Management of infectious diseases in remote northwestern Ontario with telemedicine videoconference consultations

Abstract

Northwestern Ontario in Canada provides a unique clinical challenge for providing optimal medical care. It is a large geographic area (385,000 km²) and is home to 32 remote First Nations communities, most without road access. These communities suffer a heavy burden of infectious disease and specialist consultations are difficult to obtain. The Division of Infectious Diseases at the Ottawa Hospital and the Sioux Lookout Meno Ya Win Health Centre established a telemedicine-based infectious disease consultation service in July 2014. We describe the implementation of this service, types of cases seen and patient satisfaction, as well as some of the challenges encountered. Information on visits was prospectively collected through an administrative database, and patient satisfaction surveys were administered after each initial consultation. During our first year of operation, 191 teleconsultations occurred: 76 initial consultations, 82 follow-up appointments and 33 case conferences. The scope of cases has been broad, mostly involving musculoskeletal infections (26%), followed by skin and soft tissue infections (23%). HCV, acute rheumatic fever, and respiratory infections (including pulmonary tuberculosis) were other diagnoses. Patient satisfaction has been very high and 28 telemedicine patient visits have occurred in their remote home communities, minimizing travel. The infectious disease consulting service and local clinicians have succeeded in addressing needs for care in infectious diseases in northwestern Ontario, where important gaps in service to First Nations' communities continue to exist. Regular scheduled available access to an infectious disease specialist is a well-received advancement of care in this remote region of Canada.

Keywords

Telemedicine infectious diseases remote indigenous

Introduction

Infectious diseases are very common in the remote 32 First Nations communities in the Sioux Lookout region in northwestern Ontario. The area suffers from a high incidence of tuberculosis, and has documented higher rates of other infectious diseases such as hepatitis C, blastomycosis, acute rheumatic fever, and infections due to CA-MRSA, compared to the rest of Canada.^1–4 Reasons for this are thought to primarily reflect social determinants of health: lack of access to clean running water, and overcrowded and inadequate housing.¹ Some infections, such as blastomycosis, are highly endemic in the region. Illnesses are often advanced on presentation, due to a high prevalence of comorbidities such as diabetes, drug use and limited access to health resources.

While rural physicians are used to diagnosing and treating complex diseases, the high burden of infectious diseases in the region benefits from the integrated, systematic support of infectious disease specialists who are familiar with the geographic and cultural characteristics of the region and its population. Involvement of infectious diseases specialists in the care of patients with infections has been shown to improve patient and economic outcomes.^5–8

Sioux Lookout Zone is primarily a First Nations population, 82% of the 28,000 population being Ojibway or Cree First Nations members.⁹ The region covers an area of 385,000 km² with Sioux Lookout Meno Ya Win Health Centre (SLMHC) in Sioux Lookout serving as the regional hospital. Of its 32 remote northern communities, only seven can be reached by road. All others rely on scheduled flight connection to Sioux Lookout operated by small aircraft for non-emergent medical transfer by the provincial air ambulance for emergent cases, at a cost of approximately CDN$3000 and CDN$15,000 respectively. The closest tertiary care centers are located in Thunder Bay, Ontario (370 km from Sioux Lookout) and Winnipeg, Manitoba (440 km from Sioux Lookout and crossing provincial boundaries).

The need for infectious disease consultations and the introduction of high-speed Internet connectivity in many regional First Nations nursing stations over the last decade allowed for the development of a regional infectious disease telemedicine service. Prior to this program, infectious disease expertise was only available through informal telephone “curbside” consultations to specialists at either of the tertiary care centers, with no formal assessments or follow-up available save for a minority of complex patients. These patients were flown over 300 km to Thunder Bay or Winnipeg for an in-person consultation. Telemedicine has successfully been applied to provide infectious disease expertise in both acute and chronic infectious diseases across a variety of settings, including rural communities.¹⁰ While telemedicine has also been used to connect to remote and isolated Aboriginal communities,^11,12 its use and acceptability in the infectious disease context has not been documented in this setting.

We describe the development and first year of operation of a telemedicine-based consultation service between SLMHC, Ontario, Canada, and the Division of Infectious Diseases at The Ottawa Hospital (TOH), Ontario, Canada.

Characteristics of the telemedicine application

Development

The first aspect of program development was two independent visits to the region by the infectious disease specialists (RS, YSS). They met with local healthcare providers, hospital and laboratory facility, telemedicine service providers, Sioux Lookout First Nations Health Authority (SLFNHA) leaders and visited nearby nursing stations and First Nations community leaders. Plans for regular consultations were created from this local needs assessment and discussion. While infectious diseases expertise was available as an ad-hoc, informal telephone consultation, telemedicine consultation or in-person visits, particularly follow-ups, were rare owing largely to limited human resources at the tertiary care center, jurisdictional barriers (specialists in Winnipeg, Manitoba, not being responsible to provide service to another province), high costs of transport, and absence of systematic referral and follow-up pathways.

Technical characteristics

Telemedicine videoconferencing facilities existed at both the SLMHC and the remote communities via the Ontario Telemedicine Network (OTN) and Keewaytinook Okimakinak eHealth Telemedicine Services (KOeTS). The latter is a community-based and owned network providing telehealth infrastructure to First Nations communities in the Sioux Lookout region, and partners with OTN to connect communities to other sites in Ontario. Telemedicine video-consultations had already been applied to other services in the region, and examples include mental health, critical care, nutrition, diabetes care, and various ad-hoc specialist consultations from tertiary care centers. The infectious diseases clinic was able to start without further infrastructure requirements in July 2014.

Current use

Patients attended the clinic by regional referral. Physicians at SLMHC or in the communities would refer patients to the infectious diseases clinic though a referral pathway that was integrated into the local electronic medical records system (OSCAR). The hospital-based telemedicine nurse scheduled appointments during clinic days with the infectious disease specialist in Ottawa (weekly July 2014–March 2015 and twice weekly thereafter) and on an ad-hoc basis if clinically required. A telemedicine nurse was in attendance to help with the appointment and assist the specialist at SLMHC, but the patient was seen alone at community stations (a nurse was available on request). Translators were present as necessary. Infectious disease specialists had obtained privileges at SLMHC and thus were able to access electronic health records (EHRs) remotely. Follow-up patient appointments were arranged as necessary. In addition to telemedicine visits, the local family physicians and the two infectious disease specialists conducted patient case conferences (without the patient attending) by videoconferencing to ensure that follow-ups had taken place. In order to create a legal, permanent record of the visit, patients were registered in TOH’s EHR as telemedicine visits and clinic notes were distributed directly from this EHR to SLMHC. Orders, test requisitions, and other forms were faxed directly to the SLMHC telemedicine office and were then forwarded along with clinic notes to the referring physicians, health records for inclusion into the local EHR, and community nursing stations.

Evaluation

Patient satisfaction surveys were conducted following each patient’s initial consultation. The questionnaire was administered at the end of the initial consultation by a non-clinical team member, and addressed experience related to technical components and physician-patient interaction through telemedicine. Patient demographics and general clinical data were collected through an administrative database for a one-year period, July 2014–July 2015.

Demographic data included: age, gender, home community, diagnoses, visit type (consultation or follow-up), and location of visit (Sioux Lookout or remote First Nations community). Ethical approval was received by SLMHC Research Review and Ethics Committee.

Demographics and summary of operations

Of the 76 patients seen over a one-year period in the infectious diseases telemedicine clinic, all but one were First Nations (see Table 1). Ages ranged from 2–84 years, with a mean age of 45.1 years. English was the mother tongue of only 24 of the 50 survey respondents and translators were available at all clinics. Most (61/76) patients lived in remote First Nations communities; 11 patients were from Sioux Lookout and four from neighboring rural communities.

Table 1.

Patient demographics (n = 76 patients).

Gender
Male	49 (65%)
Female	27 (35%)
Age groups
0–17 years	4 (5%)
18–44 years	30 (40%)
45–64 years	28 (37%)
65+ years	14 (18%)
Ethnicity
First Nations	75 (98.6%)
Caucasian	1 (1.4 %)
Mother tongue (collected from surveys), n = 50
English	24
Ojicree	14
Ojibway	12

In this first year of operation there were 76 initial consultations and 115 follow-up appointments or case conferences, for a total of 191 infectious diseases telemedicine appointments (see Table 2). Out of 191 appointments, 28 (14.7%) were seen in their home community thus eliminating travel to SLMHC. The number of follow-up appointments per patient ranged from 0–10, with an average of 1.1 (standard deviation (SD) ± 1.87) (see Table 2).

Table 2.

Visit types.

	Consultations	Follow-ups
Visits (n = 191)
Sioux Lookout	67	96
Community	9	19
Patients (n = 76)
Seen in Sioux Lookout alone	57
Transferred care to community	10
Only seen in community	9

The scope of diagnoses was broad and included rare conditions such as pediatric cases of acute rheumatic fever and active adult tuberculosis. Skin and soft tissue infections (23%) such as infected diabetic foot ulcers were common, accounting for 32 of the 76 diagnoses. Respiratory infections accounted for nearly one-fifth of visits and included one case of pulmonary blastomycosis and three patients with active tuberculosis. Table 3 summarizes visits in relation to type of infection. During the time of implementation of the infectious diseases telemedicine clinic, a high incidence of acute rheumatic fever was observed.¹ Three patients with rheumatic fever were also seen in the clinic to assist public health with case management. About a quarter of visits occurred for musculoskeletal infection (including osteomyelitis and pyomyositis). Three visits were in relation to HCV.

Table 3.

Reason for visit (n = 191 visits).

Infection site	No. of visits (%)
Skin and soft tissue	43 (23%)
Respiratory	37 (19%)
Musculoskeletal	50 (26%)
Genitourinary	15 (9%)
Intra-abdominal	5 (3%)
Bloodstream	26 (14%)
Blood borne	3 (2%)
CNS	7 (4%)
Other	5 (3%)
Total	191

CNS: central nervous system.

Overall patient satisfaction was 98% in the nine questions asked of each patient (see Table 4). Patients who indicated an unsatisfactory experience did not provide any reasons in the free commentary section of the questionnaire. Interestingly, two people were satisfied but would not recommend telemedicine to a friend. Image and sound quality were acceptable from a patient perspective, but clinicians felt examination of wounds was limited by poor image resolution and lack of three-dimensionality. Inability to conduct a hands-on physical exam, especially in the assessment of pedal pulses and assessment of sensation in patient with diabetic foot ulcers, was identified as a particular limitation by the specialists, especially when no healthcare provider was present at the interview.

Table 4.

Results from patient satisfaction surveys.

Patient satisfaction survey question	Number of patients who either strongly agreed or agreed (n = 50)
Patient understood the nurse's explanation of how their session would run.	49 (98%)
Help was available if problems were to arise.	50 (100%)
Able to hear specialist comfortably.	49 (98%)
Satisfied with picture quality of specialist.	47 (94%)
Privacy was respected.	49 (100%)
Would use telemedicine again.	47 (94%)
Would recommend to family/friends.	46 (92%)
Overall satisfied with appointment.	49 (98%)
Number of team members was not overwhelming.	48 (96%)

Smooth running of the program was largely driven by a core team of “telemedicine champions” at either end: the two infectious diseases specialists and their administrative assistant in Ottawa, and a family physician and the nurse telemedicine coordinator in Sioux Lookout. Absence of one or more of the members negatively impacted the scheduling of patients, visit and/or follow-up process (distribution of documentation). Transfer of patients out-of-province for tertiary care resulted in difficulty accessing important health records.

Discussion

Rural northwestern Ontario in Canada comprises a unique clinical challenge for providing optimal medical care. Infectious diseases are common in this First Nations population, and gaps in access to and support for healthcare and healthcare workers have been thoroughly documented in the 2015 Auditor General of Canada’s spring report on the state of healthcare in the First Nations.¹³ First Nations communities in northwestern Ontario are not only remote and isolated geographically, but have been the subject of systemic under-resourcing and neglect. In addition, patients and healthcare providers alike are often caught in jurisdictional red-tape when attempting to access care, in view of the common need for care across a provincial boundary. Most healthcare in Canada comes under provincial jurisdiction, with the exception being care of First Nations on reserves which is a federal responsibility. Amongst others, these factors have contributed to an ever-growing gap in the provision of healthcare to First Nations compared to the rest of Canada.¹³

Previously described telemedicine specialist care programs have been found to benefit patient and physicians and demonstrate high patient satisfaction.^11,12 There is limited information on the use of telemedicine in indigenous communities. While support for infectious diseases through telemedicine has been used in the management of different types of infections¹⁰ in various settings, our program is the first (to our knowledge) to implement an infectious diseases telemedicine program in a region with primarily First Nations communities. Overall, most patients were pleased with the encounter and would recommend it to others.

A review of the types of consultations received indicates that complex infections are common in this population, and that our telemedicine program can provide clinical expertise and follow-up care. Although we did not assess patient outcomes, other studies have demonstrated infectious diseases consultants’ involvement improves patient-related outcomes and shortens length of hospital stay.^5,7,8 The latter may be particularly important since patients are often required to stay in Sioux Lookout for their care. Earlier return home would allow patients to benefit from their personal support systems in their communities and follow-up care at their local nursing station. Allowing a visit to occur in the community minimizes disruption of work and family life.

Furthermore, we were able to assist local public health initiatives addressing a high number of incident acute rheumatic fever cases. Active case management was provided through our telemedicine clinic. This clinical link created the foundation for specialists’ involvement in regional rheumatic fever control efforts through establishment of a multidisciplinary Acute Rheumatic Fever working group, and most, recently, an Emerging Infectious Diseases Response Team.

Avoiding expensive travel out of community (CDN$3000–15,000 per flight) for patients for visits in Sioux Lookout, Thunder Bay and Winnipeg has the potential for massive government cost savings. Currently, most communities lack the infra-structure and resources to support administration of intravenous antibiotics in the communities. For this reason, patients are often required to stay in Sioux Lookout to complete their intravenous treatment. Once there is adequate support for home intravenous programs in the communities, lengths of stay could be further reduced and more follow-ups could occur in the community. Previously published economic analyses question whether telemedicine is indeed cost-effective from the standpoint of the provider.¹⁴ It is generally believed that true monetary gains rely on overall socioeconomic benefits that take patient and physician travel costs and hours of missed work for appointments into account.¹⁵ Our study underlines the potential positive impact that specialist consultations through telemedicine can have on health and well-being, as well as on community and healthcare associated costs.

Limitations of our study include no formal assessment of clinical outcomes. Similarly, we can only hypothesize that the program helps save costs from transportation, but we did not perform an economic analysis. Savings on travel for a specialist appointment may be offset in part by requirements for travel from the community to Sioux Lookout, Thunder Bay or Winnipeg for imaging procedures. Overall, the telemedicine program was well-received among most patients. Unfortunately, we were unable to gain more insight on why telemedicine may not be satisfactory since no explanations were provided by the two patients who did not enjoy the experience. Understanding why telemedicine may not be favorably received by some, while also aiming to update audiovisual components, will help improve the experience.

There are program limitations regarding the ability to perform physical examination. These limitations relate in part to the technology available. As the technology improves, the ability to auscultate and to observe the three-dimensionality of lesions and perhaps even palpate lesions may increase. In the interim, the presence of a healthcare provider who can perform a physical examination under the direction of the specialist would be useful in bridging this gap. Heavy reliance on “telemedicine champions” at either end jeopardizes the sustainability of the program in face of high staff turn-over in northern communities. Formalizing the relationship through contracts or a memorandum of understanding can assist in securing reliability and ensuring accountability.

Our program began by initiating community visits by the urban infectious disease specialist clinicians, who met local key stakeholders, patients and First Nations leadership, as well as local clinicians. Now well-informed on the regional and cultural character of our patients, the specialists provide a valuable integrated service to the region. Future work will involve assessment of the economic impact of the program, assessing the opinions of local family physicians who initiate the consultations, assessing patient outcomes, and ongoing monitoring of patient satisfaction.

Conclusion

With our program we demonstrate telemedicine to be a meaningful tool for clinical specialist support in rural practice, specifically in First Nations communities. Understanding local needs and infrastructure is key to filling important gaps. Regular scheduled available access to an infectious disease specialist from a region that suffers a large burden of infectious disease and geographic challenges is a well-received clinical advancement for care in our region, with potential for major socioeconomic benefits.

Footnotes

Acknowledgements

The authors would like to thank Allison O’Dell from SLMHC and Dora Kleis from TOH for considerable logistical and patient-related work, Len Kelly for his help with reviewing the manuscript, as well as SLFNHA, KOeTS and OTN for their support of the infectious diseases telemedicine initiative.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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