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The use of remote presence for health care delivery in a northern Inuit community: A feasibility study


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To evaluate the feasibility of remote presence for improving the health of residents in a remote northern Inuit community. A pilot study assessed patient's, nurse's and physician's satisfaction with and the use of the remote presence technology aiding delivery of health care to a remote community. A preliminary cost analysis of this technology was also performed. This study deployed a remote presence RP-7 robot to the isolated Inuit community of Nain, Newfoundland and Labrador for 15 months. The RP-7 is wirelessly controlled by a laptop computer equipped with audiovisual capability and a joystick to maneuver the robot in real time to aid in the assessing and care of patients from a distant location. Qualitative data on physician's, patient's, caregiver's and staff's satisfaction were collected as well as information on its use and characteristics and the number of air transports required to the referral center and associated costs. A total of 252 remote presence sessions occurred during the study period, with 89% of the sessions involving direct patient assessment or monitoring. Air transport was required in only 40% of the cases that would have been otherwise transported normally. Patients and their caregivers, nurses and physicians all expressed a high level of satisfaction with the remote presence technology and deemed it beneficial for improved patient care, workloads and job satisfaction. These results show the feasibility of deploying a remote presence robot in a distant northern community and a high degree of satisfaction with the technology. Remote presence in the Canadian North has potential for delivering a cost-effective health care solution to underserviced communities reducing the need for the transport of patients and caregivers to distant referral centers.
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The use of remote presence for health
care delivery in a northern Inuit
community: a feasibility study
Ivar Mendez
*, Michael Jong
, Debra Keays-White
Gail Turner
Remote Medicine Program, Division of Neurosurgery, Dalhousie University and Queen Elizabeth II Health
Sciences Centre, Halifax, NS, Canada;
Faculty of Medicine, Memorial University, St. John’s, NL, Canada;
Health Canada, First Nations and Inuit Health Branch Atlantic, Halifax, NS, Canada;
Nunatsiavut Department of Health and Social Development, St. John’s, NL, Canada
Objective. To evaluate the feasibility of remote presence for improving the health of residents in a remote
northern Inuit community.
Study design. A pilot study assessed patient’s, nurse’s and physicians satisfaction with and the use of the
remote presence technology aiding delivery of health care to a remote community. A preliminary cost analysis
of this technology was also performed.
Methods. This study deployed a remote presence RP-7 robot to the isolated Inuit community of Nain,
Newfoundland and Labrador for 15 months. The RP-7 is wirelessly controlled by a laptop computer equipped
with audiovisual capability and a joystick to maneuver the robot in real time to aid in the assessing and
care of patients from a distant location. Qualitative data on physician’s, patient’s, caregiver’s and staffs
satisfaction were collected as well as information on its use and characteristics and the number of air
transports required to the referral center and associated costs.
Results. A total of 252 remote presence sessions occurred during the study period, with 89% of the sessions
involving direct patient assessment or monitoring. Air transport was required in only 40% of the cases that
would have been otherwise transported normally. Patients and their caregivers, nurses and physicians all
expressed a high level of satisfaction with the remote presence technology and deemed it beneficial for
improved patient care, workloads and job satisfaction.
Conclusions. These results show the feasibility of deploying a remote presence robot in a distant northern
community and a high degree of satisfaction with the technology. Remote presence in the Canadian North
has potential for delivering a cost-effective health care solution to underserviced communities reducing the
need for the transport of patients and caregivers to distant referral centers.
Keywords: Aboriginal health; air transport; health care costs; patient care; patient satisfaction; remote presence; robots;
rofound disparities in the provision of health care
services to Canadians who live in the north have
had a major negative impact on their life expec-
tancy. Indigenous inhabitants such as the Inuit are the
most vulnerable ethnic group in the Canadian North and
have an average life expectancy that is 11 years lower
than the rest of Canadians (1). A low population density
within a vast and remote territorial expanse in the context
of jurisdictional issues, socio-economical and historical
realities have contributed to this inequality in health
status. Inuit have higher rates of preterm birth, stillbirth
and infant mortality than other Canadians (2). The
incidence of chronic diseases, substance abuse and inju-
ries continue to increase in Inuit communities (3). Sixty-
eight percent of Inuit children aged 614 years report
being hungry on a regular basis (4) compared to 1.2%
of children in other Canadian families (5). Infectious
diseases such as lower respiratory tract infections are 11
times more frequent in Nunavik than in other Canadian
regions (6) and Inuit women have higher rates of human
papilloma virus infections compared to other Canadian
women (7).
Int J Circumpolar Health 2013. # 2013 Ivar Mendez et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution-
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Citation: Int J Circumpolar Health 2013, 72: 21112 -
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Health expenditure per capita in the Canadian North
is higher than in the rest of Canada (8). For example, the
per capita health expenditure in Nunavut is 2.7 times
greater than the national average and constitutes more
than 30% of its GDP, the highest in the world. These high
levels of health care expenditure do not correlate with
improved health indicators. This failure to achieve better
health outcomes despite high levels of spending is multi-
factorial and complex (9). Although historical, cultural,
socio-economic and geographical dynamics are at play,
the model of health care delivery to remote communities
in the Canadian North may be a critical factor in this
Remote northern Canadian communities typically have
community health clinics that are staffed by advanced
care regional nurses who practice in an extended role
with the support of off-site family physicians located
in regional health centers that help with the delivery of
elective and emergent care. Although there are periodic
visits from physicians to the remote clinics, the system
relies heavily on air transport as the main conduit for
accessing physician care in the regional or specialized
referral centers (9). The reliability and sustainability of
air transport in providing services to remote locations
is heavily dependent on financial resources and climatic
conditions which are unpredictable in the North. Tele-
medicine has opened the door for the development of
solutions that may help address the unmet needs of
remote communities. Although telemedicine applications
in the Canadian North were initially conducted in the late
1970s and early 1980s (10,11) with some focused programs
having been successful over the years (1214), the adop-
tion of telemedicine as a widespread and effective pathway
for health care delivery to remote northern communities
has not occurred. Several barriers and challenges have
impeded the adoption of telemedicine as a routine strat-
egy for the effective and timely delivery of health care
to underserviced remote regions (15,16). As part of our
telehealth partnership program, we have explored the
feasibility of using a remote presence robot to deliver real-
time physician expertise to Nain, a remote Inuit commu-
nity in northern Newfoundland and Labrador, Canada.
The Nain community health clinic
The community of Nain is located at the northern tip
of the province of Newfoundland and Labrador, on
Canada’s east coast and is the administrative capital of
Nunatsiavut, the newest Inuit land claim. Nunatsiavut is
located on a geographically diverse area of approximately
72,000 km
of land and 48,690 km
of sea that is home
to a population of about 2,200 Inuit. The community of
Nain has 1,188 residents (17) and is served by a com-
munity health clinic staffed by 6 regional nurses.
The Nain clinic provides primary care to the commu-
nity (it is not an inpatient facility) with 4 holding beds
and a treatment room with basic resuscitation equipment.
The referral center for the Nain Clinic is at the Labrador
Health Center in Happy Valley-Goose Bay, 367 km south
of Nain. Emergency or urgent care patients are evacuated
to the referral center by air. Although a physician from
the Labrador-Grenfell Regional Health Center visits
Nain once a month, patients requiring further diagnostic
tests or assessment are transported by air to Happy
Valley-Goose Bay or the tertiary care referral center in
St. Johns, 1,207 km away.
Physician support for the Nain nurses has been mainly
through telephone complemented in the past 5 years with
videoconferencing equipment and a telehealth coordina-
tor stationed in Happy Valley-Goose Bay. Air transport
from Nain to the referral centers is dependent upon
weather conditions and restricted to the day time as the
Nain runway has no night time capabilities.
Remote presence robot
To provide physician remote presence expertise to the
Nain clinic, we used the RP-7 remote presence robot (In
Touch Health Inc., Santa Barbara, CA, USA). The RP-7
has been designated by the US Food and Drug Admin-
istration (FDA) as a class II medical device and fulfills
the US FDA requirements for active patient monitoring
in clinical situations in which immediate clinical action
may be required (18). The RP-7 was flown to Nain and
deployed in the community clinic, the robot was nick-
named ‘‘Rosie’’ by the clinical staff in Nain. Physicians in
the referral center in Happy Valley-Goose Bay and nurses
in the Nain clinic were trained on the use of the system
before its operation.
The RP-7 is controlled wirelessly by a laptop computer
(control station) equipped with headphones, microphones
and a joystick to maneuver the robot in real time. The
RP-7 is 165 cm in height and has a wheeled triangular
base of 6376 cm, roughly comparable to the size of a
human. The robot can travel at speeds of about 3 km/h
and has an 8-h rechargeable battery (Fig. 1).
The head of the RP-7 has a mobile flat screen monitor
that displays the image of the operator and a picture-in-
picture window that displays the image of the person
standing in front of the robot. The head of the robot
is movable and is fitted with two sophisticated digital
cameras as well as audio, microphone and amplification
components allowing for real-time two-way audiovisual
communication (Fig. 1B). The robot also has a digital
stethoscope, privacy handset and a printer capable of
providing hard copies of orders and recommendations
with the digital signature of the physician conducting the
remote presence clinical session (Fig. 1C). Connectivity
between the control station and the RP-7 robot is pro-
vided by a standard 802.11 Wi-Fi internet link.
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Citation: Int J Circumpolar Health 2013, 72: 21112 -
The control station allows the clinician to have real-
time control of the robot’s movement, videoconferencing
systems, digital stethoscope and printer. The clinician
operating the robot is able to telestrate using a cursor
that is seen in the robot’s head screen. Telestration is
important, as the clinician can use it to impart real-time
visual instructions in the remote location environment
such as pointing to the patient’s anatomy while conduct-
ing a physical examination with the aid of a nurse (Fig. 2).
The control station is also capable of storing video and
still images of the remote presence sessions for further
analysis and archival purposes.
The project duration was 15 months, from January 1, 2010
to March 31, 2011, and data were collected using a com-
bination of surveys, qualitative interviews and compiling
information on travel and communication costs as well as
the network time used during the RP-7 sessions. As regu-
lar videoconferencing continued to be used in Nain, com-
parison data were collected for the same period of time.
Evaluation forms were completed after each remote
presence session by the physician, the Nain nurse and
the patient or caregiver accompanying the patient. The
remote session surveys provided data on the demograph-
ics of the patients, diagnosis, outcome after the session,
ease of RP-7 use as well as the participant’s satisfaction
with the session.
A third-party evaluator conducted qualitative inter-
views at the end of the project with physicians and nurses
participating in the study. Data on the number and cost
of air transport, accommodation and meals for Nain
patients and caregivers accompanying the patient for the
period of this study were collected. The number and
duration of RP-7 activations were recorded. Activations
were divided into 3 session categories; clinical sessions,
education sessions and technical/maintenance activations.
Remote presence usage
There were 252 activations of the RP-7 robot during the
15-month study period of which the majority (89%) were
for patient care (Table I). There was an average of 11.8
robotic remote presence clinical sessions per month.
During this time, regular videoconference clinical ses-
sions remained relatively stable from 9.3 per month prior
to commencement of the project to 7.8 per month during
Fig. 1. Photographs of the (A) RP-7 remote presence robot that is 165 cm in height and has a 63 76 cm wheeled triangular base;
(B) a close-up view of the RP-7 monitor and the two affixed high-resolution cameras; and (C) is capable of connecting diagnostic
peripherals, such as a stethoscope. The RP-7 robot has a printer (P) for printing orders and prescriptions from the referring physician
and a telephone handset (H) for private communication with the distant physician.
Remote presence in the Canadian North
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the course of the study. The combination of the RP-7
clinical sessions and regular videoconferencing sessions
represented a 150% increase in telehealth access to the
residents of Nain. Forty-nine percent of the clinical
sessions were for mental health care assessments and
follow-up. Although only 3% of RP-7 activations were for
purely education purposes, the Nain nurses placed a high
value on these sessions, and reported that in 50% of the
clinical sessions they had learned something new.
Impact on air transport
Air transport of patients from remote communities to
the referral center is a major economic burden to health
care delivery in remote northern Labrador communities.
There are two methods for transporting patients by air
from Nain to the referral center in Happy Valley-Goose
Bay; (1) Medical Evacuation (Medivac) which is a
dedicated flight for patient transport or (2) a regularly
scheduled commercial flight. The costs associated with
these two flights are significantly different. A regularly
scheduled flight costs $875 CND round trip, in compar-
ison to a Medivac flight, which costs $1,800 CND one-
way (not included escort costs and call-back costs for
ambulance dispatch staff). Other costs that are incurred
when patients are referred for outpatient assessments and
diagnostic tests to the Happy Valley-Goose Bay Center
are accommodations ($150 CND per night) and meals
($29 CND per day). These costs are also applicable to the
patient’s caregiver/translator that usually accompanies
the patient on these trips. The flight costs are subsidized
by the provincial government and the associated costs
of travel are born by the Nunatsiavut government-
administered Non-Insured Health Benefits Program.
Analysis of air transportation parameters for 47
remote presence sessions where data were complete in-
dicated that in 60% of those cases air transport to the
referral center was avoided, where it normally would have
been considered (Table II). In those cases, the physician
conducting the remote session felt satisfied that the
Fig. 2. Photographs of the RP-7 remote presence robot, nicknamed ‘‘Rosie’’ (A) at a patient’s bedside assessment; (B) the remote
physician interacting with the patient and the clinical team in Nain; (C) control station used by the remote physician conducting the
clinical assessment in the Nain clinic and (D) snapshot of the control screen for the RP-7 remote presence robot.
Table I. Purpose for activation of the remote RP-7 robot during
a 15-month period in Nain, Labrador
Type of session % of sessions (252 total)
Initial consult 20
Follow-up 44
Emergent/urgent 25
Charting/nurse consult 7
Education/in-service 3
Technical/maintenance 1
Total 100
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Citation: Int J Circumpolar Health 2013, 72: 21112 -
patient could be effectively managed and followed in
Nain and did not require transport to the referral center.
Furthermore, 7 of the 14 patients who were assessed
using the RP-7 robot for emergency or urgent reasons
and would have potentially required Medivac transport,
were effectively managed in Nain Of these 7 patients,
6 patients (43%) were deferred to a regularly scheduled
commercial flight and only 1 patient (7%) required a
Medivac flight (Table II).
Satisfaction assessments
The learning curve for driving the RP-7 robot is not steep
as the controls and operability are very intuitive. Parti-
cipating physicians required approximately 1 h of training
prior to being comfortable in operating the RP-7 robot.
All physicians participating in the project indicated that
the technical capabilities of the RP-7 robot were superior
to that of the conventional videoconference setup for
telehealth delivery routinely used in Nain (Fig. 2). There
was a high degree of satisfaction with use of the RP-7
robot for making real-time clinical decisions, patient
follow-up and enhanced interaction with both nurses
and patients. Furthermore, 100% of physicians felt the
RP-7 improved clinical collaboration with nurses, facili-
tated workflow and decreased stress levels when making
diagnostic and management decisions from a distant
central location.
Deployment of the RP-7 robot in Nain had a very
positive impact on the nurses with 100% of the nurses
feeling that the RP-7 robot was superior to the conven-
tional videoconference telehealth setup. Eighty-four per-
cent of the nurses felt that remote presence facilitated the
diagnosis and management of the patient and 80% of
nurses reported that the RP-7 robot facilitated physician
patient interaction. All nurses reported that improved
access to physician support in real time as provided by
the RP-7 robot could facilitate retention and recruitment
of nurses to remote northern communities in Canada.
There was a high degree of satisfaction amongst patients
being evaluated in the Nain clinic using the RP-7 robot
by physicians located in the referral center. Ninety-five
percent of the patients indicated that they would use the
RP-7 robot again for their clinical evaluations, with 84%
of patients reporting that they were ‘‘very comfortable’’ in
their interaction with the assessing physician using the
RP-7 robot. In 53% of the remote presence sessions, an
interpreter or family member accompanied the patient.
Ninety percent of those caregivers felt that the use of the
RP-7 robot was very helpful in promoting interaction
with the physician conducting the session.
The Nain experience
This is the first experience using a remote presence
robot to provide real-time physician expertise to a remote
community in the Canadian North. The transport,
deployment and operation of the RP-7 robot in the
Nain clinic were straightforward and well-received. The
learning curve for physicians and nurses in the routine
operation of the RP-7 robot was not steep and could be
accomplished with about 1 h of training. Physicians and
nurses reported that the intuitive controls of the robot, its
mobility, stable connectivity, high-resolution cameras and
two-way audiovisual capabilities were distinct advantages
over the conventional videoconference setup for tele-
health routinely used in Nain. The ability to drive the
RP-7 robot to the patients’ location and have high-
resolution real-time audiovisual connectivity with the
patient, nurses and family members improved both the
physicians’ and nurses’ comfort with the clinical assess-
ment as well as enhanced the interaction with the patient.
All physicians and nurses reported that use of the RP-7
robot improved workflow and reduced stress levels.
Nurses reported that the higher level of collaboration
with physicians during remote presence sessions was
paramount to gaining community confidence in the new
technology. This collaboration was particularly effective
during mental health sessions that represented 49% of all
remote presence sessions. Those sessions were reported to
be ‘extremely helpful’’ in managing the high prevalence
of mental health issues in the community. The nurses also
felt that remote presence technology may have a crucial
impact in retention and recruitment of nurses to isolated
northern communities and empower them to provide a
Table II. Remote presence assessments performed and the outcome of the sessions
Assessment Medivac Scheduled flight Number of transport required Total
Initial consult 0 0 10 10
Follow-up 9 3 11 23
Emergent/urgent 1 6 7 14
Total 10 9 28 47
% of total 21 19 60 100
Remote presence in the Canadian North
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wider range of services in collaboration with real-time
input from physicians using remote presence.
The acceptance of the RP-7 robot by patients was
very high with 95% of the patients indicating that they
would use the RP-7 robot again and 84% reporting being
‘‘very comfortable’’ interacting with their physician via the
robot. Having access to physician expertise in their own
community without the need for transport to the referral
center has profound implications on the attitudes of the
community for seeking medical attention. These attitudes
have been influenced by historical events in northern
Canadian communities related to tuberculosis outbreaks
as far back as two generations ago. It is possible that the
availability of remote presence systems such as the RP-7
robot and an increase in their sophistication for point-of-
care diagnosis, such as real-time blood chemistry analysis,
portable imaging systems, electrophysiological assessment
tools and other diagnostic implements will not only
change these attitudes but also remove barriers of distance
and time for providing effective health care to under-
serviced populations such as Nain.
Although health expenditures per capita in the Cana-
dian North are high, they are not correlated with
improved health care access or health indicators. The
model of care in the Canadian North relies heavily upon
transportation of patients by air to regional referral
centers for hospital admissions, outpatient clinical assess-
ments, follow-up and diagnostic tests. The costs of flights
and other associated expenses such as meals and accom-
modation for the patients and in many cases their
companions can be overwhelming (9). Providing effective
clinical care using remote presence devices and avoiding
unnecessary air transportation to referral centers can
significantly improve the cost-effectiveness of health care
provision in the Canadian North. Our results in Nain
provide some initial evidence that remote presence can
dramatically reduce the number of flights to a distant
referral center by about 60%. Although a reduction in the
number of flights could lead to obvious savings in the costs
associated with transportation and accommodation of
patients, redirection of this money to the timely diagnosis
and improved management of patients in remote commu-
nities is the foremost benefit of remote presence.
Robotic telepresence
Developments in robotic and telecommunications tech-
nology may help address the provision of medical ex-
pertise in underserviced remote communities. In fact,
there is growing evidence for the benefits of the RP-7
robotic system in clinical applications and telementoring.
One of the earliest applications of the RP-7 has been in
critical care where there is a chronic shortage of intensi-
vists and increasing demands, resulting in challenges
for providing on-site coverage (19). Several studies have
demonstrated the utility of remote presence using the
RP-7 in providing critical care coverage, resulting in
decreased lengths of stay in the intensive care unit
(ICU), reduced unexpected events, cost savings and high
satisfaction scores by patients, ICU staff and intensivists
(20,21). Furthermore, a recent study has showed that
robotic telepresence was viewed positively by ICU
patients and their families and they felt that the use of
the RP-7 was beneficial to their care and indicated their
support for its continued use (22). Remote presence has
also been recently used for the treatment of stroke through
acute thrombolytic therapy, where it has been crucial for
facilitating remote neurological assessments reducing the
time for onset of therapy, thereby resulting in improved
neurological outcomes (2325). Use of the RP-7 in the
perioperative follow-up of patients undergoing laparo-
scopic gastric bypass showed significant savings by
decreasing the length of stay (26).
Robotic telepresence has also been used in surgical
mentoring, the RP-7 and its earlier version the RP-6
were used in mentoring laparoscopic surgery for adult
and pediatric procedures and considered very useful and
reliable for mentoring minimally invasive surgery (27,28).
Long-distance telementoring in laparoscopic urological
procedures has also been performed with the RP-7 system
(29), and we have also used a remote robotic telecollabora-
tion system capable of controlling robotic arm movements
for long-distance telementoring of cranial and spine
surgeries (30).
Remote presence systems provide an expert the ability
to telementor in real-time, a non-expert individual to
perform sophisticated diagnostic tests. Complex ultra-
sound examinations under real-time remote guidance
have been conducted aboard the International Space
Station where crewmembers in orbit performed thoracic,
vascular and echocardiographic examinations under the
guidance of an earth-based expert (31). Furthermore,
a recent study has shown the feasibility of telementor-
ing paramedics with no previous experience to perform
ultrasound trauma assessments with great accuracy under
the guidance of a remote expert (32).
Our experience in Nain showed that physicians in a
regional referral center were able to provide real-time
medical expertise to nurses in a remote Canadian Inuit
northern community for the diagnosis and management
of patients seen on an emergency or elective basis at
the community health clinic. High satisfaction scores by
physicians, nurses and patients using the RP-7 robot and
a reduction of patient transport to the referral center
strongly suggest that remote presence may help provide
effective and cost-efficient health care delivery to remote
communities lacking on-site physician expertise.
Potential barriers
Potential barriers for the implementation of remote
presence in remote communities would not likely be
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Citation: Int J Circumpolar Health 2013, 72: 21112 -
technological. The exponential advances in the telecom-
munications, robotics and mobile device industry provide
a solid platform for implementing remote presence
systems such as the RP-7 robot used in Nain. The barriers
are likely to be related to issues pertaining to medical
liability, jurisdictional legal considerations, provider re-
muneration, data and patient confidentiality, competing
health priorities, and the lack of regional and national
strategies and standards for implementation of this type
of telemedicine application. A recent study examining the
barriers for implementing robotic telemedicine has deter-
mined that the top barriers for adoption of telemedicine
solutions in emergency and critical care are regulatory
barriers for physician’s privileges, financial barriers for
billing of remote presence services and resistance to the
change of established clinical paradigms (16). However,
the explosive increase in the use of consumer mobile
devices for medical applications may force streamlining of
the regulatory and remuneration issues. Public expecta-
tions and pressure for cost-effective and decentralized
health care provision may play a significant role in
removing cultural barriers to remote presence medicine,
especially in underserviced communities such as Nain in
the Canadian North. The acceptance of patients and their
families to remote presence solutions for health care
delivery is quite favorable (22). In this study, 95% of the
patients indicated that they would use the RP-7 robot
again for their clinical evaluations.
Health expenditure per capita in the Canadian North
is higher than in the rest of Canada (8); however, they are
not correlated with improved health indicators or health
care access within northern communities. Although the
costs of emerging technologies such as the RP-7 are
initially high (the RP-7 cost is approximately $145,000
USD), it will decrease substantially as the adoption of the
technology increases and savings in air transport would
foreseeably offset its costs.
Future directions
This study established the feasibility of using the RP-7
remote presence system to provide real-time access to
physician expertise in a remote northern Inuit community.
This initial experience was felt to be so positive for the
community of Nain that the Nunatsiavut Government
has decided to deploy an RP-7 robot in the community
permanently. This is a great opportunity to explore long-
term impact of remote presence technology for health care
delivery in remote northern Canadian communities.
Although consumer portable communication devices
such as smart phones and tablets are being increasingly
used to transmit medical information, it is likely that
portable remote presence devices that fulfill standards and
regulatory parameters for dedicated medical use will see
more widespread use due to their enhanced capabilities.
Cellular phone networks have grown exponentially in the
world. The latest survey by the International Commu-
nication Union indicated that by 2010, 90% of the world’s
population was covered by mobile cellular networks
and that the number of mobile cell subscriptions was
approaching 6 billion (33). Mobile broadband is also
increasing with 4G connectivity rapidly becoming the
norm and will likely continue to increase allowing for the
transmission of more complex data. This exponential
advance in telecommunications technology may be a
powerful and cost-efficient tool in narrowing the gap of
inequality in health care delivery to remote northern
communities in the near future.
The authors thank K. Adam Baker (Atlantic Clinical Consultants)
for his assistance in the formatting and editing of this article and
Tatjana Vukoya for her help with the figures.
Conflict of interest and funding
The authors have not received any funding or benefits from
industry or elsewhere to conduct this study.
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*Ivar Mendez
Division of Neurosurgery
QEII Health Sciences Centre
Halifax Infirmary
#3806-1796 Summer Street
Halifax, NS B3H 4H7, Canada
Tel: 1-902-473-7046
Fax: 1-902-494-4013
Ivar Mendez et al.
(page number not for citation purpose)
Citation: Int J Circumpolar Health 2013, 72: 21112 -
... Nunavut is the largest geographical region in Canada, representing 20% of the country [1]. With a large land mass and remoteness, Nunavut has faced challenges in healthcare delivery and availability of services, often within the context of historical injustice and oppression, and with social disparities that persist today [2][3][4]. Nunavut has some of the highest rates of suicide and mental health issues across the country [4][5][6][7][8]. Previous literature has suggested that involvement with the criminal justice system is frequently an initial stop for individuals in Nunavut with mental disorders and/or those without access to the appropriate care [9,10]. ...
... With a large land mass and remoteness, Nunavut has faced challenges in healthcare delivery and availability of services, often within the context of historical injustice and oppression, and with social disparities that persist today [2][3][4]. Nunavut has some of the highest rates of suicide and mental health issues across the country [4][5][6][7][8]. Previous literature has suggested that involvement with the criminal justice system is frequently an initial stop for individuals in Nunavut with mental disorders and/or those without access to the appropriate care [9,10]. ...
... Nunavut has the highest government health expenditures per capita in Canada [21,24]. Despite this finding, on average, the territory reports a substantially worse health status than the rest of the country, including mental health [2,4,24,25]. Similar to many Arctic regions, Nunavut has faced challenges in establishing efficient mental healthcare systems for the sparsely populated region [2,4,26]. ...
There is a paucity of research on forensic psychiatry patients from Nunavut, including no published data concerning the prevalence and characterisation of patients in this territory. The lack of basic information hinders the evaluation of services and establishing best practices. The current paper aims to characterise forensic psychiatry patients from Nunavut and further the understanding of the challenges in organising forensic psychiatry healthcare in Nunavut. A retrospective chart review design was used to examine individuals from Nunavut who are engaged with the Ontario forensic psychiatry system. The sample included all Unfit to Stand Trial (26.7%) and Not Criminally Responsible (73.3%) patients (N = 15) under the jurisdiction of the Nunavut Review Board in a one-year period. The average distance between the patient's place of residence in Nunavut and the Ontario facilities was 2,517 km. Overall, 26.7% were living in Nunavut, 60.0% remained in Ontario, and 13.3% resided in Alberta. Results are presented for sociodemographics, forensic status, personal and familial history, psychiatric and criminal history, diagnoses, index offence characteristics, treatment, assessment tools, and aggression. The prevalence and many characteristics of forensic psychiatry patients from Nunavut differ from the rest of Canada and have important implications for the delivery of services.
... 25,26 Experience in a remote Inuit northern community found deploying a remote-presence robot feasible, cost-effective and highly satisfactory by patients, caregivers, nurses and physicians deeming it as improving patient care, workload, and job satisfaction. 27 Pharmacists have a substantial opportunity to extend their care to patients in underserviced community hospitals by using a mobile robotic platform to care for patients. In addition, due to recent changes in pharmacy practice, because of pandemic-related precautions on distancing and shortage of personal protective equipment, exploring the use of a telepresence robot as an alternative to in-person care may lead to less stress to the system. ...
... Our exploration of patient satisfaction with patient/pharmacist interaction with the telepresence robot discovered an experience similar to reported results of physicians providing health care via telepresence robot in a northern rural community hospital study. 27 As well, the high rate of unintentional admission and hospital discharge medication list discrepancies found in the literature 1-3 resembled our results. ...
Introduction: Medication reconciliation (MedRec) reduces the risk of preventable medication-related adverse events (ADEs). A best possible medication discharge plan (BPMDP) is a revised list of medications a patient will take when discharged from hospital; a pharmacist review ensures accuracy. For many hospitals, on-site pharmacists are non-existent. Extension of a visual presence via a mobile robotic platform with real-time audiovisual communication by pharmacists to conduct MedRec remains unstudied. This study explored patient perceptions of a pharmacist-led BPMDP using a telepresence robot. Time requirements, unintentional discharge medication discrepancies (UMD), programme inefficiencies/barriers and facilitators involved in pharmacist review of the discharge medication list and patient interviews were also described. Methods: This prospective cohort study enrolled adult patients admitted to a 12-bed community hospital at high risk of an ADE. Remote pharmacists reviewed the discharge prescription list, identified/resolved UMDs, and interviewed/counselled patients using a telepresence robot. Thereafter, patients completed an anonymous satisfaction questionnaire. Prescriber discharge UMDs were classified, and barriers/inefficiencies and facilitators were documented. Results: Nine patients completed an interview, with a 75% interview agreement rate. All patients were comfortable with the robot and 76% felt their care was better. With a median of 11 discharge medications/patient, the UMD rate was 78%; 71% had omitted medications, 43% involved a cardiovascular medication, 88% were due to a hospital system cause, and 43% were specifically due to an inaccurate best possible admission medication history. Median times for interview preparation, interview and UMD/drug therapy problem resolution were 45, 15 and 10 min, respectively. Conclusion: Using a telepresence robot to provide pharmacist-led BPMDPs is acceptable to patients and an innovative, effective solution to identify/resolve UMDs.
... [7][8][9] In NL, physicians and nurses have been using POCUS in their practice increasingly for the past 20 years. 10 Despite the increased use of POCUS in clinical practice, its prevalence has never been reported in Canada to our knowledge. Knowing where and how POCUS is used in NL is important if we want to plan healthcare services and educational programmes that respond to the health needs of our aging population. ...
... Telemedicine has been used to deliver healthcare and education in NL for many years. 10,21 While teleguidance for ultrasound mentoring is in its infancy, it may eventually provide a solution for training rural practitioners in POCUS and needs further investigation. 22,23 Implementing POCUS training by engaging both rural and urban centres using competency-based frameworks such as CanMEDS may provide excellent learning experiences for residents and nurse practitioners in NL. ...
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Introduction: Point-of-care ultrasound (POCUS) is used for diagnostic and procedural guidance by physicians in Newfoundland and Labrador (NL). POCUS use is largely limited to urban locations and the training is variable amongst physicians. The primary aim of this study was to determine the prevalence of POCUS devices in NL and the secondary aim was to characterise the patterns of POCUS use amongst physicians in NL. Methods: This is a mixed-methods cross-sectional study. We determined the prevalence of POCUS devices from purchase records and the patterns of POCUS use through theme-based interviews. The interviews were transcribed, coded and analysed using standardised qualitative methods. Results: Ten physicians (3 females, 5 rural) participated in the interviews. The overall prevalence of POCUS devices in NL was 12.5/100,000 population. Participants in urban areas had more access to POCUS training and devices. Participants used POCUS on a daily or weekly basis to rule in or out life-threatening conditions and improve access to specialist care. The benefits of POCUS included expedited investigations, decreased radiation and increased patient satisfaction. The barriers to using POCUS were lack of training, time, devices, image archiving software, difficulty generating and interpreting images and patient body habitus. Conclusion: This is the first study to our knowledge to report the prevalence of POCUS devices in Canada. Physicians who practise in rural NL have limited access to POCUS devices and have identified barriers to POCUS training. Connecting physicians in rural areas with POCUS experts through a province-wide POCUS network may address these barriers and improve healthcare access.
... This is particularly significant given Cloutier-Fisher et al. 's (2006) assessment that avoidable hospitalization rates are consistently higher in rural as compared to urban communities [20]. In particular, two studies focusing on the use of telemedicine for rural and remote communities in Northern Canada support the potential of telehealth to reduce the expenses of travel at both an individual level as well as at a systems-level [21,22]. In terms of quality, an Australian study compared the diagnoses and treatment plans made during video conference appointments to in-person consultations for paediatric ENT surgery and found that the diagnosis was the same in 99% of cases (67 out of 68) and surgical management treatment plans were the same in 93% of cases (63 out of 68) [23]. ...
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Background A significant concern for rural patients is the cost of travel outside of their community for specialist and diagnostic care. Often, these costs are transferred to patients and their families, who also experience stress associated with traveling for care. We sought to examine the rural patient experience by (1) estimating and categorizing the various out of pocket costs associated with traveling for healthcare and (2) describing and measuring patient stress and other experiences associated with traveling to seek care, specifically in relation to household income. Methods We have designed and administered an online, retrospective, cross-sectional survey seeking to estimate the out-of-pocket (OOP) costs and personal experiences of rural patients associated with traveling to access health care in British Columbia. Respondents were surveyed across five categories: Distance Traveled and Transportation Costs, Accommodation Costs, Co-Traveler Costs, Lost Wages, and Patient Stress. Bivariate relationships between respondent household income and other numerical findings were investigated using one-way ANOVA. Results On average, costs for respondents were $856 and $674 for transport and accommodation, respectively. Strong relationships were found to exist between the distance traveled and total transport costs, as well as between a patient’s stress and their household income. Patient perspectives obtained from this survey expressed several related issues, including the physical and psychosocial impacts of travel as well as delayed or diminished care seeking. Conclusions These key findings highlight the existing inequities between rural and urban patient access to health care and how these inequities are exacerbated by a patient’s overall travel-distance and financial status. This study can directly inform policy related efforts towards mitigating the rural-urban gap in access to health care.
... We examined material contexts, including access to resources, through assessing food insecurity and urban/rural location, as both food insecurity (Pourmotabbed et al., 2020) and remoteness (Mendez et al., 2013) have been associated with poorer mental health in prior research. We also examined relational contexts, referring to interpersonal interactions and social dynamics, by assessing dating violence, as this is a noted challenge among adult women in the NWT (Government of Northwest Territories, 2019) and is associated with poorer mental health among adolescents (Devries et al., 2013). ...
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Background Persons in Arctic regions disproportionately experience depression. Knowledge gaps remain regarding factors associated with depression among adolescents in the Northwest Territories (NWT), Canada, where child and adolescent mental health hospitalizations are nearly 2.5 times the national rate. This study assesses correlates of depression among adolescents in the NWT. Methods We conducted a cross-sectional survey with adolescents aged 13–18 in 17 NWT communities. We assessed associations between socio-demographic characteristics, dating violence, food insecurity and depression, measured with the 9-item Patient Health Questionnaire. We conducted ordered logistic regressions to assess associations with no, mild, or moderate/severe depression scores. Results Participants ( n = 399; mean age: 14.3, s.d. : 1.3) were mostly Indigenous (79%) and 45% reported food insecurity. Nearly half (47%) reported minimal/no depression symptoms, 25% mild symptoms and 28% moderate/severe symptoms. In multivariate analyses, participants who were cisgender women compared to other genders, sexually diverse v . heterosexual, and food insecure had double the odds of more severe depression symptoms. Among those dating, dating violence was associated with double the odds of moderate/severe depression symptoms. Conclusions Findings support tailored interventions to address material (food insecurity), relational (dating violence) and symbolic (gender and sexual orientation norms) contextual factors associated with depression among adolescents in the NWT.
... Mobile telepresence robotic platforms usually consist of a mobile base, a camera, a screen, loudspeakers and a microphone, making them mobile videoconference systems, commonly referred by some to be "Skype on wheels" [10]. Commercial consumer-based mobile telepresence robotic platforms have been available over the last decade (see reviews in ref. [4,8,[11][12][13][14][15][16]) and provide mobility to sensors, effectors and interactive devices for usage in hospitals, offices and homes [17], outlining recommendations for moving toward their use in practical settings. Most have no or very limited autonomy [4,8,18] which, according to ref. [4], is attributed to simplicity, scalability and affordability reasons. ...
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In health care, a telepresence robot could be used to have a clinician or a caregiver assist seniors in their homes, without having to travel to these locations. However, the usability of these platforms for such applications requires that they can navigate and interact with a certain level of autonomy. For instance, robots should be able to go to their charging station in case of low energy level or telecommunication failure. The remote operator could be assisted by the robot’s capabilities to navigate safely at home and to follow and track people with whom to interact. This requires the integration of autonomous decision-making capabilities on a platform equipped with appropriate sensing and action modalities, which are validated out in the laboratory and in real homes. To document and study these translational issues, this article presents such integration on a Beam telepresence platform using three open-source libraries for integrated robot control architecture, autonomous navigation and sound processing, developed with real-time, limited processing and robustness requirements, so that they can work in real-life settings. Validation of the resulting platform, named SAM, is presented based on the trials carried out in 10 homes. Observations made provide guidance on what to improve and will help identify interaction scenarios for the upcoming usability studies with seniors, clinicians and caregivers.
... The challenges of provision of health care is compounded by a shortage and high turnover of health professionals in the North (Cameron, 2011). One of the potential solutions for the high expenditures is to improve efficiency in access to care through telehealth (Mendez, Jong, Keays-White & Turner, 2013). Telehealth can support the work of northern nurses and other health care providers, reduce the stress of working in remote locations, and potentially improve recruitment and retention of health professionals, including but not limited to nurses (Jong, 2013). ...
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Background: Artificial intelligence is a field of computer science that is capable of analyzing complex medical data. Objectives: To describe the awareness and Perception of uses of artificial intelligence among providers in Medical health care settings. Methodology: Data was collected by a questionnaire filled by health care physicians in king Khaled University Hospital and King Saud Medical City in Riyadh. Results: Out of 105 participants, about 58% of those physicians were either denied access to AI or AI was not available in the facility where they work. Access to artificial intelligence was not statistically different among the three professional groups. About 51% of those physicians rarely or never use AI. Out of 105 (64%) of the doctors chose excellent to the relationship between acquaintance and attitudes towards the AI. (16%) of the physicians chose moderate and finally (20%) of them chose poor. Conclusion: There's no significant difference in the attitude and acquaintance of physicians towards Artificial intelligence in relation to their gender, categories or years of experience. Although most physicians have good acquaintance and attitude towards Artificial intelligence, unfortunately there's no proper accessibility to AI.
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The issue of research on patient satisfaction with healthcare services took on a completely new dimension due to the COVID-19 pandemic and the developing telehealth services. This results from the fact that during the pandemic, remote healthcare was often the only possible form of care provision to the patient. The COVID-19 pandemic has substantially accelerated the implementation of remote healthcare in healthcare institutions and made it an essential tool for providing healthcare services. The objective of the literature review was to study the research on patient satisfaction with remote healthcare services prior to and during the pandemic. The study featured a literature review of electronic databases, such as: Medline, ProQuest, PubMED, Ebsco, Google Scholar, WoS. The identified empirical papers were classified in two groups concerning the research on patient satisfaction prior to and during the COVID-19 pandemic, and were divided and descriptively synthesised. Certain limitations to the methodical quality of the research were demonstrated as result of the conducted analyses. It was also ascertained that researchers lack clarity on the method of defining and measuring satisfaction prior to and during the COVID-19 pandemic.
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CONTEXT Two important areas of medicine, care of the critically ill and management of pulmonary disease, are likely to be influenced by the aging of the US population. OBJECTIVE To estimate current and future requirements for adult critical care and pulmonary medicine physicians in the United States. DESIGN, SETTING, AND PARTICIPANTS Analysis of existing population, patient, and hospital data sets and prospective, nationally representative surveys of intensive care unit (ICU) directors (n = 393) and critical care specialists (intensivists) and pulmonary specialists (pulmonologists) (n = 421), conducted from 1996 to 1999. MAIN OUTCOME MEASURES Influence of patient, physician, regional, hospital, and payer characteristics on current practice patterns; forecasted future supply of and demand for specialist care through 2030. Separate models for critical care and pulmonary disease. Base-case projections with sensitivity analyses to estimate the impact of future changes in training and retirement, disease prevalence and management, and health care reform initiatives. RESULTS In 1997, intensivists provided care to 36.8% of all ICU patients. Care in the ICU was provided more commonly by intensivists in regions with high managed care penetration. The current ratio of supply to demand is forecast to remain in rough equilibrium until 2007. Subsequently, demand will grow rapidly while supply will remain near constant, yielding a shortfall of specialist hours equal to 22% of demand by 2020 and 35% by 2030, primarily because of the aging of the US population. Sensitivity analyses suggest that the spread of current health care reform initiatives will either have no effect or worsen this shortfall. A shortfall of pulmonologist time will also occur before 2007 and increase to 35% by 2020 and 46% by 2030. CONCLUSIONS We forecast that the proportion of care provided by intensivists and pulmonologists in the United States will decrease below current standards in less than 10 years. While current health care reform initiatives and modification of existing practice patterns may temporarily forestall this problem, most anticipated effects are minor in comparison with the growing disease burden created by the aging US population.
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Today there is much debate about why telemedicine has stalled. Teleradiology is the only widespread telemedicine application. Other telemedicine applications appear to be promising candidates for widespread use, but they remain in the early adoption stage. The objective of this debate paper is to achieve a better understanding of the adoption of telemedicine, to assist those trying to move applications from pilot stage to routine delivery. We have investigated the reasons why telemedicine has stalled by focusing on two, high-level topics: 1) the process of adoption of telemedicine in comparison with other technologies; and 2) the factors involved in the widespread adoption of telemedicine. For each topic, we have formulated hypotheses. First, the advantages for users are the crucial determinant of the speed of adoption of technology in healthcare. Second, the adoption of telemedicine is similar to that of other health technologies and follows an S-shaped logistic growth curve. Third, evidence of cost-effectiveness is a necessary but not sufficient condition for the widespread adoption of telemedicine. Fourth, personal incentives for the health professionals involved in service provision are needed before the widespread adoption of telemedicine will occur. The widespread adoption of telemedicine is a major -- and still underdeveloped -- challenge that needs to be strengthened through new research directions. We have formulated four hypotheses, which are all susceptible to experimental verification. In particular, we believe that data about the adoption of telemedicine should be collected from applications implemented on a large-scale, to test the assumption that the adoption of telemedicine follows an S-shaped growth curve. This will lead to a better understanding of the process, which will in turn accelerate the adoption of new telemedicine applications in future. Research is also required to identify suitable financial and professional incentives for potential telemedicine users and understand their importance for widespread adoption.
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The health of the Inuit has undergone substantial changes over the past five centuries, as a result of social, cultural, and economic changes brought about by interactions with Europeans. This process was accelerated considerably in the second half of the twentieth century. The incidence of infectious diseases has declined considerably but is still high compared with Western societies. Chronic diseases such as diabetes and cardiovascular disease are on the increase, while accidents, suicides, violence, and substance abuse are of major importance for the pattern of ill health in most Inuit communities. Lifestyle changes, social change, and changes in society and the environment are major determinants of health among the Inuit.
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The perception of Canada as a nation with a polar region is gradually changing with the emergence of pressing public policy issues such as climate change, resource development, endangered wildlife and sovereignty disputes. These issues have given rise to Canada’s Northern Strategy (, which focuses on issues such as environmental heritage, economic and social development, sovereignty and devolution of governance.1 Canada not only has a polar region, it is part of a circumpolar neighbourhood. In terms of health care, Canada may well benefit from looking to its circumpolar neighbours for partnerships, context and direction as it works to promote health equity throughout its northern regions. The creation of the Arctic Human Health Expert Group within the Arctic Council in 2009 provides an international and policy-based forum for issues of concern to human health to be discussed in a circumpolar context. It promotes the exchange and dissemination of knowledge for improving health. In Canada, the design and delivery of health services for the North have been oriented mostly along a north–south axis. Less attention has been given to circumpolar (i.e., north–north) perspectives. The predominance of north–south partnerships has resulted in fragmented administrative and operational services, with Nunavut often being served from regional centres in Ontario, the Northwest Territories being served from Alberta, and Yukon being served from British Columbia. Inuit people in Iqaluit, Nunavut, would have much more to gain if their service providers looked for collaboration in Nuuk, Greenland, rather than in Ottawa, when exploring best practices for prevention, primary care services or research. Given the historical, jurisdictional and political complexities of the current system, it is worthwhile to examine health and health care in northern Canada from a circumpolar perspective and highlight lessons that may be learned from such partnerships.
Little is known about adoption or success of telestroke networks outside of published or federally funded programs. Under contract to the Health Resource Services Administration, we conducted an environmental scan of telestroke programs in the United States. An analyst contacted all potential programs identified in comprehensive online searches, interviewed respondents, and collected response data about structural and functional components of currently operating telestroke programs. Among 97 potential programs contacted, 56 programs had confirmed telestroke activity, and 38 programs (68%) from 27 states participated. Hospital and community characteristics of nonparticipating programs were similar to those of participating ones. The top 3 clinical needs met by the telestroke were emergency department consultation (100%), patient triage (83.8%), and inpatient teleconsultation (46.0%). Telestroke programs were in operation a median of 2.44 years (interquartile range, 1.36-3.44 years); 94.6% used 2-way, real-time interactive video plus imaging, but only 44% used dedicated telemedicine consultation software. The mean number of spokes per hub increased significantly from 2007 to 2008 to 2009 (3.78 versus 7.60; P<0.05), and >80% of spoke sites were rural or small hospitals. Reimbursement was absent for >40% of sites. Sites rated inability to obtain physician licensure (27.77%), lack of program funds (27.77%), and lack of reimbursement (19.44%) as the most important barriers to program growth. Telestroke is a widespread and growing practice model. Important barriers to expansion amenable to change relate to organizational, technical, and educational domains and external economic and regulatory forces.
Pre- and intrahospital time delays are major concerns in acute stroke care. Telemedicine-equipped ambulances may improve time management and identify patients with stroke eligible for thrombolysis by an early prehospital stroke diagnosis. The aims of this study were (1) to develop a telestroke ambulance prototype; (2) to test the reliability of stroke severity assessment; and (3) to evaluate its feasibility in the prehospital emergency setting. Mobil, real-time audio-video streaming telemedicine devices were implemented into advanced life support ambulances. Feasibility of telestroke ambulances and reliability of the National Institutes of Health Stroke Scale assessment were tested using current wireless cellular communication technology (third generation) in a prehospital stroke scenario. Two stroke actors were trained in simulation of differing right and left middle cerebral artery stroke syndromes. National Institutes of Health Stroke Scale assessment was performed by a hospital-based stroke physician by telemedicine, by an emergency physician guided by telemedicine, and "a posteriori" on the basis of video documentation. In 18 of 30 scenarios, National Institutes of Health Stroke Scale assessment could not be performed due to absence or loss of audio-video signal. In the remaining 12 completed scenarios, interrater agreement of National Institutes of Health Stroke Scale examination between ambulance and hospital and ambulance and "a posteriori" video evaluation was moderate to good with weighted κ values of 0.69 (95% CI, 0.51-0.87) and 0.79 (95% CI, 0.59-0.98), respectively. Prehospital telestroke examination was not at an acceptable level for clinical use, at least on the basis of the used technology. Further technical development is needed before telestroke is applicable for prehospital stroke management during patient transport.
A national shortage of intensivists coupled with an increased demand for 24/7 intensive care unit (ICU) attending coverage poses staffing problems. To extend physician availability, many institutions have adopted varying forms of remote presence technology (RPT). The authors examine their experience with robotic technology to extend physician presence. The RP-7 experience (InTouch Health, Santa Barbara, CA) was examined from March 1, 2008, to December 31, 2010. Intensivists were on site daily from 8:00 AM to 5:00 PM. Evening rounds were conducted by either RP-7 or telephone. Data were acquired after each session and included demographic data, patients evaluated, interventions made, nighttime discussions regarding plan of care, signal drops, time spent, subsequent calls, unexpected events, and a user evaluation. In addition, Acute Physiology and Chronic Health Evaluation II data, length of stay (LOS), and mortality data were tracked for each group. Data are presented as mean ± standard deviation. Statistical analysis was done using Student's t test. The two groups did not differ in regard to age, Acute Physiology and Chronic Health Evaluation II score, or mortality. The RP-7 group demonstrated a decreased hospital and ICU LOS and less subsequent unexpected events. RPT rounds were longer, resulted in more interventions, intensivists received less subsequent calls, and users reported a higher rate of satisfaction with RP-7. Communication between attending physician and staff is enhanced by RPT. In addition, hospital and ICU LOS are improved with RPT. Although the two groups do not differ in mortality, improved patient safety was inferred by the decreased number of untoward events.
The purpose of this study was to assess how surgical intensive care unit (SICU) patients and their families would perceive robotic telepresence. We hypothesized that they would view such technology positively. This research was an Institutional Review Board-approved prospective observational study. Our robotic telepresence program augmented the SICU multidisciplinary team rounding process. We anonymously surveyed patients and their families on their perceptions. Those who interacted at least once with the robot served as our participant base. Twenty-four patients and 26 family members completed the survey. Ninety-two percent of respondents were comfortable with the robot, and 84% believed communication was "easy." Ninety percent did not perceive the robot as "annoying" and 92% did not believe that "the doctor cared less about them" because of the robot. Ninety-two percent of respondents supported the continued use of the robot. Robotic telepresence was viewed positively by patients and their families in the SICU. Furthermore, they believed the robot was beneficial to their care and indicated their support for its continued use.
The present study of current telemedicine users is a unique attempt to understand the barriers and motivational factors related to the utilization of telemedicine. A survey of emergency and critical care remote presence telemedicine users was conducted to determine the factors that motivate and the barriers that impede the acceptance and maintenance of a robotic telemedicine (RTM) program. The majority of the survey users were in the Emergency Department or in the Intensive Care Unit. E-mail invitations were sent to 483 individuals representing 63 healthcare institutions and groups in North America and Europe. Respondents were directed to a Web-based survey. The survey consisted of 96 separate questions, addressing user familiarity and 5-point Likert scales, addressing issues spanning the conceptual and practical issues surrounding adoption of telemedicine. A total of 106 surveys were completed, representing an individual response rate of 21.9% but an institutional response rate of 60.3%. More than two-thirds of the respondents were physicians who participated in active RTM programs. Across seven different topics related to barriers to implementing RTM, the majority of all respondents indicated that cultural issues did not constitute meaningful hurdles, technological matters were generally favorable, and that most personnel were agreeable to both achieving the buy-in to start an RTM program and to maintaining RTM once started. However, respondents proclaimed that RTM's success was still hampered by licensing, credentialing, and malpractice protection, as well as costs, billing, and reimbursement issues. Achieving immediate patient access, overcoming service gaps, improving quality, providing clinical support, maintaining patient satisfaction, and adhering to practice guidelines were viewed as significant motives for RTM implementation. The leading applications of RTM included emergency response and consultation. The patients, physicians, nurses, nor hospital executives served as barriers to implementation. However, licensing, costs for technology, and reimbursement for RTM continue to impede progress.