Innovation

Health care connected

Award-winning program lets doctors talk to patients - wherever
they are

Award-winning program lets doctors talk to patients - wherever they are
Dr. James Zacharias says telehealth allows him to reach out to patients in northern and remote areas.
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National recognition for MBTelehealth

BY JOEL SCHLESINGER
Winnipeg Health Region
Wave, March / April 2011

It's about 9 a.m. on a Thursday morning in February, and the patient in Room D of the Local Centre Dialysis Clinic at the Health Sciences Centre campus is ready to go.

Within a few minutes, a succession of health-care providers appear - first a nurse, followed by a dietitian, a pharmacist, a social worker and a doctor. Each health-care provider has a specific mission: The nurse, for example, will discuss health education issues related to the patient's condition - renal failure brought on by kidney disease.

The social worker might discuss the patient's housing needs or the possibility of supplementing income so they can afford healthy food or drugs. The dietitian will discuss the right things to eat while on dialysis, while a pharmacist will talk about drug therapies and possible interactions with other drugs. And, finally, the doctor will discuss their overall condition.

It all seems pretty straightforward, except for one little thing: There is no patient in Room D - at least not in person. In fact, this morning's patient is actually at Thompson General Hospital's telehealth room, more than 700 kilometres north of Winnipeg. And instead of talking to the health-care team in person, he is communicating with them through a 27-inch television with a high-definition camera on top.

Welcome to the world of MBTelehealth. Administered by the Winnipeg Health Region, MBTelehealth is responsible for providing access to a high-speed telecommunications network that allows patients from more than 100 sites around the province to "visit" with health-care providers in Winnipeg and other regional health centres. In the case of the dialysis and renal health clinic, for example, as many as 12 patients each week tap into the specially designed high-speed connection to talk with clinical team members.

The telehealth system is also used for a number of other clinical purposes. For example, a doctor may use it to check on a pediatric patient with respiratory issues. In addition to linking up to talk to the patient, the doctor can use a digital stethoscope to effectively listen to his or her lungs over the telehealth network. The system has also been used to provide counselling to residents in remote areas who are losing their eyesight.

MBTelehealth is a prime example of how the Region uses technology to efficiently deliver quality care. And the efforts are not going unnoticed. Just last fall, MBTelehealth won an Award from COACH: Canada's Health Informatics Association for telehealth technology innovation. Previously, it received the Canadian Society of Telehealth (CST) Award of Excellence in 2007. The recognition is a reflection of just how far MBTelehealth has come since it was established in 2001.

"We have been pioneers in building a province-wide telehealth system that is responsive to local needs," says Liz Loewen, Director, Coordination of Care, Manitoba eHealth. "We really started from scratch. We didn't have scheduling software or a service desk," she says in reference to two of the tools required to run a telehealth system.

But over time, the system has grown and been strengthened through new staff with new skills and ideas. "We also work closely with local stakeholders and funding partners at each site, including clinicians, regional health authorities, Manitoba Health, First Nations and First Nations Inuit Health. The strength of the network is a result of those relationships," says Loewen.

The effort is paying off. "Our hard work has been acknowledged through awards and through the contacts we continue to receive from other networks asking how we're doing it," says Loewen.

The Local Centre Dialysis Program, part of the Manitoba Renal Program, started taking advantage of MBTelehealth's services in 2009. Dr. James Zacharias, Medical Director for the LCDP, says the ability to participate in digital video-conferencing in real-time, right from their clinic, significantly improves the delivery of care to patients in remote areas. "We started in 2009 because we asked for and received a telehealth connection which enabled us to work these patients into our clinics," says Zacharias.

Located on the HSC campus, the clinic has a total of four examination rooms, including one that was transformed into a room for telehealth patients. "You don't have to trudge all the way over to a special desk to video-conference," he says. "If you go into Room A, there's a person who is physically there - same with Room B and C. But in Room D, there happens to be what I call a "virtual patient," but it's not really. It's a patient via telehealth." The picture is crystal clear, and there is virtually no lag time, making the discussion between patient and health-care provider seamless.

The arrangement could not have come at a better time. Almost a quarter of Manitoba's more than 800 dialysis patients normally make the trek to the Health Sciences Centre at least once a year to meet with kidney health specialists. Many travel hundreds of kilometres at great expense - covered mostly by the province. "For some of the people coming from Thompson, for instance, they don't pay necessarily, but the system pays $1,400 round-trip," Zacharias says, adding that patients may have to come to the clinic in Winnipeg as many as six times a year in rare cases, especially before they start dialysis.

But thanks to telehealth, a Winnipeg-based specialist can talk to a patient in Norway House, Thompson, Swan River, The Pas, or any one of the more than 100 MBTelehealth sites across the province. In any given week, the Local Centre Dialysis Clinic might see eight patients, with 25 per cent of the visits via telehealth. That's in addition to the weekly follow up telephone calls to various units around the province.

Although patients can be several hundred kilometres away, the meeting with the health-care specialists doesn't differ much from an in-person appointment. The doctor can even use a specialized camera to focus in on a problem - like a pesky skin ulcer that doesn't seem to want to heal, a common problem for people with renal failure.

The MBTelehealth consultations are an important component of the overall care program for patients with kidney disease throughout the province. Manitoba has the highest rate of kidney disease in Canada, with many of its cases in remote First Nations communities. Zacharias says First Nations are especially prone to kidney disease, often caused by chronic illnesses like diabetes. While these conditions can be managed, in many cases they can lead to kidney failure.

As a result, patients need renal dialysis - a treatment in which blood is effectively cleaned by a machine. The province has set up a network of soon to be 16 centres where patients in need of dialysis can come, usually three times a week.

The dialysis machine assumes the role of the kidneys, removing mineral by-products from blood. Without the treatment, these insoluble minerals would build up and eventually cause widespread problems with other organs, such as fluid build-up in the lungs or an infection of the heart muscle. If left untreated, kidney failure is fatal, as the body is no longer able to balance mineral and chemical levels in the blood.

Even though their dialysis needs are being met in the community, these patients still need regular supervision by specialists, who are often only located in major centres such as Winnipeg. "We've generally always brought patients down to Winnipeg to the clinic," Zacharias says. "Every once in a while, we fly up and see them."

But the need for travel can pose a problem."It is a tremendous, often difficult journey coming to Winnipeg," Zacharias says. "Even if they don't have to pay for travel, driving in a car, riding a bus or flying in a plane is often very hard if you're not feeling well." Often, the patients will have to stay overnight, an additional cost, and all for what is really a two-hour visit.

With telehealth, a nurse and physician at one of the clinics up north can provide most of the physical examination, including doing bloodwork, and send the results to the team of specialists in Winnipeg. Nurses and doctors at the clinic in Winnipeg can also perform a physical exam on the patient using the camera and some online diagnostic tools, such as a digital stethoscope, if need be. Zacharias says that can be tricky at times because of the complexity of some cases. "That's why we ended up having the docs up north do the physical exam."

Nonetheless, the reviews of the telehealth system from both staff and patients have been glowing. "We did a patient satisfaction survey when we were piloting the project, and universally, they were overjoyed," he says.

"They thought the experience was good, that it was close to being like an in-patient experience, and that it benefitted them."

Moving forward, the Manitoba Renal Program is also piloting a telehealth program for patients who are not yet on dialysis. "These are nephrology clinic patients with kidney disease who may or may not end up on dialysis, but we are now transitioning them to be seen primarily by telehealth," says Zacharias. "The current model is they come to Winnipeg - again at a fair amount of cost - and they may come anywhere from once to, in rare cases, six times a year as they transition to dialysis."

Again, the patients have access to a "very robust multidisciplinary clinic" with a nurse, a social worker, a pharmacist, a dietitian and a physician who provide care. As with those on dialysis, educating the patients about kidney disease, how to care for themselves, and the different treatments that are available is a major component of this clinic. "We have to have them choose what kind of dialysis they want, so we have to give them modality education."

The pilot endeavours to deliver much of this care via MBTelehealth. But to supplement the virtual clinic, a nurse specialist at the satellite clinic - in Thompson, for instance - can provide additional education and primary care, such as taking the patient's blood pressure and doing bloodwork.

The pilot, which began Feb. 1, only has one patient at the moment. But like those involved in the dialysis follow-up clinics via telehealth, the patient is pleased, Zacharias says.

Over the next decade, both the pilot program for pre-dialysis patients and the current clinical program for patients on dialysis will play a lead role in providing care for what is believed to be a rising tide of kidney disease in Manitoba. The number of Manitobans with diabetes in the province is expected to grow by an estimated 48 per cent over the next decade, according to the Canadian Diabetes Association. Zacharias says about 40 per cent of patients treated through the program suffer from diabetes.

MBTelehealth will be instrumental in helping to contain escalating healthcare costs. But more importantly, it will improve the quality of care being delivered to patients in remote areas of the province whose previous choices were travelling great distances to meet medical specialists in person or discussing their issues over the phone.

"As much as we're used to working over the telephone, the ability to have that personal linkage where you can see the patient allows us to make a lot of assessments that could previously only be made in person," Zacharias says.

"The patient also feels like they've been seen, whereas a telephone conversation doesn't provide that same level of connection."

Loewen agrees. "The years ahead are going to be exciting as we build on this and begin to branch into new areas, more sites, more users and other systems to build a truly co-ordinated care network."

Joel Schlesinger is a Winnipeg writer

About Wave

Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.

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