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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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International Journal of Circumpolar Health
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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
1
*, Michael Jong
2
, Debra Keays-White
3
and
Gail Turner
4
1
Remote Medicine Program, Division of Neurosurgery, Dalhousie University and Queen Elizabeth II Health
Sciences Centre, Halifax, NS, Canada;
2
Faculty of Medicine, Memorial University, St. John’s, NL, Canada;
3
Health Canada, First Nations and Inuit Health Branch Atlantic, Halifax, NS, Canada;
4
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;
telemedicine
P
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).
æ
FEATURED PRESENTATIONS
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-
Noncommercial 3.0 Unported License (http://creativecommons.org/licenses/by-nc/3.0/), permitting all non-commercial use, distribution, and reproduction
in any medium, provided the original work is properly cited.
1
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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
discrepancy.
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.
Methods
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
2
of land and 48,690 km
2
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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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.
Assessments
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.
Results
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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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
Physicians
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.
Nurses
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.
Patients
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.
Discussion
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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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.
Acknowledgements
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
Email: mendez@dal.ca
Ivar Mendez et al.
8
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Citation: Int J Circumpolar Health 2013, 72: 21112 - http://dx.doi.org/10.3402/ijch.v72i0.21112
... Fraser and team [31] Few studies looked at the development of implementation frameworks for Indigenous virtual healthcare programs and services. Without clear guidelines on how to engage with Indigenous communities in the virtual space to appropriately and effectively provide care, studies identified that there is an increased risk of harm and/ or undue stress for patients [16,35,36] One study spoke to the lack of regional and national strategies and standards for the implementation of [37]. Adding to this, several studies pointed to the lack of cultural inclusion into frameworks and virtual care [31,38,39]. ...
... Similarly, Caffery and colleagues [40] discovered that there is a lack of evidence surrounding evaluation and evaluation frameworks for the delivery of virtual healthcare to Indigenous Australians which was confirmed by other [36] who discussed similar concerns in Canada, USA, and Australia. Another critical consideration is privacy of patients' data as well as the privacy of a patient's environment or space [37,41]. Ensuring that virtual platforms are compliant with privacy regulations is a major ongoing challenge highlighted by several studies [28,42]. ...
... Rights reserved. equipment and training that is needed upfront [37]. Technology also requires sustainable long-term funding to be maintained, which is a common challenge within Indigenous communities and with virtual care programs that are being delivered from short-term research grant [32,33,37,41]. ...
Article
Full-text available
Background Virtual care has become an increasingly useful tool for the virtual delivery of care across the globe. With the unexpected emergence of COVID-19 and ongoing public health restrictions, it has become evident that the delivery of high-quality telemedicine is critical to ensuring the health and wellbeing of Indigenous peoples, especially those living in rural and remote communities. Methods We conducted a rapid evidence review from August to December 2021 to understand how high quality Indigenous primary healthcare is defined in virtual modalities. After completing data extraction and quality appraisal, a total of 20 articles were selected for inclusion. The following question was used to guide the rapid review: How is high quality Indigenous primary healthcare defined in virtual modalities? Results We discuss key limitations to the delivery of virtual care, including the increasing cost of technology, lack of accessibility, challenges with digital literacy, and language barriers. This review further yielded four main themes that highlight Indigenous virtual primary healthcare quality: (1) limitations and barriers of virtual primary healthcare, (2) Indigenous-centred virtual primary healthcare, (3) virtual Indigenous relationality, (4) collaborative approaches to ensuring holistic virtual care. Discussion: For virtual care to be Indigenous-centred, Indigenous leadership and users need to be partners in the development, implementation and evaluation of the intervention, service or program. In terms of virtual models of care, time must be allocated to educate Indigenous partners on digital literacy, virtual care infrastructure, benefits and limitations. Relationality and culture must be prioritized as well as digital health equity. Conclusion These findings highlight important considerations for strengthening virtual primary healthcare approaches to meet the needs of Indigenous peoples worldwide.
... Few studies looked at the development of implementation frameworks for Indigenous virtual healthcare programs and services. Without clear guidelines on how to engage with Indigenous communities in the virtual space to appropriately and effectively provide care, studies identi ed that there is an increased risk of harm and/or undue stress for patients [16, 29,30] One study spoke to the lack of regional and national strategies and standards for the implementation of telemedicine [31]. Adding to this, several studies pointed to the lack of cultural inclusion into frameworks and virtual care programs [25,32,33]. ...
... Similarly, Caffery and colleagues (2017) [34] discovered that there is a lack of evidence surrounding evaluation and evaluation frameworks for the delivery of virtual healthcare to Indigenous Australians which was con rmed by other researchers [30] who discussed similar concerns in Canada, USA, and Australia. Another critical consideration is privacy of patients' data as well as the privacy of a patient's environment or space [31,35]. Ensuring that virtual platforms are compliant with privacy regulations is a major ongoing challenge highlighted by several studies [24,36]. ...
... Many Indigenous communities experience lower socioeconomic status, may not have access to technology platforms and are commonly located in geographically rural areas with varying levels of bandwidth and internet connection [25,26,[37][38][39]. As highlighted in the literature, the technology requires expensive equipment and training that is needed upfront [31]. Technology also requires sustainable long-term funding to be maintained, which is a common challenge within Indigenous communities and with virtual care programs that are being delivered from short-term research grant funding[26, 27,31,35]. ...
Preprint
Full-text available
Background: Virtual care has become an increasingly useful tool for the virtual delivery of care across the globe. With the unexpected emergence of COVID-19 and ongoing public health restrictions, it has become evident that the delivery of high-quality telemedicine is critical to ensuring the health and wellbeing of Indigenous peoples, especially those living in rural and remote communities. Methods: We conducted a rapid evidence review from August to December 2021 to understand how high quality Indigenous primary healthcare is defined in virtual modalities. After completing data extraction and quality appraisal, a total of 20 articles were selected for inclusion. The following question was used to guide the rapid review: How is high quality Indigenous primary healthcare defined in virtual modalities? Results: We discuss key limitations to the delivery of virtual care, including the increasing cost of technology, lack of accessibility, challenges with digital literacy, and language barriers. This review further yielded three main themes that highlight Indigenous virtual primary healthcare quality: (1) the importance of Indigenous-centred virtual care, (2) virtual Indigenous relationality and the building of trust, and (3) collaborative approaches to ensuring holistic virtual care. Discussion: For virtual care to be Indigenous-centred, Indigenous leadership and users need to be partners in the development, implementation and evaluation of the intervention, service or program. In terms of virtual models of care, time must be allocated to educate Indigenous partners on digital literacy, virtual care infrastructure, benefits and limitations. Relationality and culture must be prioritized as well as digital health equity. Conclusion: These findings highlight important considerations for strengthening virtual primary healthcare approaches to meet the needs of Indigenous peoples worldwide.
... 28,38,45,49, 64,82,84,126,143,162,191,197,210,212,219,240 Ability to monitor your own health 9 89,99,100,114,139,140,148,169,182,185,187,234,236,237,243 Anonymity that some services warranted 6 33, 87,92,108,120,132,174,189,200,205,227 Improved coordination of services 4 145,151,167,206,214,231 Health focus of the telehealth interventions ...
... Among these, 38% viewed telehealth as a way to improve the continuity and consistency of the therapeutic relationships, mainly by improving the frequency of contact and providing a sense of connection. 8,18,33,39,41,45,46,61,70,76,78,[85][86][87][88][89]92,95,97,101,103,107,109,114,125,131,137,139,143,144,154,158,160,163,169,[173][174][175][176][177]183,185,187,189,191,193,194,196,198,200,205,208,209,214,216,217,227,231,234,242,243,248 In one study, the Stay Strong App, designed to addresses mental health and wellbeing concerns of First Nations Australians, was described by service providers as a good "leveler," equalizing the power imbalance often present in their relationships with clients. 61 One participant said it would help changing the perception of his role from a "monitor and accountability person" to a partner in making change. ...
Article
Full-text available
Introduction: Telehealth has the potential to address health disparities experienced by Indigenous people, especially in remote areas. This scoping review aims to map and characterize the existing evidence on telehealth use by Indigenous people and explore the key concepts for effective use, cultural safety, and building therapeutic relationships. Methods: A search for published and gray literature, written in English, and published between 2000 and 2022 was completed in 17 electronic databases. Two reviewers independently screened retrieved records for eligibility. For included articles, data were extracted, categorized, and analyzed. Synthesis of findings was performed narratively. Results: A total of 321 studies were included. The most popular type of telehealth used was mHealth (44%), and the most common health focuses of the telehealth interventions were mental health (26%) and diabetes/diabetic retinopathy (13%). Frequently described barriers to effective telehealth use included concerns about privacy/confidentiality and limited internet availability; meanwhile, telehealth-usage facilitators included cultural relevance and community engagement. Although working in collaboration with Indigenous communities was the most frequently reported way to achieve cultural safety, 40% of the studies did not report Indigenous involvement. Finally, difficulty to establish trusting therapeutic relationships was a major concern raised about telehealth, and evidence suggests that having the first visit-in-person is a potential way to address this issue. Conclusion: This comprehensive review identified critical factors to guide the development of culturally-informed telehealth services to meet the needs of Indigenous people and to achieve equitable access and positive health outcomes.
... In the literature, the most common VC scenario in emergency care is when a rural, small hospital connects with an urban emergency department in a consultation between two physicians [20,23]. The use of VC in emergency care has also been investigated for certain acute medical conditions, such as psychiatric emergencies [24] and acute stroke [25,26] but few studies have explored emergency care via VC in a rural primary care setting [27,28]. In northern rural Sweden the residents have access to primary care at 7 small community hospitals and emergency care with a general practitioner (GP) via VC, which has not been evaluated. ...
Article
Full-text available
Background Delivering emergency care in rural areas can be challenging, but video consultation (VC) offers opportunities to make healthcare more accessible. The communication and relationship between professionals and patients have a significant impact on the patient’s experience of safety and inclusion. Understanding the patient perspective is crucial to developing good quality healthcare, but little is known about patient experiences of emergency care via VC in a rural context. The aim of this study was to explore patient experiences of emergency care via VC in northern rural Sweden. Methods Using a qualitative approach, semi- structured interviews (n = 12) were conducted with individuals aged 18—89 who had received emergency care with a registered nurse (RN) on site and VC with a general practitioner (GP). The interviews were conducted between October 2021 and March 2023 at community hospitals (n = 7) in Västerbotten County, Sweden. Interviews were analysed with content analysis. Results The analysis resulted in main categories (n = 2), categories (n = 5) and subcategories (n = 20). In the main category, “We were a team of three”, patients described a sense of inclusion and ability to contribute. The patients perceived the interaction between the GP and RN to function well despite being geographically dispersed. Patients highly valued the opportunity to speak directly to the GP. In the main category, “VC was a two-sided coin”, some experienced the emergency care through VC to be effective and smooth, while some felt that they received a lower quality of care and preferred face-to-face consultation with the GP. The quality of the VC was highly dependent on the RN’s ability to function as the hub in the emergency room. Conclusion Patients in rural areas perceived being included in 'the team' during VC, however they experienced disadvantages with the system on individual basis. The nursing profession plays an important role, and a proper educational background is crucial to support RNs in their role as the hub of the visit. The GP’s presence via VC was seen as important, but to fully enable them to fulfil their commitments as medical professionals, VC needs to be further improved with education and support from technical devices.
... Different types of algorithms, such as supervised, unsupervised, and reinforcement learning, are used in machine learning. [23]. ...
Article
Over the next ten years, expect to witness the emergence of a Sixth Era (6G) of innovation owing to the explosive expansion of 5G applications and rising demand for even faster communication solutions. Many researchers predicted that the 6G remote arrangement standard may appear around 2030. The Sixth Era (6G) organization, which is anticipated to be the next major amusement changer in the media transmission sector, is now the focus of attention in both academia and business. The use of rambles in healthcare will further help to lower healthcare expenditures. The need for expensive ground transportation is eliminated by using rambles to deliver the medical supplies. Additionally, the use of rambles in the inquiry and collecting of therapeutic information will reduce the need for expensive human labour. As the information gathered can be easily and swiftly analysed, this will also reduce the time and costs associated with therapeutic drugs. Long-term improvements in healthcare outcomes and lower healthcare expenditures will follow from this. Numerous organizing hubs and terminal devices provide services for use in the healthcare industry, but this requires a spine system to consider the time-consuming advantage. For future 6G age healthcare frameworks using ramble by machine learning computations with big data. Without being explicitly altered, the framework may provide the ability to memorize and advance spontaneously through machine learning from experience. AI can accurately recognize data, treatment approaches, and generally produces superior, quiet outcomes. It is essential to verify their quality and identify the appropriate linkages for big data analytics to be useful inside the healthcare industry. to ship haematological supplies, defibrillators, and immunizations via drone. The reference layered communication system for hubs and devices in real-time communication, which is part of the suggested approach, demonstrates cutting-edge healthcare application for persuasive treatment and clever integration of benefit provided by 6G distant systems.
... Evaluation Hospitalization rates have dropped significantly Mendez et al. [27] 2013 ...
Conference Paper
Heart failure is one of the leading causes of mortality in both developing and developed nations, with strokes and other brain illnesses coming in second and third. In terms of patient numbers, hospitalization rates, and expenses, it is one of the most pressing healthcare concerns. This study investigates the research trend for e-health applications and systems in the field of telemonitoring of heart failure since 2010, by conducting systematic literature review (SLR) on publications made available in several scientific databases, such as ACM Digital Library, IEEE Xplore, Science Direct, Google Scholar, and PubMed. The articles that portray most interest concerning evaluation of success and failure, treatment, prevention, self-empowerment, and patient satisfaction, were picked. Since 2010, almost 100 publications on telemonitoring of heart failure have been discovered, with the most relevant ones being chosen based on scientific value. Many of them demonstrate that telemonitoring of patients at high risk of heart failure is an effective way to lower the chance of developing the heart failure condition. Following the review, it can be concluded that telemonitoring systems can assist in lowering the expenses of treating heart failure, resulting in fewer re-hospitalization of patients. In addition to that, rural and distant residents are typically happy with telehealth as a way of service delivery since it may enhance access to health care while avoiding the difficulty of travel.
... A typical utilization of drones for various healthcare applications in a few countries is tabulated (Table 2) below. In spite of the worldwide acceptability of drones in the healthcare sector, India being a massive country with equi-differentiable geographical and health-care disparities issued UAV guidelines and a framework for a Drone Ecosystem Policy Roadmap to implement drone delivery solutions for medical and healthcare applications such as Pre-hospital Care, Laboratory Testing, vaccine and blood delivery [21,[38][39][40], etc. Environmental monitoring (e.g., wildfire, landslide, and air quality monitoring) with drones [41][42][43][44][45][46][47], drones to deliver automated external defibrillators (AEDs) for cardiac emergencies [48][49][50][51][52][53], drones for transporting biological samples [54][55][56][57], drones for search and rescue operations [58,59] and emergency service delivery [60,61], are a few other subjectively applicable areas of drones. Earmarking the roundabout utilization of drones, the government of India in association with other states formulated a pilot project titled 'Medicines from the Sky' to investigate the increasing utility of drones in the healthcare sector [62]. ...
Article
Full-text available
The substantial applicability of technological advancements to the healthcare sector and its allied segments are on the verge of questioning the abilities of hospitals, medical institutions, doctors and clinical pathologists in delivering world class healthcare facilities to the global patient community. Investigative works pertinent to the role played of technological advancements in the healthcare sector motivated this work to be undertaken. Part-I of the review addressed the applicable role play of advanced technologies such as Artificial intelligence, Big-data, Block chain, Open-Source and Cloud Computing Technologies, etc., to the healthcare sector and its allied segments. The current Part-II manuscript is critically focused upon reviewing the sustainable role of additional disrupting technologies such as Robotics, Drones, 3D-Printing, IoT, Virtual/Augmented/Mixed Reality, etc., to uncover the vast number of implicit problems encountered by the clinical community. Investigations governing the deployment of these technologies in various allied healthcare segments are highlighted in this manuscript. Subsequently, the unspoken challenges and remedial future directions are discussed thereof.
... This has been our experience with the use of remote presence technology for virtual acute care in remote communities. 21,22 Additionally, as telerobotic technology evolves, the proportion of exams which are non-diagnostic (leading to a recommendation for a repeat conventional exam) may decrease, minimizing the number of repeated exams and lowering costs for models incorporating telerobotic ultrasound. ...
Article
Introduction: Telerobotic ultrasound technology allows radiologists and sonographers to remotely provide ultrasound services in underserved areas. This study aimed to compare costs associated with using telerobotic ultrasound to provide ultrasound services in rural and remote communities to costs associated with alternate models. Methods: A cost-minimization approach was used to compare four ultrasound service delivery models: telerobotic ultrasound (Model 1), telerobotic ultrasound and an itinerant sonographer (Model 2), itinerant sonographer without telerobotic ultrasound (Model 3), and travel to another community for all exams (Model 4). In Models 1-3, travel was assumed when exams could not be successfully performed telerobotically or by an itinerant sonographer. A publicly funded healthcare payer perspective was used for the reference case and a societal perspective was used for a secondary non-reference case. Costs were based on the literature and experience using telerobotic ultrasound in Saskatchewan, Canada. Costs were expressed in 2020 Canadian dollars. Results: Average cost per ultrasound exam was $342, $323, $368, and $478 for Models 1, 2, 3, and 4, respectively, from a publicly funded healthcare payer perspective, and $461, $355, $447, and $849, respectively, from a societal perspective. In one-way sensitivity analyses, Model 2 was the lowest cost from a payer perspective for communities with population >2075 people, distance >350 km from the nearest ultrasound facility, or >47% of the population eligible for publicly funded medical transportation. Conclusion: Health systems may wish to consider solutions such as telerobotic ultrasound and itinerant sonographers to reduce healthcare costs and improve access to ultrasound in rural and remote communities.
Article
Full-text available
Background: Telemedicine has revolutionized health-care services with its unprecedented abilities to connect patients with health-care professional across the distances. Patient satisfaction is an important measure of the quality and effectiveness of health-care services. Aim: The goal of this systematic review is to investigate patient satisfaction with telemedicine in acute care setting. Methods and results: Four sources of data were searched PubMed, Cumulative Index of Nursing and Allied Health Literature, Scopus, and Web of Science. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis as our basis of organization. Our analysis has showed that acute telemedicine was effective in managing a broad spectrum of acute medical conditions while achieving high levels of patient satisfaction. Conclusion: Patient satisfaction is a complex product of expectations and experiences. Furthermore, it is an important indicator of the quality of the service. Despite the challenging nature of acute medicine, telemedicine services were successful in improving the quality of the service and achieving high levels of patient satisfaction. Relevance for patients: Telemedicine is rapidly evolving as an essential component of our healthcare system. Implementing telemedicine in acute care is a relatively new concept and patient satisfaction in these settings needs to be evaluated.
Preprint
Full-text available
Background. Arctic Indigenous communities are unique, geographically remote and/or isolated, and currently among the most susceptible populations in the world to the effects of the coronavirus disease 2019 (COVID-19) pandemic. Since colonization, Indigenous communities have been particularly susceptible to infectious disease outbreaks. Methods. This study reviewed current knowledge regarding social determinants of health (SDH) and pandemics in Arctic Canada and highlighted the implications of the current COVID-19 pandemic on individuals, families, and communities in Arctic Canada. Studies published in English and French pertaining to SDH or pandemics in the Canadian Arctic were located using key search words in three databases (PubMed, Medline, and CINAHL) as well as reference tracking of relevant articles up to September 2021. Studies were categorized according to infectious disease (COVID-19, H1N1 influenza, and tuberculosis) or SDH (healthcare access, food security, mental health, socioeconomic status, cultural continuity, housing, and community infrastructure). NVivo was used to theme and sub-theme findings of selected studies. Results. One hundred studies were included in this scoping review. Two articles related to COVID-19, five to influenza, and five to TB; 27 healthcare access, 19 to food security, 17 to mental health, nine to SES, seven to cultural continuity, six to housing, and three to community infrastructure. Documented lessons learned from previous pandemics in Arctic communities provides evidence to inform public health policies and culturally safe programs for the current COVID-19 pandemic where many SDH exist as challenges for Indigenous communities. The SDH included limited healthcare access, food insecurity, mental health challenges, low socioeconomic status, limited cultural considerations in healthcare, and suboptimal housing. These findings are also relevant to Indigenous communities in other Arctic regions facing similar challenges due to the pandemic. Conclusions.: It is essential to understand how SDH underlie the health and wellbeing of Indigenous communities in the Arctic and to utilize this information to inform critical policy and practice decisions for COVID-19 prevention, management, and treatment. This review indicated that many SDH are unique to Canadian Arctic settings and pose specific challenges for the prevention and management of infectious diseases, such as COVID-19.
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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 (www.northernstrategy.gc.ca/index-eng.asp), 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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.