements

• The authors greatly acknowledge the
  contributions of the twelve project managers and
  their project teams who contributed substantially
  to the contents of this manuscript.

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Reprint Requests

• Reprint requests should be directed to
• Dr. Penny Jennett,
• Head, Health Telematics Unit,
• Professor, Faculty of Medicine,
• University of Calgary,
• Health Sciences Centre,
• 3330 Hospital Drive N.W.,
• Calgary, Alberta, Canada,
• T2N 4N1