This chapter highlights innovations employed across the country in e-health, telehealth and telerobotics, including the benefits that these technologies offer for health care delivery. In particular, it examines the role of mobile health devices and web-based applications in promoting self-care among patients; the implementation of EHRs in different jurisdictions and organizations; and the role of telehealth and telerobotics in improving access to health care in rural and remote areas. It also outlines the challenges associated with the development and adoption of some of these technologies, as highlighted by witnesses. Finally, it also examines the adoption of these technologies in First Nations and Inuit communities. The chapter concludes with the Committee’s observations and recommendations in this area.

A. Technological Innovation in E-Health, Telehealth and Telerobotics

1. The Role of Mobile Health Devices and Web-based Applications in the Promotion of Self-Care among Patients

Several witnesses described to the Committee how e-health tools such as mobile health devices and web-based applications could be used to promote self-care among patients. Self-care e-health tools can effectively help patients manage diseases, such as diabetes, cardiovascular disease, renal disease and HIV, in turn resulting in improved health outcomes and lower health care costs. For example, the Committee heard about a program led by the Centre for Global eHealth Innovation, called home hemodialysis, which provides patients with end-stage renal disease with a dialysis machine in the home.[52] Home hemodialysis has improved health outcomes for patients in comparison to in-hospital treatment. Patients can get as much as 60% renal replacement function via home hemodialysis in comparison to an increase of only 15% within a hospital setting. This increased function reduces the amount of toxins in the blood, which has allowed patients of child-bearing age receiving the treatment to conceive and bring pregnancies to term. In addition, providing hemodialysis in the home instead of a health care facility saves approximately $10,000 per patient annually. These savings are mostly due to the fact that patients administer their care themselves and rely less on nurses.[53]

The Committee learned that the Centre for Global eHealth Innovation has also developed several mobile phone applications to promote self-care among patients. One of them is an application for mobile phones called Bant, which aims to help teenagers with diabetes manage their blood sugars on a regular basis. The Bant application communicates with patients’ blood glucose meters and regularly captures the blood sugar readings.[54] A study conducted on the outcomes of the application showed that teenagers using the application tested their blood 50% more frequently than in the three months previous to using the application.

Another example of an application promoting self-care and self-management is a Bluetooth-enabled blood pressure monitor that communicates with patients’ BlackBerrys.[55] The application encourages patients to measure their blood pressure regularly, which improves their awareness of their blood pressure. After one year, the cardiovascular mortality risk of patients using the new device dropped by 20%. The Committee learned that this reduction was attributable solely to the new application since there were no additional medications prescribed and no additional visits to physicians among these patients. Committee members were told that an application for consumer asthma management was also available.[56]

Finally, the Committee also heard about web-based initiatives aimed at self-care, including providing patients with the skills to manage their diseases. For example, Ms. José Côté, the Research Chair in Innovative Nursing Practices at the Université de Montréal, has developed TAVIE, a virtual nursing assistance program that consists of providing patients with the skills necessary to manage their chronic health problems through interactive web-sessions led by a nurse in another location.[57] TAVIE focuses on helping patients in self-management, self-observation, emotional-regulation and social-skills learning processes. The program has also been adapted for patients living with HIV, HIV-TAVIE focuses on helping patients improve the management of their antiretroviral medications.

Similarly, the Committee heard from Dr. Scott Lear from the British Columbia Alliance on Telehealth Policy and Research about a virtual cardiac rehabilitation program, which consists of a website that mimics the hospital-based standard cardiac rehabilitation program.[58] Patients participating in the program are given a recordable heart rate monitor that they can wear while they exercise. They can upload the data to the website, which allows the health staff in the hospital to monitor the patients’ heart rate and provide feedback as needed. According to Dr. Lear, patients participating in the virtual cardiac rehabilitation program increased their physical activity levels and reduced their cholesterol levels to rates that were comparable to those participating in hospital-based programs. This virtual model is now being applied to the management of other diseases such as, diabetes, renal disease and lung disease.

The Committee also heard from Mr. Paul Lepage that TELUS, in partnership with the Lawson Health Research Institute, has developed a personal health record to help monitor patients with mental illness.[59] According to Mr. Lepage, patients suffering from mental illnesses, including schizophrenia, are supplied with an electronic personal health record that is configured in such a way that both the patient and provider have access to the record. The patient is able to enter information in the system during the day about their mood and experiences, which allows for exchanges of information with the physician. Mr. Lepage explained that physicians had received more information through this program than through regular treatment, allowing them to move their patients’ treatment forward faster.

Many of the witnesses indicated that the use of mobile health devices and web-based applications in the treatment and management of diseases is the way of the future, as the devices promote the engagement of patients in their own care and reduce costs to the health care system while improving patient outcomes.[60] In addition, these e-health applications are also successful in improving patient access by enabling patients to overcome geographic barriers to receive care and treatment for their diseases.[61] For these reasons, witnesses recommended that CIHR maintain and possibly increase funding to its e-health funding program to support research developing and evaluating new projects in this area.[62] However, one witness also explained that one of the challenges with e-health applications is ensuring that the most disadvantaged groups in society have access to these technologies.[63] This witness suggested that they could be provided through community settings. The Committee also heard about the importance of ensuring that patients, including seniors, who may have physical and/or cognitive challenges, are able to use these innovations as well, a subject that is dealt with in greater detail in chapter 5. Mr. Joseph Cafazzo, appearing on behalf of the Centre for Global eHealth Innovation also noted that while mobile health devices reduce costs for the health care system, the cost-savings associated with these devices do not account for the contribution made by informal care givers as a result of shifting care to the home.[64] Consequently, he explained that it is necessary to ensure that informal care givers are also provided with the necessary supports. Finally, witnesses believed that for self-care to be fully realized through mobile health applications, patients need to have access to their personal health information through EHR systems.[65]

2. The Implementation of Electronic Health Record Systems Across Canada

It is important to note that an Electronic Health Record (EHR) is sometimes confused with an Electronic Medical Record (EMR). The EMR stores complete patient’s health information (i.e., lab results, images, consultant or hospital notes) in a single location, such as a physician’s office or a community health centre; this information is accessible only by authorized professionals working in that location. EMRs are a key component of a comprehensive EHR. An EHR refers to a secure and private record that provides, in a digital or computerized format, lifetime information on a person’s history within the health care system.[66] There are six main components that make up EHR systems, including a patient registry; provider registry; diagnostic imaging repositories; laboratory information repositories; drug information repositories; other information repositories.[67] The patient health information stored in these different components comes from various sources such as physicians, hospitals, diagnostic laboratories and pharmacists. In order to achieve the goal of sharing information across a region and jurisdiction, a common, interoperable or compatible network needs to be developed to link the different components of the system to each other.

Witnesses outlined progress towards the implementation of different components of EHRs within their respective jurisdictions and health care organizations across Canada. The Committee heard about Manitoba’s efforts to implement different components of an EHR system through Manitoba eHealth, the agency responsible for the delivery of all e-health projects within the province.[68] The Committee heard that since 2006, the province has invested over $260 million in health ICT projects across the province .[69] These projects have been facilitated by additional funding from Canada Health Infoway Inc, amounting to $67 million.[70] As a result of these investments, all of the provinces diagnostic imaging services in hospitals and other public facilities are fully digital; approximately 70% of family doctors have EMRs in place; and their version of an EHR, called E-chart has gone live and is deployed in 78 locations across all of Manitoba.[71] The implementation of these projects has reduced wait times for health care services in remote areas, improved the coordination of patient care and improved patient safety by reducing the number of medication incidents by 45% in St. Boniface Hospital in Winnipeg alone.[72] Mr. Roger Girard, Chief Information Officer for Manitoba’s e-Health Program explained that this progress would not have been achieved without the investments and partnership of Canada Health Infoway Inc., which also ensured the interoperability of the province’s system. Despite this progress, he noted that automation still needs to occur across different areas of the health care system, including home care, community care and mental health, and long-term care and consequently, on-going support from Canada Health Infoway Inc. is necessary.

The Committee also heard about how the Ottawa Hospital is implementing different components of EHR systems, resulting from support received from eHealth Ontario and Canada Health Infoway Inc.[73] According to Dr. Glen Geiger, the Ottawa Hospital is now electronically linked to regional hospitals and they were rolling out EMRs that would link primary care physicians to the health records of their patients in the Ottawa Hospital. He also explained that the initiatives being introduced are not simply about introducing new technologies, but are focused on changing health care delivery processes that increase efficiencies and improve health outcomes for patients. For example, he explained that their electronic ordering of diagnostic imaging at the Ottawa Hospital is paperless from end to end, from the creation of the order to the receipt of the order in the radiology department and the return of the report to the physician on their iPad. He noted that the Ottawa Hospital’s lab tests were done the same way.

Finally, the Committee learned that efforts are being made to develop EMRs that do not simply automate processes for physicians but are designed to promote meaningful use by the physician. The Committee heard from Dr. David Price from McMaster University, who had participated in the development of an EMR called OSCAR, which is now one of the leading EMRs in the country and has been adopted by approximately 2,000 family physicians.[74] Apps or add-ons for OSCAR are being developed to help physicians prevent, monitor and treat different diseases, such as chronic kidney disease, through prompts in the system. Similarly, McMaster University’s BORN initiative is introducing prompts in the system to manage perinatal and pregnant women to ensure they receive appropriate screenings and tests based upon certain risk factors such as age and weight that are included in the EMR system. In addition, the Committee heard that McMaster, in partnership with the Federal Economic Development Agency for Southern Ontario, York University and NexJ, is developing a personal health record called MyOscar, which is a platform for patients to both store their health information and provide a secure electronic medium for patients to interact with their clinicians.

While the Committee heard from witnesses that jurisdictions and health care organizations are well on their way in terms of developing and implementing different components of EHR systems, there are several on-going challenges in this area. In particular, witnesses highlighted challenges associated with the interoperability, or the ability of different electronic health systems to communicate with each other. Dr. Peter Rossos, Chief Medical Information Officer from the University Health Network explained that problems of interoperability result from the fact that different health care organizations had initially implemented different types of electronic information systems that were not readily designed to communicate with each other.[75] He explained that most community-based EMRs in Canada are provided by local or smaller vendors, whereas hospital EMRs have been designed by larger or foreign companies, but not necessarily for local interoperability. Consequently, hospital systems need to be upgraded to link with regional or province-wide EHRs developed in line with Canada Health Infoway Inc.’s standards for interoperability. Moreover, these hospital information systems were not designed for the current more mature uses of these systems. As a result of these challenges, Dr. Rossos indicated that most Canadian hospitals ranked low on the HIMSS Analytics maturity model of the adoption of EMRs.

According to witnesses, the federal government has a role to play in ensuring that there are common interoperability and privacy standards across Canada through its on-going support for Canada Health Infoway Inc. and its common EHR service blueprint.[76] Some witnesses suggested that the dynamic nature of the electronic health information systems market in Canada means that the private sector would also be able to develop solutions to address problems related to interoperability.[77]

Witnesses also pointed out that clinician adoption is also an issue, as approximately only 39% of Canadian physicians are currently using EMRs, in comparison to 50%-55% in the United States and up to 90% in other countries.[78] It was suggested that some health professionals do not use e-health systems because of a lack of familiarity or understanding of e-health tools that are available or the benefits for their patients.[79] In order to promote clinician adoption, one witness suggested that e-health training could be integrated into both medical student training and continuing education of physicians, nurses and pharmacists.[80] Another witness proposed that incentives in the form of compensation be considered.[81] However, another witness suggested that physician adoption would no longer be an issue, as physicians currently graduating from medical school would not move back to paper records and there could be a shift in adoption patterns in the next three to five years.[82]

3. The Role of Telehealth and Telerobotics in Improving Access to Health Care in Rural and Remote Settings

Witnesses highlighted the important role that telehealth and telerobotics are playing in improving access to health care for people living in rural and remote areas, while also reducing health care costs. The Committee heard that improving access to health care in rural and remote settings is necessary because individuals living in rural and remote areas face poorer health outcomes in comparison to those living in urban areas, including higher morbidity and mortality rates, which is due, in part, to a lack of access to health care services.[83] In addition, the Committee heard that rural and remote communities also face higher costs of care because of their dependence on medical travel to access care in urban centres.[84]

i. Telehealth

The Committee heard examples of how telehealth initiatives in different jurisdictions are improving access to care, while reducing health care costs. For example, the Committee heard that Manitoba has established 125 telehealth sites that are allowing people living in rural areas to connect with specialists in urban centres by visiting their local health centres, saving rural Manitobans both time and money. It has been estimated that, in Manitoba, telehealth saves over one million kilometres of patient travel, $2.6 million in out-of-pocket expenses for families and $1 million per year in travel costs for health professionals.[85] Mr. Girard, Chief Information Officer of Manitoba’s eHealth Program explained that telehealth has an important role to play improving access to services for people living in rural and remote areas, but also cannot replace the health care practitioners that are necessary to deliver hands-on care in these communities.[86]

Another example that the Committee heard about was the Ontario Telemedicine Network (OTN), which is an independent not-for-profit corporation that provides telehealth services for the Province of Ontario, including rural areas and remote areas of the province. OTN also works in partnership with Canada Health Infoway Inc., Keewaytinook Okimakanak Telemedicine, and eHealth Ontario. The Committee heard that OTN is one of the largest and most active telemedicine networks in the world, providing support to more than 1,500 telemedicine sites in Ontario and 3,000 video-conferencing platforms that deliver care to more than 200,000 patients a year.[87] OTN offers a number of services in the Province of Ontario, including routine health consultation and emergency services, such as telestroke, teleburn, sign language services, mental health crisis services, critical care services and a trauma pilot program.[88] Other programs offered by the OTN include: education and training of health professionals, telehomecare, which supports remote monitoring and nurse coaching for people living with chronic diseases, and an e-consult service through which primary care physicians can send data and pictures to a specialist to seek advice. The Committee learned that these services had resulted in a savings of about 207 million kilometres in travel in 2011. It also saved the Ontario government $45 million in travel grant subsidies in 2011, which it normally offers to people living in Northern Ontario.

ii. Telerobotics

The Committee heard that telerobotics, like telehealth, could also be an effective tool in improving access to health care in rural and remote settings. The Committee heard from Dr. Ivar Mendez from Dalhousie University that Nova Scotia has developed a RP-7 telerobot system to deliver care in different parts of the province and in Nain, Labrador. These telerobots enable physicians in one location to appear in a hospital in another location by videoconference through a human-sized robot, whose movements they are able to control at a distance.[89] The robot enables the physician to move virtually in health care facilities and enter patients’ rooms to deliver care, assess patients, speak with them directly and provide hands-on support to nurses and other health care professionals that are physically with the patients. Moreover, advanced practice procedures could be performed by nurses with the assistance of physicians through the telerobots. The Committee heard that other applications of telerobotics include: patient follow ups with cancer specialists; medication and care management; resuscitations; ultrasound exams; mental health services; nutritional consultations; surgical consults, as well as education and training.[90]

The Committee heard that Nova Scotia’s network of telerobots consists of five units in Nova Scotia and one in Nain, Labrador, a community of around 1,300 Inuit people with only six nurses. The telerobot in Nain is a project that was implemented through collaboration among Dalhousie University, Labrador-Grenfell Health, the Nunatsiavut Government’s Department of Health and Social Development, and Health Canada’s First Nations and Inuit Health Branch.[91] The placement of a telerobot in Nain means that the community now has 24/7 access to a physician, who otherwise would be available only through the telephone, or a visit that occurs once every six weeks. The Committee heard that the presence of “Rosie the Robot” has reduced medical travel for people living in Nain by half.[92] Furthermore, it has reduced the stress and difficulties faced by nurses working in the community. As a result, they are much more satisfied and more willing to remain in the community. Because of the positive impact “Rosie” is having in the community, the Committee heard that the Government of Newfoundland and Labrador will continue funding the use of telerobotic medicine in Nain. Furthermore, witnesses indicated that this remote telerobotic presence is helping to improve access to health services for individuals living in remote health communities.

Dr. Mendez also discussed other types of telerobotic devices that are being tested and used in his province to improve access to care, in particular, portable telerobotic systems that work through cellular phone connectivity.[93] These portable systems are used by first responders, who are able to bring them to the location of the accident. The devices allow physicians to see patients more quickly at the scene of the accident rather than only at the hospital. Through these portable systems, physicians are not only able to see the patient right away and diagnose a condition from a remote location, but are also able to start managing the patient. Moreover, portable systems allow patients to be followed by physicians during their transportation in ambulance.

Finally, he also described another telerobotics program developed and located in Halifax, which improves access to health care specialists located across Canada for patients with movement disorders. In order to control movement disorders such as dystonia[94] and tremors, it is necessary to put electrodes in patients’ brains.[95] These internal computers can be programmed remotely through portable systems that nurses can bring to patient’s homes. Through these portable systems, patients can receive their follow-up treatments at home with the help of a nurse, rather than travelling to Halifax. Consequently, patients with these disorders from all over Canada have on-going access to this treatment from their homes.

Witnesses felt that the use of telerobotics in the delivery of health care is “unstoppable” and part of the future of health care delivery in Canada. However, they noted that there are some challenges to its adoption in Canada.[96] In particular, there are jurisdictional barriers associated with delivery care across provincial and territorial boundaries including: the need to establish governance and accountability models and identify how health care professionals using these systems would be paid. The Committee also heard that improvements in broadband access in remote communities are also necessary to realize these systems.[97] In addition, health professionals need adequate training to make use of these systems.[98] Witnesses did not indicate that the costs to acquire telerobots and portable telerobotic are a significant barrier, since the alternative to these systems is medical transportation, which occurs mostly through relatively expensive plane travel in northern Canada. In fact, Committee members were told that the portable systems that first responders carry with them cost the equivalent of two trips on a plane for medical patients. The Committee heard that the cost of a telerobot is around $140,000, whereas the portable units cost about $25,000 each.[99]

4. The Implementation of E-Health and Telehealth in First Nations Communities[100]

The Committee heard from the Assembly of First Nations that e-health and telehealth are indispensable tools for the development of comprehensive effective and efficient health systems in First Nations communities. E-health and telehealth systems offer many benefits to First Nations communities, including: extending basic and specialist health services, as well as health promotion and disease prevention education to underserviced areas; creating efficiencies within the health system by reducing medical transportation costs; providing support and continuing education opportunities to health professionals in turn improving their recruitment and retention; improving the management and storage of health information within the communities; and helping evidence-based policy development. Furthermore, the Committee heard that the development and use of EHR systems could improve the coordination of care between jurisdictions, described as a constant challenge for First Nations people.

According to the Assembly of First Nations, e-health and telehealth projects are underway in First Nations communities across the country. For example, in British Columbia, the Cowichan Tribes have developed their own EMR, called Mustimuhw cEMR, which is also being used by communities in Saskatchewan and Manitoba. Similarly, British Columbia’s tripartite agreement process aimed at integrating health care delivery for First Nations communities is also prioritizing the development and implementation of comprehensive and integrated information management and information technology services. Furthermore, the Committee heard that the Kenora Chiefs Advisory in Ontario has also developed a client registry project that is collating data from seven First Nations communities into a single database.

Finally, the Committee also heard that the Assembly of First Nations is working on engaging First Nations and federal, provincial, territorial partners in discussions on how to accelerate e-health alignment, convergence and clinical data integration. The Committee was informed that on 20 June 2012, the Assembly of First Nations and Canada’s Health Informatics Association, with the support of Health Canada and Canada Health Infoway Inc., had hosted the First Nations eHealth Convergence Forum. The Assembly of First Nations is now focusing on data sharing, including the creation of a guide to develop data sharing agreements.

Despite this progress, the Committee heard that the development and implementation of e-health and telehealth in First Nations communities remains challenging. The development of e-health projects in First Nations communities were described as lagging behind in comparison to initiatives in the rest of Canada. The Assembly of First Nations was of the view that sufficient investments in infrastructure and capacity to support these projects have not been made.[101] It therefore recommended that funding for Health Canada’s EHealth Infostructure Program be maintained to help First Nations communities realize the full potential of these technologies. In addition, the Committee heard that a lack of access to broadband networks remains a key concern, as at least 10% of First Nations communities still do not have access to broadband networks. Jurisdictional barriers also remain a concern, as Canada Health Infoway Inc. works mainly with provinces rather than First Nations communities. The Committee heard that the Assembly of First Nations and Health Canada were working closely with Canada Health Infoway Inc. to address this issue.

Finally, the Committee also heard that e-health and telehealth systems alone could not address the gap in health outcomes between First Nations communities and other Canadians. The Assembly of First Nations explained that the rates of type 2 diabetes in on-reserve First Nations communities are three to five times higher than rates among the general population and that infant mortality is approximately 1.5 times higher than the national average. Moreover, the Committee heard that First Nations people lack access to health care for a variety of reasons beyond geography, which were identified in a recent First Nations health survey and include: the inability to cover child care costs, difficulty arranging and paying for medical transportation, excessive wait times, and inadequate and culturally inappropriate care.[102] Consequently, they believe that it is also necessary to examine the broader social determinants of health, including: housing, education, poverty, mental health and addictions, in order to reduce health disparities for First Nations people, particularly those living in more northern and remote communities.

B. Committee Observations and Recommendations

The Committee’s study found that innovations in e-health, telehealth and telerobotics are leading to improved health outcomes for patients and lowering the costs of health care delivery in Canada. The Committee learned that mobile health devices and web-applications for the management of diseases are engaging patients in the management of their health. Furthermore, these devices are helping patients overcome geographic barriers to accessing hospital-based disease management programs without affecting the quality of their care. The Committee heard that there is an on-going need for CIHR to continue its investment in the development and evaluation of research programs promoting the implementation of these e-health tools. With respect to the implementation of EHRs, the Committee heard that there are still on-going challenges particularly in the area of interoperability. Witnesses saw Canada Health Infoway Inc. as having a key role to play in ensuring that EHR systems are being developed and implemented in accordance with common standards for interoperability and privacy.

The Committee also heard that Canada is a world leader in the area of telehealth and telerobotics, which is improving access to care for residents of rural and remote communities and providing significant savings to health care systems by reducing the need for medical travel. In particular, the Committee heard about the benefits of “Rosie the Robot,” which provides the community of Nain, Labrador with round-the-clock access to a physician. Evaluations of Rosie’s impact on the community suggest that a telerobotic presence can have a positive impact on health care delivery in northern Canada. Finally, the Committee learned that progress is being made in First Nations communities in the development and implementation of e-health and telehealth systems, as a result of investments made by Health Canada’s eHealth Infostructure Program in partnership with First Nations communities, provincial governments and private partners. Consequently, there is a need for Health Canada to continue investing in this program to ensure that the development of e-health and telehealth systems in First Nations communities does not lag behind the rest of Canada. Furthermore, the Committee heard that there is a need to ensure that the remaining First Nations communities have access to broadband networks, and that Health Canada, Canada Health Infoway Inc., and First Nations communities continue to work together to address jurisdictional barriers in the development and implementation of these systems.

Reflecting these findings, the Committee therefore recommends that:

1.     The Canadian Institutes of Health Research continue to fund research promoting the development, implementation and evaluation of e‑health tools in Canada.

2.     The Government of Canada and Canada Health Infoway Inc. focus its investments on the development of e-health tools that engage patients in their own care.

3.     The Government of Canada continue to fund Health Canada’s e-Health Infostructure Program.

4.     Health Canada, through its e‑Health Infostructure Program, continue to ensure that remote and northern First Nations and Inuit communities have sufficient access to broadband networks.

5.     Canada Health Infoway Inc. continue to work with Health Canada, First Nations, Inuit communities and provincial governments to address jurisdictional challenges in the development and implementation of e-health and telehealth systems.

6.     Health Canada, in partnership with First Nations and Inuit communities, provincial and territorial governments, and other relevant stakeholders, consider promoting the adoption of telerobotic systems in northern and remote communities where feasible.