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

Scoping review of telehealth use by Indigenous populations from Australia, Canada, New Zealand, and the United States

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.

Emergency care via video consultation: interviews on patient experiences from rural community hospitals in northern Sweden

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.

Understanding virtual primary healthcare with Indigenous populations: a rapid evidence review

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.

Economic Evaluation of Telerobotic Ultrasound Technology to Remotely Provide Ultrasound Services in Rural and Remote Communities

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.

Patient satisfaction with telemedicine in acute care setting: A systematic review

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.

The prevalence and patterns of use of point-of-care ultrasound in Newfoundland and Labrador

Introduction

Point-of-care ultrasound (POCUS) is used for diagnostic and procedural guidance by physicians in Newfoundland and Labrador (NL). POCUS use is largely limited to urban locations and the training is variable amongst physicians. The primary aim of this study was to determine the prevalence of POCUS devices in NL and the secondary aim was to characterise the patterns of POCUS use amongst physicians in NL.

Methods

This is a mixed-methods cross-sectional study. We determined the prevalence of POCUS devices from purchase records and the patterns of POCUS use through theme-based interviews. The interviews were transcribed, coded and analysed using standardised qualitative methods.

Results

Ten physicians (3 females, 5 rural) participated in the interviews. The overall prevalence of POCUS devices in NL was 12.5/100,000 population. Participants in urban areas had more access to POCUS training and devices. Participants used POCUS on a daily or weekly basis to rule in or out life-threatening conditions and improve access to specialist care. The benefits of POCUS included expedited investigations, decreased radiation and increased patient satisfaction. The barriers to using POCUS were lack of training, time, devices, image archiving software, difficulty generating and interpreting images and patient body habitus.

Conclusion

This is the first study to our knowledge to report the prevalence of POCUS devices in Canada. Physicians who practise in rural NL have limited access to POCUS devices and have identified barriers to POCUS training. Connecting physicians in rural areas with POCUS experts through a province-wide POCUS network may address these barriers and improve healthcare access.

Patient satisfaction with a pharmacist-led best possible medication discharge plan via tele-robot in a remote and rural community hospital

Introduction

Medication reconciliation (MedRec) reduces the risk of preventable medication-related adverse events (ADEs). A best possible medication discharge plan (BPMDP) is a revised list of medications a patient will take when discharged from hospital; a pharmacist review ensures accuracy. For many hospitals, on-site pharmacists are non-existent. Extension of a visual presence via a mobile robotic platform with real-time audiovisual communication by pharmacists to conduct MedRec remains unstudied. This study explored patient perceptions of a pharmacist-led BPMDP using a telepresence robot. Time requirements, unintentional discharge medication discrepancies (UMD), programme inefficiencies/barriers and facilitators involved in pharmacist review of the discharge medication list and patient interviews were also described.

Methods

This prospective cohort study enrolled adult patients admitted to a 12-bed community hospital at high risk of an ADE. Remote pharmacists reviewed the discharge prescription list, identified/resolved UMDs, and interviewed/counselled patients using a telepresence robot. Thereafter, patients completed an anonymous satisfaction questionnaire. Prescriber discharge UMDs were classified, and barriers/inefficiencies and facilitators were documented.

Results

Nine patients completed an interview, with a 75% interview agreement rate. All patients were comfortable with the robot and 76% felt their care was better. With a median of 11 discharge medications/patient, the UMD rate was 78%; 71% had omitted medications, 43% involved a cardiovascular medication, 88% were due to a hospital system cause, and 43% were specifically due to an inaccurate best possible admission medication history. Median times for interview preparation, interview and UMD/drug therapy problem resolution were 45, 15 and 10 min, respectively.

Conclusion

Using a telepresence robot to provide pharmacist-led BPMDPs is acceptable to patients and an innovative, effective solution to identify/resolve UMDs.

The rural tax: comprehensive out-of-pocket costs associated with patient travel in British Columbia

BACKGROUND

A significant concern for rural patients is the cost of travel outside of their community for specialist and diagnostic care. Often, these costs are transferred to patients and their families, who also experience stress associated with traveling for care. We sought to examine the rural patient experience by (1) estimating and categorizing the various out of pocket costs associated with traveling for healthcare and (2) describing and measuring patient stress and other experiences associated with traveling to seek care, specifically in relation to household income.

METHODS

We have designed and administered an online, retrospective, cross-sectional survey seeking to estimate the out-of-pocket (OOP) costs and personal experiences of rural patients associated with traveling to access health care in British Columbia. Respondents were surveyed across five categories: Distance Traveled and Transportation Costs, Accommodation Costs, Co-Traveler Costs, Lost Wages, and Patient Stress. Bivariate relationships between respondent household income and other numerical findings were investigated using one-way ANOVA.

RESULTS

On average, costs for respondents were $856 and $674 for transport and accommodation, respectively. Strong relationships were found to exist between the distance traveled and total transport costs, as well as between a patient's stress and their household income. Patient perspectives obtained from this survey expressed several related issues, including the physical and psychosocial impacts of travel as well as delayed or diminished care seeking.

CONCLUSIONS

These key findings highlight the existing inequities between rural and urban patient access to health care and how these inequities are exacerbated by a patient's overall travel-distance and financial status. This study can directly inform policy related efforts towards mitigating the rural-urban gap in access to health care.

Forensic psychiatry services in Nunavut

There is a paucity of research on forensic psychiatry patients from Nunavut, including no published data concerning the prevalence and characterisation of patients in this territory. The lack of basic information hinders the evaluation of services and establishing best practices. The current paper aims to characterise forensic psychiatry patients from Nunavut and further the understanding of the challenges in organising forensic psychiatry healthcare in Nunavut. A retrospective chart review design was used to examine individuals from Nunavut who are engaged with the Ontario forensic psychiatry system. The sample included all Unfit to Stand Trial (26.7%) and Not Criminally Responsible (73.3%) patients (N = 15) under the jurisdiction of the Nunavut Review Board in a one-year period. The average distance between the patient’s place of residence in Nunavut and the Ontario facilities was 2,517 km. Overall, 26.7% were living in Nunavut, 60.0% remained in Ontario, and 13.3% resided in Alberta. Results are presented for sociodemographics, forensic status, personal and familial history, psychiatric and criminal history, diagnoses, index offence characteristics, treatment, assessment tools, and aggression. The prevalence and many characteristics of forensic psychiatry patients from Nunavut differ from the rest of Canada and have important implications for the delivery of services.

'I didn't feel judged': exploring women's access to telemedicine abortion in rural Australia

INTRODUCTION Regardless of geographical location, safe and legal abortion is an essential reproductive health service. Accessing an abortion is problematic for women in rural areas. Although telemedicine is globally established as safe and effective for medical abortion in urban settings, there is a paucity of research exploring access to telemedicine abortion for women in rural locations. AIM The aim of this qualitative research is to explore and better understand women's access to telemedicine abortion in Australian rural areas. METHODS Structured interviews were conducted with women (n=11) living in rural areas who had experienced a telemedicine abortion within the last 6 months. Phone interviews were recorded and transcribed verbatim. Data underwent a Patient-Centred Access framework analysis and were coded according to the domain categories of approachability/ability to perceive, acceptability/ability to seek, availability/ability to reach, affordability/ability to pay, and appropriateness/ability to engage. RESULTS Rural women had severely limited access to abortion care. The five domains of the Patient-Centred Access model demonstrated that when women with the prerequisite personal skills and circumstances are offered a low-cost service with compassionate staff and technical competence, telemedicine can innovate to ensure rural communities have access to essential reproductive health services. DISCUSSION Telemedicine offers an innovative model for ensuring women's access to medical abortion services in rural areas of Australia and likely has similar applicability to international non-urban contexts. Strategies are needed to ensure women with lower literacy and less favourable situational contexts, can equitably access abortion services through telemedicine.

The Research on Patient Satisfaction with Remote Healthcare Prior to and during the COVID-19 Pandemic

The issue of research on patient satisfaction with healthcare services took on a completely new dimension due to the COVID-19 pandemic and the developing telehealth services. This results from the fact that during the pandemic, remote healthcare was often the only possible form of care provision to the patient. The COVID-19 pandemic has substantially accelerated the implementation of remote healthcare in healthcare institutions and made it an essential tool for providing healthcare services. The objective of the literature review was to study the research on patient satisfaction with remote healthcare services prior to and during the pandemic. The study featured a literature review of electronic databases, such as: Medline, ProQuest, PubMED, Ebsco, Google Scholar, WoS. The identified empirical papers were classified in two groups concerning the research on patient satisfaction prior to and during the COVID-19 pandemic, and were divided and descriptively synthesised. Certain limitations to the methodical quality of the research were demonstrated as result of the conducted analyses. It was also ascertained that researchers lack clarity on the method of defining and measuring satisfaction prior to and during the COVID-19 pandemic.

Contextual factors associated with depression among Northern and Indigenous adolescents in the Northwest Territories, Canada

BACKGROUND

Persons in Arctic regions disproportionately experience depression. Knowledge gaps remain regarding factors associated with depression among adolescents in the Northwest Territories (NWT), Canada, where child and adolescent mental health hospitalizations are nearly 2.5 times the national rate. This study assesses correlates of depression among adolescents in the NWT.

METHODS

We conducted a cross-sectional survey with adolescents aged 13-18 in 17 NWT communities. We assessed associations between socio-demographic characteristics, dating violence, food insecurity and depression, measured with the 9-item Patient Health Questionnaire. We conducted ordered logistic regressions to assess associations with no, mild, or moderate/severe depression scores.

RESULTS

Participants (n = 399; mean age: 14.3, s.d.: 1.3) were mostly Indigenous (79%) and 45% reported food insecurity. Nearly half (47%) reported minimal/no depression symptoms, 25% mild symptoms and 28% moderate/severe symptoms. In multivariate analyses, participants who were cisgender women compared to other genders, sexually diverse v. heterosexual, and food insecure had double the odds of more severe depression symptoms. Among those dating, dating violence was associated with double the odds of moderate/severe depression symptoms.

CONCLUSIONS

Findings support tailored interventions to address material (food insecurity), relational (dating violence) and symbolic (gender and sexual orientation norms) contextual factors associated with depression among adolescents in the NWT.

Preliminary clinical algorithm to optimise remote delivery of paediatric concussion care in Canada's North

Concussion is a form of traumatic brain injury that affects thousands of children and adolescents across Canada annually. With timely access to comprehensive medical care, the majority of patients with acute concussion will recover within 1–4 weeks. Those who develop persistent post-concussion symptoms often benefit from early recognition and referral to multi-disciplinary concussion clinics that have the personnel and resources to meet their complex needs. Youth who live in remote and isolated communities within Canada’s North, a significant proportion of whom are Indigenous, face unique barriers and obstacles to accessing primary and specialised concussion care. Although telemedicine has recently emerged as a tool that can help address these gaps in care, there are presently no clinical guidelines or tools available to assist multi-disciplinary concussion clinics in providing remote concussion care to these medically underserved patients. Here we incorporate literature from a scoping review and our early institutional experience to present an evidence-informed preliminary clinical algorithm and resources to help guide and optimise remote paediatric concussion care delivery in Canada’s North. We also discuss how innovative technologies and partnerships can be leveraged to enhance the delivery of safe, equitable, cost-effective and culturally appropriate care to these communities.

Patient experience studies in the circumpolar region: a scoping review

OBJECTIVES

Patient experiences with health systems constitute a crucial pillar of quality care. Across the Arctic, patients' interactions with the healthcare system are influenced by challenges of access, historical inequities and social determinants. This scoping review sought to describe the range and nature of peer-reviewed literature on patient experience studies conducted within the circumpolar region.

DESIGN

In a partnership between Danish/Greenlandic, Canadian and American research teams, a scoping review of published research exploring patient experiences in circumpolar regions was undertaken.

DATA SOURCES

Seven electronic databases were queried: MEDLINE, Embase, Scopus, 'Global Health 1910 to 2019 Week 11', CINAHL, PsycINFO and SveMed+.

ELIGIBILITY CRITERIA

Articles were eligible for inclusion if they (a) took place in the circumpolar region, (b) reported patients' perspective and (c) were focussed primarily on patient experiences with care, rather than satisfaction with treatment outcome.

DATA EXTRACTION AND SYNTHESIS

Title and abstract screening, full-text review and data extraction was conducted by four researchers. Bibliometric information such as publication date and country of origin was extracted, as was information regarding study design and whether or not the article contained results relevant to the themes of Indigenous values, rural and remote context, telehealth and climate change. Two researchers then synthesised and characterised results relevant to these themes.

RESULTS

Of the 2824 articles initially found through systematic searches in seven databases, 96 articles were included for data extraction. Findings from the review included unique features related to Indigenous values, rural and remote health, telehealth and climate change.

CONCLUSIONS

The review findings provide an overview of patient experiences measures used in circumpolar nations. These findings can be used to inform health system improvement based on patient needs in the circumpolar context, as well as in other regions that share common features. This work can be further contextualized through Indigenous methodologies such as sharing circles and community based participatory methods.

The Application of Drones in Healthcare and Health-Related Services in North America: A Scoping Review

Using drone aircraft to deliver healthcare and other health-related services is a relatively new application of this technology in North America. For health service providers, drones represent a feasible means to increase their efficiency and ability to provide services to individuals, especially those in difficult to reach locations. This paper presents the results of a scoping review of the research literature to determine how drones are used for healthcare and health-related services in North America, and how such applications account for human operating and machine design factors. Data were collected from PubMed, CINAHL, Scopus, Web of Science, and IEEE Xplore using a block search protocol that combined 13 synonyms for “drone” and eight broad terms capturing healthcare and health-related services. Four-thousand-six-hundred-and-sixty-five documents were retrieved, and following a title, abstract, and full-text screening procedure completed by all authors, 29 documents were retained for analysis through an inductive coding process. Overall, findings indicate that drones may represent a financially feasible means to promote healthcare and health-related service accessibility for those in difficult-to-reach areas; however, further work is required to fully understand the costs to healthcare organizations and the communities they serve.

Enhancing access to care in northern rural communities via telehealth

The cost of providing health care in northern Canada is higher than the rest of Canada. Telehealth has the potential to reduce health care expenditures. Yet this is still underutilised in Canada and globally. This paper describes the services provided through telehealth in some northern regions of Canada. It provides recommendations on the requirements for setting up real presence telehealth and how utilisation can be enhanced. Telehealth offers potential benefits for health outcomes by increasing access to healthcare, and reducing expenditures.

Systematic review of patient and caregivers' satisfaction with telehealth videoconferencing as a mode of service delivery in managing patients' health

Telehealth is an alternative method of delivering health care to people required to travel long distances for routine health care. The aim of this systematic review was to examine whether patients and their caregivers living in rural and remote areas are satisfied with telehealth videoconferencing as a mode of service delivery in managing their health. A protocol was registered with PROSPERO international prospective register of systematic reviews (#CRD42017083597) and conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A systematic search of Ovid Medline, Embase, CINAHL, ProQuest Health Research Premium Collection, Joanna Briggs Institute and the Cochrane Library was conducted. Studies of people living in rural and remote areas who attended outpatient appointments for a health condition via videoconference were included if the studies measured patient and/or caregivers' satisfaction with telehealth. Data on satisfaction was extracted and descriptively synthesised. Methodological quality of the included studies was assessed using a modified version of the McMaster Critical Review Forms for Quantitative or Qualitative Studies. Thirty-six studies of varying study design and quality met the inclusion criteria. The outcomes of satisfaction with telehealth were categorised into system experience, information sharing, consumer focus and overall satisfaction. There were high levels of satisfaction across all these dimensions. Despite these positive findings, the current evidence base lacks clarity in terms of how satisfaction is defined and measured. People living in rural and remote areas are generally satisfied with telehealth as a mode of service delivery as it may improve access to health care and avoid the inconvenience of travel.

Remoteness and its impact on the potential for mental health initiatives in criminal courts in Nunavut, Canada

Remoteness in the isolated communities of Nunavut, Canada adversely affects access to mental health services. Mental health initiatives in criminal courts exist in many cities to offer healthcare alternatives to regular criminal court processing for people affected by mental illness. These initiatives do not exist in Nunavut. A qualitative multiple-case study in 3 Nunavut communities involving 55 semi-structured interviews and 3 focus groups explored perceptions by health, justice and community stakeholders of the potential for criminal court mental health initiatives in the territory. Findings suggest remoteness is perceived to hinder mental healthcare support for court responses to people affected by mental illness, creating delay in psychiatric assessments and treatment. While communication technologies, such as tele-mental health, are considered an effective solution by most health professionals, many justice-sector participants are sceptical because of perceived limits to accessibility, reliability and therapeutic value. These perceptions suggest remoteness is a significant hurdle facing future criminal court mental health initiatives in Nunavut. Additionally, remoteness is viewed as affecting decisions by lawyers to bypass legislated mental health avenues, possibly resulting in more people with mental illness facing criminal justice sanctions without assessment and treatment.

Comparing health care workforce in circumpolar regions: patterns, trends and challenges

Background: The eight Arctic States exhibit substantial health disparities between their remote northernmost regions and the rest of the country. This study reports on the trends and patterns in the supply and distribution of physicians, dentists and nurses in these 8 countries and 25 regions and addresses issues of comparability, data gaps and policy implications

Methods: We accessed publicly available databases and performed three types of comparisons: (1) among the 8 Arctic States; (2) within each Arctic State, between the northern regions and the rest of the country; (3) among the 25 northern regions. The unit of comparison was density of health workers per 100,000 inhabitants, and the means of three 5-year periods from 2000 to 2014 were computed.

Results: The Nordic countries consistently exceed North America in the density of all three categories of health professionals, whereas Russia reports the highest density of physicians but among the lowest in terms of dentists and nurses.

The largest disparities between “north” and “south” are observed in the Northwest Territories and Nunavut of Canada for physicians, and in Greenland for all three categories. The disparity is much less pronounced in the northern regions of Nordic countries, while Arctic Russia tends to be oversupplied in all categories.

Conclusions: Despite efforts and standardisation of definitions by international organisations such as OECD, it is difficult to obtain an accurate and comparable estimate of the health workforce even in the basic categories of physicians, dentists and nurses . The use of head counts is particularly problematic in jurisdictions that rely on short-term visiting staff. Comparing statistics also needs to take into account the health care system, especially where primary health care is nurse-based.

List of Abbreviations ADA: American Dental Association; AHRF: Area Health Resource File; AMA: American Medical Association; AO: Autonomous Okrug; AVI: Aluehallintovirasto; CHA: Community Health Aide; CHR: Community Health Representative; CHW: Community Health Worker; CIHI: Canadian Institute for Health Information; DO: Doctor of Osteopathic Medicine; FTE: Full Time Equivalent; HPDB: Health Personnel Database; MD: Doctor of Medicine; NOMESCO: Nordic Medico-Statistical Committee; NOSOSCO: Nordic Social Statistical Committee; NOWBASE: Nordic Welfare Database; NWT: Northwest Territories; OECD: Organization for Economic Co-operation and Development; RN: Registered Nurse; SMDB: Scott’s Medical Database; WHO: World Health Organization

What role can unmanned aerial vehicles play in emergency response in the Arctic: A case study from Canada

This paper examines search and rescue and backcountry medical response constraints in the Canadian Arctic and potential for unmanned aerial vehicles (UAV) to aid in response and preparedness. Semi-structured interviews (n = 18) were conducted with search and rescue responders, Elders, and emergency management officials to collect data on current emergency response and potential for UAV use. UAV test flights (n = 17) were undertaken with community members. We analyzed five years of weather data to examine UAV flight suitability. Numerous challenges face Arctic search and rescue and backcountry emergency response. Changing social and environmental conditions were described as increasing vulnerability to backcountry emergencies. Responders desired additional first aid and emergency training. Legal and weather restrictions were found to limit where, when and who could fly UAVs. UAVs were demonstrated to have potential benefits for hazard monitoring but not for SAR or medical response due to legal restrictions, weather margins, and local capacity. We find that communities are ill-prepared for ongoing SAR demands, let alone a larger disaster. There are numerous limitations to the use of consumer UAVs by Arctic communities. Prevention of backcountry medical emergencies, building resilience to disasters, and first responder training should be prioritized over introducing UAVs to the response system.

The robot nurses are coming to a workplace near you

As robot technology rapidly encroaches into most areas of our lives, second-year Kingston and St George's universities nursing student Jack Sherry remains optimistic that he will still have a job, jsherry38@gmail.com.

Robot Assisted Surgical Ward Rounds: Virtually Always There

BACKGROUND

 While an explosion in technological sophistication has revolutionized surgery within the operating theatre, delivery of surgical ward-based care has seen little innovation.  Use of telepresence allowing off-site clinicians communicate with patients has been largely restricted to outpatient settings or use of complex, expensive, static devices.  We designed a prospective study to ascertain feasibility and face validity of a remotely controlled mobile audiovisual drone (LUCY) to access inpatients.  This device is, uniquely, lightweight, freely mobile and emulates 'human' interaction by swiveling and adjusting height to patients' eye-level.   METHODS: Robot-assisted ward rounds(RASWR) were conducted over 3 months. A remotely located consultant surgeon communicated with patients/bedside teams via encrypted audiovisual telepresence robot (DoubleRoboticstm, California USA).  Likert-scale satisfaction questionnaires, incorporating free-text sections for mixed-methods data collection, were disseminated to patient and staff volunteers following RASWRs.  The same cohort completed a linked questionnaire following conventional (gold-standard) rounds, acting as control group. Data were paired, and non-parametric analysis performed.  RESULTS: RASWRs are feasible (>90% completed without technical difficulty). The RASWR(n=52 observations) demonstrated face validity with strong correlations (r>0.7; Spearman, p-value <0.05) between robotic and conventional ward rounds among patients and staff on core themes, including dignity/confidentiality/communication/satisfaction with management plan. Patients (96.08%, n=25) agreed RASWR were a satisfactory alternative when consultant physical presence was not possible. There was acceptance of nursing/NCHD cohort (100% (n=11) willing to regularly partake in RASWR).  CONCLUSION: RASWRs receive high levels of patient and staff acceptance, and offer a valid alternative to conventional ward rounds when a consultant cannot be physically present.

Adding navigation, artificial audition and vital sign monitoring capabilities to a telepresence mobile robot for remote home care applications

A telepresence mobile robot is a remote-controlled, wheeled device with wireless internet connectivity for bidirectional audio, video and data transmission. In health care, a telepresence robot could be used to have a clinician or a caregiver assist seniors in their homes without having to travel to these locations. Many mobile telepresence robotic platforms have recently been introduced on the market, bringing mobility to telecommunication and vital sign monitoring at reasonable costs. What is missing for making them effective remote telepresence systems for home care assistance are capabilities specifically needed to assist the remote operator in controlling the robot and perceiving the environment through the robot's sensors or, in other words, minimizing cognitive load and maximizing situation awareness. This paper describes our approach adding navigation, artificial audition and vital sign monitoring capabilities to a commercially available telepresence mobile robot. This requires the use of a robot control architecture to integrate the autonomous and teleoperation capabilities of the platform.

Remote Presence Robotic Technology Reduces Need for Pediatric Interfacility Transportation from an Isolated Northern Community

BACKGROUND

Providing acutely ill children in isolated communities access to specialized care is challenging. This study aimed to evaluate remote presence robotic technology (RPRT) for enhancing pediatric remote assessments, expediting initiation of treatment, refining triaging, and reducing the need for transport.

METHODS

We conducted a pilot prospective observational study at a primary/urgent care clinic in an isolated northern community. Participants (n = 38) were acutely ill children <17 years presenting to the clinic, whom local healthcare professionals had considered for interfacility transportation (IFT). Participants were assessed and managed by a tertiary center pediatric intensivist through a remote presence robot. The intensivist triaged participants to either remain at the clinic or be transported to regional/tertiary care. Controls from a pre-existing local transport database were matched using propensity scoring. The primary outcome was the number of IFTs among participants versus controls.

RESULTS

Fourteen of 38 (37%) participants required transport, whereas all controls were transported (p < 0.0001). Six of 14 (43%) transported participants were triaged to a nearby regional hospital, while no controls were regionalized (p = 0.0001). All participants who remained at the clinic stayed <24 h, and were matched to controls who stayed 4.9 days in tertiary care (p < 0.001). There was no statistically significant difference in hospital length of stay between transported participants and controls (6.0 vs. 5.7 days).

CONCLUSIONS

RPRT reduced the need for specialized pediatric IFT, while enabling regionalization when appropriate. This study may have implications for the broader implementation of RPRT, while reducing costs to the healthcare system.

Augmented Reality as a Telemedicine Platform for Remote Procedural Training

Traditionally, rural areas in many countries are limited by a lack of access to health care due to the inherent challenges associated with recruitment and retention of healthcare professionals. Telemedicine, which uses communication technology to deliver medical services over distance, is an economical and potentially effective way to address this problem. In this research, we develop a new telepresence application using an Augmented Reality (AR) system. We explore the use of the Microsoft HoloLens to facilitate and enhance remote medical training. Intrinsic advantages of AR systems enable remote learners to perform complex medical procedures such as Point of Care Ultrasound (PoCUS) without visual interference. This research uses the HoloLens to capture the first-person view of a simulated rural emergency room (ER) through mixed reality capture (MRC) and serves as a novel telemedicine platform with remote pointing capabilities. The mentor’s hand gestures are captured using a Leap Motion and virtually displayed in the AR space of the HoloLens. To explore the feasibility of the developed platform, twelve novice medical trainees were guided by a mentor through a simulated ultrasound exploration in a trauma scenario, as part of a pilot user study. The study explores the utility of the system from the trainees, mentor, and objective observers’ perspectives and compares the findings to that of a more traditional multi-camera telemedicine solution. The results obtained provide valuable insight and guidance for the development of an AR-supported telemedicine platform.

Development and Use of Health-Related Technologies in Indigenous Communities: Critical Review

Background

Older Indigenous adults encounter multiple challenges as their age intersects with health inequities. Research suggests that a majority of older Indigenous adults prefer to age in place, and they will need culturally safe assistive technologies to do so.

Objective

The aim of this critical review was to examine literature concerning use, adaptation, and development of assistive technologies for health purposes by Indigenous peoples.

Methods

Working within Indigenous research methodologies and from a decolonizing approach, searches of peer-reviewed academic and gray literature dated to February 2016 were conducted using keywords related to assistive technology and Indigenous peoples. Sources were reviewed and coded thematically.

Results

Of the 34 sources captured, only 2 concerned technology specifically for older Indigenous adults. Studies detailing technology with Indigenous populations of all ages originated primarily from Canada (n=12), Australia (n=10), and the United States (n=9) and were coded to four themes: meaningful user involvement and community-based processes in development, the digital divide, Indigenous innovation in technology, and health technology needs as holistic and interdependent.

Conclusions

A key finding is the necessity of meaningful user involvement in technology development, especially in communities struggling with the digital divide. In spite of, or perhaps because of this divide, Indigenous communities are enthusiastically adapting mobile technologies to suit their needs in creative, culturally specific ways. This enthusiasm and creativity, coupled with the extensive experience many Indigenous communities have with telehealth technologies, presents opportunity for meaningful, culturally safe development processes.

Telehomecare telecommunication framework - from remote patient monitoring to video visits and robot telepresence

Over the last few years, the number of remote patient monitoring (RPM) products and of videoconferencing systems has exploded. There is also a significant number of research initiatives addressing the use of service robots for assistance in daily living activities. From a technological standpoint, providing telehomecare services is certainly feasible. However, one technological barrier is to have access to a telecommunication platform that can be adapted to address the broad range of specifications and requirements of clinical and telehealth applications. Handling the full spectrum of possibilities requires a telecommunication framework that can transmit vital sign data from patients to clinicians, bidirectional audio-video from a standard computing device, and also multiple video streams and bidirectional transmission of control data. This paper presents a framework that integrates such capabilities. It also illustrates the versatility of the framework by presenting custom-designed devices allowing integration of capabilities ranging from RPM to video visits and robot telepresence.

The use of technology to improve health care to Saskatchewan's First Nations communities

Background

Saskatchewan is a province of over one million people and over 13% are Indigenous peoples, many of whom live on reserve lands. Despite continued efforts, access to health care remains a significant challenge for these Indigenous people, especially those in the North.

Objective

To address this challenge, Saskatchewan's health care providers have been incorporating the use of technology for various health services. This paper describes various ways technology has been used in First Nations communities in Saskatchewan.

Methods

Several pilot projects between First Nations leaders and health care providers, in the communities as well as in the urban setting, have taken place over the past 10 years. Information on these pilots was supplemented with literature reviews and consultations with colleagues at the Northern Inter-Tribal Health Authority, the First Nations and Inuit Health Branch (FNIHB), Health Canada and lead physicians for services to the North.

Results

Numerous technologies have shown promise in aiding the timely delivery of high quality health care. Remote Presence Robotic Technology (RPRT) is a form of telemedicine that creates the sense that a clinician is at the patient's side; enabling clinical services to be provided remotely and in real time. Increasing access to internet services and providing computer tablets to community health nurses have improved patients' access to clinical care and to vital health care information. Robotic ultrasonography has been used to provide onsite care for pre-natal patients. The provision of cell phones to HIV-positive patients has improved compliance with anti-retroviral therapy and has resulted in better clinical outcomes. The Xpert MTB/RIF (Mycobacerium tuberculosis complex / resistance to rifampicin) is an automated device that, through analysis of raw sputum samples, can identify the presence of M. tuberculosis with greater speed, sensitivity and specificity than the conventional acid-fast bacilli (AFB) smear. Similarly, telemedicine remote communications equipment is being used for patient care across communities. Panorama is a comprehensive, integrated public health information system designed for public health professionals and is currently being introduced in 21 communities in Saskatchewan.

Conclusion

Not only do these innovative technologies appear to improve access and enhance the quality of timely care in remote communities but they also bring comfort to patients, prevent unnecessary transportation and minimize time away from work and family. Although these technologies are not a panacea for some of the determinants of health that can affect the incidence and severity of infectious diseases in First Nations, they do appear to address some of the geographic challenges faced in providing health services in remote communities.

Case Report: Using a Remote Presence Robot to Improve Access to Physical Therapy for People with Chronic Back Disorders in an Underserved Community

Purpose: The purpose of this case study was to evaluate the delivery of an inter-professional (IP) spinal triage management approach to chronic back disorders using remote presence robotic technology as an innovative form of telerehabilitation in a northern Saskatchewan community. Methods: The IP team, consisting of a local nurse practitioner (NP) and a physical therapist in an urban centre, completed a comprehensive neuromusculoskeletal assessment of, and one follow-up visit with, a post-surgical spinal patient. Treatment included detailed education regarding self-management after spinal surgery, provision and progression of home exercises, and reassurance. The patient was then referred to regional, in-person physical therapy care to complete her treatment. Results: A semi-structured interview with the NP revealed a high level of satisfaction; qualitative themes included the value of IP practice and the benefit to the patient of telerehabilitation achieved through patient-centred care. In a post-treatment survey, the patient expressed a high level of satisfaction with and appreciation for the patient-centred approach and the IP team. Objective clinical improvements in spinal and straight-leg raise movements were noted at the final telerehabilitation session. Conclusion: This report demonstrates the feasibility of delivering IP spinal triage management using telerehabilitation, specifically remote presence robotics, in a remote setting. Further research should include larger scale studies that investigate health, system, and economic outcomes as well as comparative studies for other forms of telehealth technology.

Transforming Health Care in Remote Communities: report on an international conference

An international conference titled “Transforming Health Care in Remote Communities” was held at the Chateau Lacombe Hotel in Edmonton, Canada, April 28–30, 2016. The event was organized by the University of Alberta’s School of Public Health, in partnership with the Institute for Circumpolar Health Research in Yellowknife, Northwest Territories, and the Qaujigiartiit Health Research Centre in Iqaluit, Nunavut.

There were 150 registrants from 7 countries: Canada (7 provinces and 3 territories), United States, Denmark, Iceland, Norway, Sweden, and Australia. They included representatives of academic institutions, health care agencies, government ministries, community organizations, and private industry.

The Conference focused on developing solutions to address health care in remote regions. It enabled new networks to be established and existing ones consolidated.

Healthcare in Canada's North: Are We Getting Value for Money?

OBJECTIVE

To determine if Canadians are getting value for money in providing health services to our northern residents.

METHOD

Secondary analyses of data from Statistics Canada, the Canadian Institute of Health Information and territorial government agencies on health status, health expenditures and health system performance indicators.

RESULTS

Per capita health expenditures in Canada's northern territories are double that of Canada as a whole and are among the highest in the world. The North lags behind the rest of the country in preventable mortality, hospitalization for ambulatory care sensitive conditions and other performance indicators.

DISCUSSION

The higher health expenditure in the North is to be expected from its unique geography and demography. If the North is not performing as well as Canada, it is not due to lack of money, and policy makers should be concerned about whether healthcare can be as good as it could be.

City mouse, country mouse: a mixed-methods evaluation of perceived communication barriers between rural family physicians and urban consultants in Newfoundland and Labrador, Canada

OBJECTIVES

To examine perceived communication barriers between urban consultants and rural family physicians practising routine and emergency care in remote subarctic Newfoundland and Labrador (NL).

DESIGN

This study used a mixed-methods design. Quantitative and qualitative data were collected through exploratory surveys, comprised of closed and open-ended questions. The quantitative data was analysed using comparative statistical analyses, and a thematic analysis was applied to the qualitative data.

PARTICIPANTS

52 self-identified rural family physicians and 23 urban consultants were recruited via email. Rural participants were also recruited at the Family Medicine Rural Preceptor meetings in St John's, NL.

SETTING

Rural family physicians and urban consultants in NL completed a survey assessing perceived barriers to effective communication.

RESULTS

Data confirmed that both groups perceived communication difficulties with one another; with 23.1% rural and 27.8% urban, rating the difficulties as frequent (p=0.935); 71.2% rural and 72.2% urban as sometimes (p=0.825); 5.8% rural and 0% urban acknowledged never perceiving difficulties (p=0.714). Overall, 87.1% of participants indicated that perceived communication difficulties impacted patient care. Primary trends that emerged as perceived barriers for rural physicians were time constraints and misunderstanding of site limitations. Urban consultants' perceived barriers were inadequate patient information and lack of native language skills.

CONCLUSIONS

Barriers to effective communication are perceived between rural family physicians and urban consultants in NL.

Rural and remote care: Overcoming the challenges of distance

The challenges of providing quality respiratory care to persons living in rural or remote communities can be daunting. These populations are often vulnerable in terms of both health status and access to care, highlighting the need for innovation in service delivery. The rapidly expanding options available using telehealthcare technologies have the capacity to allow patients in rural and remote communities to connect with providers at distant sites and to facilitate the provision of diagnostic, monitoring, and therapeutic services. Successful implementation of telehealthcare programs in rural and remote settings is, however, contingent upon accounting for key technical, organizational, social, and legal considerations at the individual, community, and system levels. This review article discusses five types of telehealthcare delivery that can facilitate respiratory care for residents of rural or remote communities: remote monitoring (including wearable and ambient systems; remote consultations (between providers and between patients and providers), remote pulmonary rehabilitation, telepharmacy, and remote sleep monitoring. Current and future challenges related to telehealthcare are discussed.

Climate-sensitive health priorities in Nunatsiavut, Canada

BACKGROUND

This exploratory study used participatory methods to identify, characterize, and rank climate-sensitive health priorities in Nunatsiavut, Labrador, Canada.

METHODS

A mixed method study design was used and involved collecting both qualitative and quantitative data at regional, community, and individual levels. In-depth interviews with regional health representatives were conducted throughout Nunatsiavut (n = 11). In addition, three PhotoVoice workshops were held with Rigolet community members (n = 11), where participants took photos of areas, items, or concepts that expressed how climate change is impacting their health. The workshop groups shared their photographs, discussed the stories and messages behind them, and then grouped photos into re-occurring themes. Two community surveys were administered in Rigolet to capture data on observed climatic and environmental changes in the area, and perceived impacts on health, wellbeing, and lifestyles (n = 187).

RESULTS

Climate-sensitive health pathways were described in terms of inter-relationships between environmental and social determinants of Inuit health. The climate-sensitive health priorities for the region included food security, water security, mental health and wellbeing, new hazards and safety concerns, and health services and delivery.

CONCLUSIONS

The results highlight several climate-sensitive health priorities that are specific to the Nunatsiavut region, and suggest approaching health research and adaptation planning from an EcoHealth perspective.

Robotic Telepresence in a Medical Intensive Care Unit--Clinicians' Perceptions

BACKGROUND

Robotic telepresence has been used for outsourcing of healthcare services for more than a decade; however, its use within an academic medical department is not yet widespread. Intensive care unit (ICU) robots can be used to increase access to off-site supervising physicians and other specialists, reducing possible wait time for difficult admissions and procedures.

OBJECTIVE

To study the use of ICU robots through a pilot program in an academic hospital and examine provider attitudes toward the usability and effectiveness of an ICU robot.

MATERIALS AND METHODS

The study was done as a postinterventional cross-sectional seven-question survey in a medical ICU in an urban academic hospital. Participants were attending physicians, fellows, residents, nurses, and respiratory therapists.

RESULTS

Users of the ICU robot reported satisfaction with communication, and improved patient care. They also reported perceived improved quality of care with the use of the robot.

CONCLUSIONS

Findings show the importance of a whole-team approach to the installation and implementation of an ICU robot. The ICU robot is an effective tool when it is used to visualize and communicate with patients, bedside staff, and families. However, a number of providers are still not trained or have not been shown how to use the ICU robot, which affects the overall utilization rate.

Cultural acceptance of robotic telestroke medicine among patients and healthcare providers in Saudi Arabia. Results of a pilot study

OBJECTIVE

To determine the degree of satisfaction and acceptance of stroke patients, their relatives, and healthcare providers toward using telestroke technology in Saudi Arabia.

METHODS

A cross-sectional study was conducted between October and December 2012 at King Abdulaziz Medical City, Ministry of National Guard Affairs, Riyadh, Saudi Arabia. The Remote Presence Robot (RPR), the RP-7i (FDA- cleared) provided by InTouch Health was used in the study. Patients and their relatives were informed that the physician would appear through a screen on top of a robotic device, as part of their clinical care. Stroke patients admitted through the emergency department, and their relatives, as well as healthcare providers completed a self-administered satisfaction questionnaire following the telestroke consultation sessions.

RESULTS

Fifty participants completed the questionnaire. Most subjects agreed that the remote consultant interview was useful and that the audiovisual component of the intervention was of high quality; 98% agreed that they did not feel shy or embarrassed during the remote interview, were able to understand the instruction of the consultant, and recommended its use in stroke management. Furthermore, 92% agreed or strongly agreed that the use of this technology can efficiently replace the physical presence of a neurologist.

CONCLUSION

Results suggest that the use of telestroke medicine is culturally acceptable among stroke patients and their families in Saudi Arabia and favorably received by healthcare providers.