In Canada, patient access to hospital and medical services is considered a fundamental human right. In theory, the poorest Canadians should experience the same level of care as the wealthiest. From an access to health care perspective, rural Canadians are at a disadvantage when compared to urban Canadians. Not only do rural Canadians have access to relatively fewer primary care physicians and fewer specialty physicians than do their urban counterparts, rural Canadians must travel farther and incur greater expense when seeking health care from physicians not living in their rural community.[1]

Provincial governments across Canada are reorganizing hospital and medical services in an attempt to make health care delivery more efficient, effective, and equitable. Telehealth is often proposed as a primary health care initiative that may help increase the rural population’s access to physicians and ease the workload of British Columbia’s rural-based physicians. Telehealth refers to the electronic transfer of audio and video pertaining to health information between distant sites and distant participants for any of the following purposes:

• Continuing education
• Patient diagnosis, treatment, and monitoring
• Delivering medical services[2,3]

Telehealth is a technology that, theoretically, can make rural and remote communities less remote by enabling rural physicians and their patients quick access to the opinions and support of a full spectrum of urban-based specialists and subspecialists.[4] It is this promise of equalizing access to health care for rural populations that underlies the fascination and proliferation of telemedicine projects across Canada and the world.[5] Telehealth also has the potential to decrease costs for patients, health care professionals, and the entire health care system.[2]

Clinical applications of telehealth technology remain more or less at the feasibility testing stage. More than a thousand clinical telehealth projects have taken place over the years, but few have lasted more than a year or two, and even fewer have demonstrated either clinical or economic benefits compared with conventional care.[6-8] In particular, most telehealth projects connect urban centres to rural sites, thereby using urban resources to support rural access to health care.

Hailey recently reviewed the evidence for the benefits of telemedicine and found that good-quality studies are scarce and the results cannot readily be generalized.[7]

Hailey identified 66 credible studies that included a comparison with a non-telemedicine alternative and that reported patient outcomes or economic assessments. Many were pilot projects, almost all were short in duration, and all were urban-centric in that the providers of telehealth services were urban based. Dermatology, mental health, transmission of echocardiographic and radiographic images, homecare for people with chronic illnesses (such as diabetes, congestive heart failure, COPD), and some kinds of medical consultations are the telemedicine applications that have demonstrated clinical benefit and economic savings for patients and clients. Of the 66 credible studies reviewed, only 14 involved rural sites, or involved patients and health care facilities located in rural-like communities.[9-22] The remaining studies involved such things as the ordering or transmission of CTs, MRIs, echocardiograms, processed pathology specimens, involved prisoners, or were non-videolink studies. Only two of these rural-relevant studies were Canadian studies, and neither was from British Columbia.[16,17] None of the rural-relevant studies looked at the efficacy, effectiveness, or cost-effectiveness of delivering telemedicine services to outpost nurses by general practitioners.

The lack of rural-relevant studies in Canada does not mean there is a lack of telehealth facilities in this country. On the contrary, most provinces and territories have or are participating in some sort of telehealth project. However, there is a paucity of written documentation on the limitations, successes, or failures associated with telehealth clinical applications in Canada.[7,23]

The Vanderhoof-Stoney Creek rural health video network is one of British Columbia’s clinical telehealth pilot projects. It is a collaboration project involving physicians and nurses from the community of Vanderhoof and their counterparts from the University of British Columbia (UBC). The proposal was put forward jointly by Dr Kendall Ho, an emergency physician at the Vancouver General Hospital, and by Dr Stuart Johnston, a family physician who lives and works in Vanderhoof. The project was funded by the British Columbia Ministry of Health Joint Standing Committee. Two components of the project were funded: clinical service delivery and education. This article focuses primarily on the Vanderhoof and Stoney Creek videolink mainly because of the uniqueness of the component: namely, the linking of a rural community served by rural physician to a smaller, more isolated community where nurses provide primary care services.

Stoney Creek (population 560) is a semi-isolated Carrier Sekani First Nations community located about 20 minutes from Vanderhoof via a well-maintained highway. There are no physicians working in Stoney Creek, but there is a community health nurse who works in a federal health nursing station. Because of the close proximity of Stoney Creek and Vanderhoof (population 4400), people with complicated primary care problems or emergency health problems are preferentially referred to the Vanderhoof Family Practice Office or to the Vanderhoof Hospital. The nurse does not provide on-call services outside of daytime work hours. Nurses working in communities that are more isolated than Stoney Creek would be expected to manage more complicated primary care and emergency problems because they would not have the luxury of a nearby, easily accessible hospital.

Results
The video network link between Vanderhoof Hospital and the nursing station at Stoney Creek (with Vancouver as backup site) was established 31 March 2002 at a cost of approximately $45 000. An appropriate fee guide to remunerate clinical service delivery of Vanderhoof physicians to Stoney Creek was in place (approximately $300 per 4 hours). The original plan was to have a clinical videoconference between Vanderhoof and Stoney Creek every Wednesday beginning 6 February 2002 and ending 28 November 2002—a total of 43 possible sessions. It was anticipated that other Vanderhoof physicians would participate in these clinical videoconferences because funding was available to pay for their time.

The main clinical finding was that the line was rarely utilized, a finding consistent with other telehealth projects.[4,6-8,24-27] At the time the project was completed (28 November 2002), only nine clinical videoconferences took place (Table). That is, of a possible 43 sessions, videoconferencing took place only nine times (21% of possible sessions). Patients were present at eight of these sessions (19% of possible sessions). Audio quality was rated as good in all nine.

Health care providers who participated in the project provided the following reasons for such a low videoconferencing usage rate.

• Difficulty freeing up time to be available to organize and attend the videoconference. This was a problem for both the Stoney Creek nurse and the Vanderhoof physicians. On more than one occasion either the nurse was available, but a physician could not be found—or vice versa.
• Only two physicians were willing to participate in the clinical videoconferencing. The other Vanderhoof physicians were too busy with their day-to-day work. 
• Patients who said they would be interested in participating sometimes did not attend.
• The Stoney Creek nurse left her job at the end of June 2002 and a replacement had not yet been found at the conclusion of this project (28 November 2002).

The three health care professionals (two physicians and one nurse) who completed surveys rated the video link favorably (78%) and they rated it as a desirable method of medical consultation (77%). Traditional face-to-face medical consultation was rated as a more desirable (97%) method of medical consultations. Drawbacks to videoconferencing were that it took longer, was less personal, did not allow for physical touch, and the occasional delays in audio interfered with spontaneous communication. Suggestions to improve videoconferencing include using it more frequently and having more instruments to allow for closer images. The reported advantages of videoconferencing were patient-related and included savings associated with not having to travel to see the consultant, patients having more time to ask questions, and perceived improvement in quality of care (e.g., patients might get treated sooner). Participants were very satisfied with the audio-video equipment and they all said they would use the process again. All participants felt videoconferencing would have a positive impact on patients living in rural communities; and all felt it had the potential to assist with health professional retention in rural communities. Ethical, confidential, and legal issues were not considered to be major problems by the three participants. One of the physicians stated that payment of specialist services remained an unresolved issue.

Patients were not asked to complete surveys for a variety of ethical and practical reasons. For example, there was no University Ethics Committee approval to collect and analyze survey data, and there was no official letter of support from the band supporting the practice of collecting survey data.[28-34]

Discussion
We believe it is important to share our experience with this telehealth pilot project, as others may be planning to develop similar rural telehealth links. We hope that they can avoid some of the problems we experienced, and perhaps build on our contributions. For example, we only recently became aware of another rural video network link that has been set up in British Columbia. That $352 639 video network link pilot project was funded by the federal government (Health Canada, First Nations, and Inuit Health Branch) and the former Central Cariboo Chilcotin Health Council (now the Thompson Cariboo Health Services Delivery Area). It was established between the Ulkatcho band, Anahim Lake Health Centre, and the Emergency Room at Cariboo Memorial Hospital in Williams Lake. That telehealth line has been in place for at least 2 years.

Discussions with the emergency room physician who helped set it up and nurses who currently practise in Anahim Lake reveal that the line has never been used for an emergency case. One of the Anahim Lake nurses stated that she had tried to use the telehealth line once, but the physician on call was busy in the operating room. She said that there has been no obvious need for using this line as an aid to emergency care. There were plans to use the line for patient information rounds (e.g., diabetic teaching) but it proved too complicated to organize nurse, patient, and physician, so that was never done. The nursing staff turnover was very high (in 2002 more than 10 nurses have worked there), resulting in inconsistent staffing with a variety of competencies, and the link may no longer even be functional. Local band members were hired to coordinate rounds, collect consent, and operate the equipment, but were eventually laid off due to lack of work.

International comparisons
Australia resembles Canada in that there are many rural and remote communities, there is a relative shortage of rural physicians, the medical workforce is unevenly distributed, and the specialists tend to reside in the larger metropolitan areas. Like Canada, Australia has a good telecommunication infrastructure. Van Gool reports that some of the telemedicine projects carried out in Australia have failed and some have not been used as successfully as initially envisioned.[35] The report of a Melbourne emergency department, which had a fully operational telemedicine system that was never used, is reminiscent of the never-used Williams Lake Emergency Room-Anahim Lake nursing station telehealth project. After 12 months, for example, the total amount of time spent on clinical videoconferencing activity by 10 Australian telehealth sites was less than 20 hours. The total amount of time spent on clinical videoconferencing in the Vanderhoof-Stoney Creek telehealth project was 9 hours. In another Australian telemedicine project—this one involving three different sites over 3 months—patients were present at only six of 116 videoconferencing sessions (5%).[35] In the Vanderhoof-Stoney Creek telehealth project, patients were present at only eight of 43 videoconferencing sessions (19%).

Underutilization of telehealth systems appears to be a worldwide phenomenon. According to a recent article published in the Medical Post, a survey of the Association of Telemedicine Service Providers found that the average number of teleconsultations per year per site for 1998 was less than 40.[36]

The most commonly cited reasons for telehealth underutilization are lack of financial resources to invest in telemedicine infrastructure, costs associated with operating the videoconferencing line, unfamiliarity with technology, inconvenience, fear of job displacement by telemedicine services, health professional remuneration, heavy demand of personnel to implement and maintain content and services, licensure issues, confidentiality issues, ethical concerns, and lack of evidence showing cost-effectiveness.[2,5,36-39]

With respect to the Vanderhoof-Stoney Creek telehealth project, infrastructure and operating costs were covered, the technology was convenient and easy to use, there was no fear of job displacement by telemedicine services, health professional remuneration was in place, there were no obvious confidentiality, licensure, liability, or ethical concerns, and personnel (including physicians and nurse) were committed to implementing and providing services. Despite this, the Vanderhoof-Stoney Creek rural video network link was underutilized. People- related factors—that is, excessive workloads and high turnover rates among both physicians and nurses—appear to be the biggest obstacles to the development and expansion of clinical telehealth in rural British Columbia. Another significant factor is a lack of administrative infrastructure in Vanderhoof, itself a rural community, to support telehealth operations. Videolink consultations had to be organized by the physician and the nurse, a stark contrast to most urban-based telehealth projects where these activities are performed by readily available, well-trained administrative support staff. Linking Vanderhoof with a more isolated Federal Healthcare facility may have resulted in more frequent use of the video network link.

Quality of life issues
In a recent study of rural physician quality of life, stepwise multiple regression analyses revealed that the greatest predictors of rural physician overall life satisfaction are satisfaction with job/career, personal relationships, health, finances, and absence of depression (H.V. Thommasen, A.C. Michalos, S. Grzybowski, et al., unpublished data, April 2003). These predictors account for 71% of the variation in rural physician overall life satisfaction. The greatest predictors of rural physician satisfaction with job/career were satisfaction with current place of practice, fewer on-call shifts, sense of personal accomplishments, and absence of emotional exhaustion. Dissatisfaction with job/career, dissatisfaction with housing situation, and emotional exhaustion were the only significant predictors of rural physician intention to relocate, accounting overall for 72.5% of the observed intend to relocate response.

Clinical telehealth, as practised in the Vanderhoof-Stoney Creek rural video network link, would not likely address any of the significant determinants of physician quality of life, nor would it affect physician satisfaction with job or career. If anything, the time required to coordinate and deliver this kind of clinical telehealth means the rural physician’s workload would be increased which, in turn, could lead to increased dissatisfaction with work and even lower physician retention rates. For telehealth to be successful, it must decrease workload, not increase it. Increasing the workload that is not matched to the health professionals’ skill set further adds to the burden and perception of chore, not improvement of health services. According to the “competing demands” theory, efforts to get physicians to improve delivery of preventive services or adopt new technology (such as telehealth) are not likely to be effective unless the burden of other demands are removed.[40,41]

The most successful clinical telehealth projects will likely be those that involve telemedicine applications that can be integrated into the health care providers’ day-to-day work, and the ones which enhance the health care provider-patient relationship. A recent telehealth project in Australia tested the competing demands theory by hiring a full-time coordinator to act as a single point of contact for telehealth consultation requests. Hiring this coordinator had the immediate effect of shifting responsibility away from the family physician, that is, decreasing workload. Within 6 months, telehealth activity increased to an average of 8 hours per month, and significant savings in the form of avoided patient transfers to and from tertiary facilities could be demonstrated.[42]

Project shows potential
We believe that the Vanderhoof-Stoney Creek video network link does have the potential of improving job satisfaction, particularly if the focus is on providing rural physicians with access to specialists who would discuss current patient-related management issues. Such sessions would decrease workload because the rural physician would not have to spend precious time reviewing the literature on how best to manage a complicated patient. Such sessions would also decrease the sense of professional isolation and probably increase the sense of accomplishment (knowing that one is doing the best for a sick patient), and both these things potentially contribute to increased physician retention. Furthermore, we believe that rural physicians will also find satisfaction in any technology that spares patients and family members the need to travel. However, this sense of satisfaction may rapidly erode if the health professional has to carry out administrative duties such as organizing the consultation themselves—a function that they do not traditionally perform.

The most valuable use of videoconferencing in rural and remote communities may prove to be a focus on providing specialist access and focusing on current, difficult patient problems or providing an expert’s opinion on the best way to deliver a public health initiative (such as smoking cessation). One of the highlights of this videoconferencing pilot project was a session on smoking cessation. The community health nurse was able to find six people on the reserve who were interested in overcoming their nicotine addiction. There was a session in February with Dr Johnston and Dr Thommasen where people’s questions about nicotine addiction were answered and options reviewed. Two of the patients agreed to try bupropion hydrochloride (Zyban). A month later, all six participants, as well as the community health nurse and the two physicians, met in Stoney Creek and had a videoconference with Dr Fred Bass—one of the provincial experts in smoking cessation. The patients who were still struggling with nicotine addiction had the opportunity to hear the same sorts of messages again, but this time from a provincial expert. It was quite a satisfying experience to see a status Indian resident of Stoney Creek discussing his nicotine addiction with a provincial expert on addiction, and neither person had to leave his home or working environment.

Other telehealth applications, such as store-and-forward systems using personal computers, may be better suited to the reality of physician and nurse day-to-day work unpredictability. The Labrador Telemedicine Project, for example, looked at a telemedicine system whereby nurses in an isolated rural community (Black Tickle) captured video, audio, and text regarding 43 complicated cases and sent this information electronically to a personal computer located in Goose Bay, Labrador.[43]

Physicians at Goose Bay Hospital reviewed the electronic information at their leisure, made decisions regarding patient management and need for costly transfer, and then electronically relayed recommendations back to the nurses. The nurses and residents in the community felt they were receiving a higher quality of care, nurses felt more confident in their ability to treat patients, patients were satisfied with this telehealth application, and there was a reduction in the number of patients transferred from Black Tickle to Goose Bay Hospital. The reduction in transfers was associated with savings in medical evacuation transportation costs and savings in personal patient travel costs.

We did not have research ethics approval to collect survey data from patients involved in the Vanderhoof-Stoney Creek telehealth project, so we cannot comment on their satisfaction with telehealth technology. Participants appeared satisfied with the technology, and there were no complaints by any of the First Nations participants or the Band that approved the project. This is consistent with the existing literature that shows that most facets of physician-patient communication can be delivered very satisfactorily with telehealth technology.[44,45] Not surprisingly, these studies confirm that difficulty reading nonverbal behavior and lack of touch are two drawbacks to telehealth. The three health professionals who completed surveys for the Vanderhoof-Stoney Creek telehealth project also identified these as drawbacks to rural telehealth videoconferencing.

Conclusions
The health professionals involved in setting up and delivering clinical rural videoconferences rated the project as a positive experience overall. Benefits associated with telemedicine include reductions in patient time and travel costs. Both patients and rural health care providers felt that the ability to link with a specialist via teleconferencing resulted in a sense of improved quality of care—even if all the specialist did was affirm that the rural physician was managing the problem in an acceptable fashion. The cost-effectiveness of a rural health video network in British Columbia remains to be determined.

The organization and delivery of telehealth conferences by the health professionals is very time consuming. The coordination of patients, physicians, and nurses so that all can agree on a time to meet is difficult. The biggest obstacles to the development and expansion of clinical telehealth between rural communities in British Columbia appear to be excessive workload and high turnover rates among both physicians and nurses, as well as a glaring lack of administrative support in the rural community for telehealth operations.

If policymakers believe that telemedicine has the potential to improve health care, longer-term (e.g., 3- to 5-year), well-designed projects must be funded and designed to answer questions such as:

• Are clinical telehealth projects cost-effective?
• Does telehealth videoconferencing improve rural physician job satisfaction?

We also recommend that future rural clinical telehealth projects have a physician dedicated to the project and that corresponding administrative support provide a long-term commitment to maintaining the link into the rural and remote communities.

Acknowledgments
We would like to thank the following individuals for their assistance with this project:

• Mr Ernie Mannering, director of Information Services, School District No. 91 Nechako Lakes, for his expert input and technical assistance in identifying appropriate technologies and the potential use of the District 91 PLNet system for this telehealth project.
• Mr David Chay, interactive communications analyst, Information Technology Services Division, Information Science and Technology Agency, for the preparation of the budget for the technology hook-up and his expert input into the potential use of PLNet for this project.
• Ms Janet McGregor, Mr Michael Darling, Ms Valerie Ashworth, BC Ministry of Health; Ms Diane Anderson, Office of Trade and Investment, Mr Lee Denny, director of HealthNet BC Division; Mr George Carson, manager, Network Services, ITSD, ISTA; Mr Lloyd Pack, customer support analyst, Network Services, ITSD, ISTA; and Mr Dave Nikolejsin, executive director, Network Services, ITSD, ISTA, for their input and advice. 
• Special thanks to Dr P. Jennett and Dr M. Watanabe for allowing us to adapt their telehealth survey tools for this study.
• Mr Jeff May for his editing suggestions.

Competing interests
None declared.

Table. Summary of clinical videoconferencing: Vanderhoof and Stoney Creek. 

VHF = Vanderhoof
SC = Stoney Creek

Stuart Johnston, MD, Robyn Atwell, RN, BSN, Shona Johansen, RN, BSN, MEd, Kendall Ho, MD, FRCPC, and Harvey V. Thommasen, MD, CCFP, OBC

Dr Johnston is clinical associate professor in the University of British Columbia Faculty of Medicine. Ms Atwell is a community health nurse in Stoney Creek. Ms Johansen is an instructor in the University of Northern British Columbia Nursing Program. Dr Ho is an assistant professor in the Division of Emergency Medicine and associate dean and director of the Division of Continuing Medical Education in the Faculty of Medicine at UBC. Dr Thommasen is professor and chair of Community Health at UNBC.