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2003 MBTelehealth: Report to Our Partners.

MBTelehealth

MBTelehealth

MBTelehealth. 2003. MBTelehealth: Report to Our Partners. MBTelehealth: Winnipeg, MB. 1-47. http://hdl.handle.net/1880/43075 unknown

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MBTelehealth Network Sites

Marquette and South Westrnan were amalgamated into ~ssiniboineRHA in Spring, 2002

By Wayne Bo-ye,MBTelehealth Director, WRHA sector suppliers of equipment and services, sent home to be official representatives of the hospital information technology (I.T.) new network. Dear Reader; departments and health administrators from all regions of the province. In less than a year, the network was ready to As you thumb through the pictures, charts and go. Manitoba Health Minister David Chomiak articles that follow, you will be struck, as I was, At the beginning of the MBTelehealth project, officiated at the network launch in February by the diversity of people, places and activities in early March 2001, the late Dr. Ron Duhamel, 2002 with a connection to Flin Flon. By April that have been a part of the growth of telehealth senior federal cabinet minister for Manitoba, all sites with the exception of Norway House in Manitoba. accompanied by Cabinet colleague Dr. Rey were functioning. It came on board in June. These past two years have been demanding, to Pagtakhan, offered support for the project while pledging $3 million for development over the At almost every site patients started coming be sure. They have involved the mastery of new immediately. Information and Communication Technologies next two years. - what we have come to call ICTs. That announcement produced a flurry of activity. Continuing Medical Education sessions, developed in partnership with the University They have involved the collaboration of people Dr. Ray Postuma and this writer immediately launched a province-wide tour to sign up of Manitoba Faculty of Medicine began in the who have never worked closely together before. spring of 2002 with respectable tumouts almost Included in the long list of regional health authorities, to stimulate interest among care providers and to set the stage for from the beginning. A total of 796 caregivers contributors to (not all doctors) have attended these sessions. MBTelehealth are staff an intensive needs assessment process. from Manitoba As staff began to settle into their roles, it was 1 Staff were recruited and hired for all 20 rural Telecom Services and A* 1 L.- -- X n. .L:.. -- ---:LT. X r-..:L-l.- time to hold "ooen houses" at each site. This nortnem locanons. Meenngs wirn ManlroDa (MTS), officials in the Hea.lth and MTS put together the switches, brought on another round of province-wide Manitoba Department rout:ers, and high speed lines that were needed traveling, but this time some of us could of Health and Health participate "virtually" over the "link". for lthe technical infrastructure. Technical Canada, . . con!wltants were hired. Video conferencing With few exceptions network usage grew every lpanies were interviewed and a series of month. This didn't happen by accident. Each :quests for proposals" were written, offered site coordinator developed a marketing plan. mto the market, reviewed and analyzed. From the central office letters were written to New offices were found. Technical, family doctors and to specialists telling them operational, financial, policy and clinical about how to access network services. files were established. Individualized posters were produced and distributed. Coffee mugs with "MBTelehealth" blazened upon them, were distributed. Clinical meetings were held with specialty teams; Cancercare Manitoba joined the Network; and by February of 2OO3,5 1different specialty areas had agreed to provide services over the Network. the network was successfully linking to 11 sites With the milestones came setbacks. Staff in in North Western Ontario to offer specialist care: Lynn Lake, Leaf Rapids, Dauphin, Thompson, to our sister Network, the NORTH Network. Portage la Prairie, Steinbach and winnifeg Today, in our first 12 months of operation 2034 Later, successful connections were made to moved on to new opportunities requiring our sessions were held. Over 1,000 of those were communities in the Kivaliq region of Nunavut. site supervisor, Liz Adair to recruit and organize training for the new staff. As network volumes clinical services to patients. It is difficult to Another important milestone for staff was the determine all the benefits and cost savings of increased, it was necessary to recruit and train mastery of the technology to link many sites backup staff for many of our sites. these events. A new piece of healthcare together for two-way video conferences. This knowledge shared with a rural or northern doctor has allowed the Network to offer much needed Like all projects dependent upon technology, or nurse that positively impacts patient care, access to grand rounds education for topics like our network has experienced "technical how does one measure that? medical ethics, SARS and cancer care. At the difficulties". They have required patience and In January 2003, Continuing Nursing Education same time, the network was growing internally, goodwill to resolve since they can occur at was added to the roster of educational activities. with more and more buildings at St. Boniface many points along the complex circuits of lines In the first three months, 286 nurses attended and the Health Sciences Centre receiving drops. and digital switches, routers, gatekeepers, sessions. Smaller projects to connect the Neonatal gateways and "Multi-Point Control Units" that Intensive Care Unit at the Children's Hospital make up our Network. In February, electronic stethoscopes began to across the HSC campus to the Women's be rolled out to sites. In March, patient exam Hospital, as well as to the nursery at the From my vantage point I've watched staff come cameras were distributed to some sites. And, Thompson Hospital some 780 km away were into their positions with initial excitement only while all these little milestones were passed, supported by MBTelehealth. to be quickly overcome with panic. "There's so much to learn", "I'm not technical", "I woke up . .I , P. I .... 1- . .. or wing time" to access specialty care. Telehealth families and children are more relaxed and less stressed compared to the traveling patients who, to keep the appointment, need to find child care, take time from work, bear much of the costs personally and navigate bv Raj. Posttima, MD FRCSC A Vision is a picture of the future that creates passion. For the MBTelehealth Medical their vehicles and themselves through confusing MBTclchealth Medical Director Director and staff that passion comes from the (and often risky) mazes of traffic, parking, picture of telehealth providing 'information and tunnels and corridors of many buildings to find knowledge at the point of care' and 'just in the tertiary care clinic. time.' Children in particular enjoy telehealth. They For the patients and families who used treat it as a familiar medium where they see MBTelehealth during the first full year of themselves, their parents and the distant care operation it meant long distance travel reduced provider safely over the video monitors. to a short trip to the local health centre to see Recently, over telehealth, I saw a very upset the same specialist over telehealth. As the youngster brought into a distant examining medical director, but also as a pediatric surgeon room. His tears and uncooperative behavior ~racticin~telehealth. I am remlarlv very quickly changed to smiles and play when his video monitor came on and he could see himself, his mother and me - now at a very safe telehealth and how grateful distance! -- 1 they are for not having to Typically, patients and families show up for spend all that "windshield the telehealth visit in their work and school clothes, ready to return to routine daily activities right after the telehealth appointment. Their

dav and-A A -Ain A Amanv A case9 a night nr twn iq nnt --,, - ---J ------D=-" -- v..- 9 ------spent away from home and loved ones, as well as other community and personal responsibilities. An increasing proportion of rural patients now receive at least part of their care by telehealth. Recently, after witnessing a telehealth consultation for his son, the father requested that his own cardiology follow up be done by telehealth. Telehealth is advantageous also for the provider malfunctioning specialized feeding tube. Manitoba traditionally serves the health needs who can now conduct a clinic from their nearest Ordinarily this would have meant an emergency of neighboring North Western Ontario, Nunavut telehealth centre. Earlier this year I was trip into Winnipeg. Over telehealth, the special and Eastern Saskatchewan. Hence, in keeping scheduled to do a telehealth clinic at the Health tubing was demonstrated to the local family with traditional referral patterns, MBTelehealth Sciences Centre, to be followed immediately doctor who was then shown how to place the provides telehealth for patients in these by an emergency neonatal procedure at St. tubing. The doctor then proceeded to place the jurisdictions. This has led to inter Boniface General Hospital. Telehealth solved tube under direct supervision over telehealth provincialherritory collaboration, physician my dilemma as I was able to do the telehealth ('tele mentoring" a.k.a. "tele presence.") This licensing agreements and physician payment clinic from St. Boniface, and then immediately safe procedure went well, the parents were mechanisms. proceed upstairs to do the surgical case, avoiding extremely gratehl and the physician was very the delays of rush hour traffic or, alternatively pleased for being of service to his patient and Other significant milestones were the selection having to cancel the patients' clinic having learned a new skill. Telehealth in this and development of central staff and telehealth appointments. case enabled not only a transfer of function site coordinators; the acquisition and training from the specialist to the generalist but also a for telehealth peripherals (digital cameras, For the rural care providers, physicians, nurses transformation of health care. patient examination cameras, stethoscopes; and allied health providers, long distance travel Doppler's), regular staff development to gain continuing professional education was Some of the significant milestones include the workshops and advisory board meetings. replaced by short distance travel to the local acquisition of more than 100 telehealth health centre to participate in small communities providers, physicians, nurse specialists and Perhaps the most significant milestone is the of interactive learning connected by telehealth. allied providers, representing 5 1 pediatric and continuing increase of direct patient care from Some of the comments received from physicians adult specialists. Not infrequently, an excited numerous specialists using telehealth. were, "we just love it," "it keeps us on our response from a provider was, "I did my first Increasingly, telehealth is being integrated into toes," "the most valuable feature of the modules telehealth consultation. It was great!" This was routine care. The Vision is now being fulfilled is the small group interaction." From the achieved through a process of professional but the passion for telehealth remains and is communities we also heard. "our doctors don't contact and encoura~ement:role modeling of shared by many, particularly by patients and involved staff recruitment, site renovation, installation of equipment, promotion and demonstration, development of the Site Manual, initial education in telehealth processes and equipment, and continuous education and b37 Liz A dair, Working with MBTelehealth since August 2001 communication. has been exciting with extraordinary challenges MB Telt?health Site Supervisor and rewards. In the position of Site Supervisor The position of Site Coordinator was advertised for the rural and northern sites, I have had the in the fall of 2001 for each of the sites. opportunity to work closely with Site Interviews were held in collaboration with local Coordinators and the Regional Health RHA representatives. The team that developed Authorities. I have witnessed sites that was one of diversity, with staff coming from had little or no previous exposure to all fields of the health care spectrum, all with telehealth become functioning the interest and excitement of working in programs in a remarkably short time. something they identified as being "the best thing that has happened in health care delivery." The needs assessment done in the spring of 200 1 provided the background Policies, procedures and guidelines were material and reference that developed to address the processes of the was required to begin network. Information on current best practices development of the was obtained from literature review, previous experience and other telehealth networks. The MBTelehealth Site Manual was developed before the initial orientation session with the Site Coordinators in October 2001. A Site . - . . .- - . - Manual Committee was identified as essential to assist in development and review of existing and future items prior to submission to the Advisory Board for approval. Following equipment selection and identification of which equipment went where, all Site Coordinators attended a weeklong orientation session in Winnipeg. During this time the Site Coordinators had the opportunity to work with the equipment they would be using, became meetings with RHA staff, committee Since starting with MBTelehealth, time has familiar with processes, and met the staff with membership, press releases, radio programs, flown by at an astonishing rate. I continue to whom they would be working. public interest groups, physicians and others. enjoy speaking to groups and individuals, and "seeing the sparkle" in their eyes as they grasp Upon returning to the sites, the Site Coordinators MBTelehealth supports continuing education. and understand what telehealth can provide for worked on Site Development plans along with Since the first orientation, MBTelehealth has their clients and programs. Listening to the Site regional staff and myself, to identify rooms to held two workshops for Site Coordinators, with Coordinators and to the clients relate be utilized to meet the varied needs for that site. one workshop held at the same time as the experiences, I am moved by the fact that I am Renovations were extensive in some sites as International HeSCA (Health Sciences fortunate enough to be a part of this wonderful they worked to change existing rooms such as Communications Association) conference in team. Recognition must be given to the current old operating room theatres and nurseries into Winnipeg. These workshops provide and past members of MBTelehealth who worked areas for clinical and non-clinical telehealth Coordinators with the opportunity to discuss diligently to develop a network built upon activity. Telehealth equipment arrived at sites progress, problem areas, approaches to problem assessed needs of the regions and a common in the early part of 2002 and staff busied solving and to review existing and new vision. Staff within the regions provided support themselves with review of procedures and equipment. In September 2002, MBTelehealth and assistance in establishing the individual initiating the first calls over the network. It sponsored back-up staff from the sites into sites and provide ongoing interest and feedback was a time of excitement for all as we were Winnipeg for a day of orientation to equipment on the program of MBTelehealth. Regional able, once again, to see what the network could and processes to help them feel more Information Technology staff, including Alex provide. Preparation for the official Grand comfortable in their role. Avecilla, in Winnipeg, became local champions Openings of the sites were coordinated so that Communication with the Site Coordinators and in the development and challenges of the staff from Winnipeg, or myself, were present network. either in person or virtually over the network. the regional contact persons throughout the All Grand Openings were attended by local network is an ongoing process. There are It has truly been an exceptional journey. regional staff, local Board members, local press monthly scheduled meetings with Coordinators ,,a :,+,,,,+,a ,,,l..,,- -CLL- ---t1:- over the network to keer, them informed on a allu IIILCIC~LCUIIICIIIUGI S UL LUG ~UUIIL;. regular basis, with changes in the program and Each site has developed a Marketing Plan for them to identify successes and problems at focusing on key clinical and non-clinical areas the sites. Communication is also held on a to promote within their regions. These plans regular basis by phone, email and over the have been shared with RHA staff. All Site telehealth link as appropriate. Network Director, 1 Coordinators have been involved in extensive Wayne Boyce, and myself meet with the I regional contact persons every three months to provide a program update and a forum to raise questions and concerns. Site visits are made by myself to each of the sites during the year to meet with staff to review process and procedures with the Site Coordinator and to assist in promoting the program. by Liz Loewen, Network Researcher The establishment and maintenance of a research specific clinical knowledge to support new both the Newborn Resuscitation Unit of role reflects the network's administrative telehealth clinicians, testing new devices such Winnipeg's Women's Hospital, located a block commitment to promoting high standards, as digital stethoscopes and scheduling software, and a half away and the newborn nursery in improving health care services through developing emerging telehealth applications Thompson, 780 krns away. All of these appropriate use of telehealth, and to promoting and continuing education services, and telehealth drops allow for direct visualization a learning and evolving organization. The promoting ongoing evaluation initiatives. of newborns and their related monitoring research role has also provided a mechanism Telehealth is a new and developing area and it equipment to support timely access to expert for obtaining fhds for new project development has been exciting and immensely fulfilling to physician and allied health support on an as that would otherwise have been unavailable. participate in projects that so quickly result in needed basis. outcomes to improve patient care and support During this initial establishment phase, research Two separately funded projects have arisen at MBTelehealth has been diverse. It has been for rural and northern clinicians. from this initiative: fulfilling to see the research role evolve from Several of the projects undertaken in the last a traditional academic focus to include other year and a half include: initiatives such as: developing standards and The S. T.A.B.L.E. 0 Program policies including those In order to support a consistent knowledge base for privacy and TeleNeonatology for rural staff involved in the TeleNeonatology security, sharing The TeleNeonatology Project, developed in link and to build on previous local research 1 discidine partnership with the Section of Neonatology, using videoconferencing for neonatal is unique within Canada. A direct 24 hour a resuscitation recertification, a research study, day, 7 day a week link has been established in The S.T.A.B.L.E. 09 Program: Comparing In- Person to Videoconferenced Delivery was T Ptncrr~rn;c In VYCUVIIUIIVU.~ctahlichprl TheI IIV U.C TL .I AX.Y.U.U.W R E m I IV61LCIII I0 U11 educational program for pre-transport stabilization of sick neonates. While well established as an in-person course both within the United States and Canada, there was no previous experience with this course using videoconference. With funding from the Children's Hospital Foundation, this study compared in-person delivery with videoconferenced delivery. Through the study, the program was delivered free of charge to 56 health care providers in three different communities and demonstrated that participants showed similar learning between both modalities. Results from this study have been used 42 times. While the internal link was TeleRadiology expected to support physician consultation, it has also assisted with discharge communication. Systematic Literature Review of TeleRadiology Staff receiving the baby in the NICU can now MBTelehealth staff have been supporting a talk to the team preparing the baby for transfer systematic review of the literature related to and visualize the baby at the same time technical requirements and cost-effectiveness improving information exchange. Recently the of teleradiology. Funding for this project was video link in the NICU provided an opportunity received from the Canadian Radiological for the mother of a newborn transported to Foundation. Results of the review are expected Winnipeg, the opportunity to see her baby, hear in Spring 2003. from staff about the child's condition, and discuss plans for her travel to Winnipeg. Project Team: Dr. MH Reed, J Gallet, G Finlayson, L Loewen Project Team: Dr. MMK Seshia, D Sawatzky- presented in poster format at the 2002 Annual Dickson, L Merrill, L Loewen Future Developments Confercncc of the Canadian Society of Telehealth, accepted for publication, and have Occupational Therapy Doppler-based Vascular Assessments been accepted for oral presentation at the MBTelehealth staff are exploring the feasibility Canadian Pediatric Society Annual Conference Enhancement of Seating Assessment Resources in Manitoba of Doppler-based assessment of AB1 and PPG in Spring, 2003. studies from remote sites to enhance vascular Project Team: L Loewen, Dr. MMK Seshia, D Access to specialized wheelchair seating services services available on the telehealth network and Fraser Askin, Dr. CMG Cronin, S Roberts is limited in rural and remote parts of Manitoba. improve diabetic foot screening in those Appropriate seating choices can be critical for locations. A review of the feasibility of training prevention of pressure ulcers and maximizing remote staff to utilize handheld doppler devices by Doug McCartney, Network Teclznical Coordinator The IP network is achieved through Manitoba 3520 Gateway allows access £rom the IP world Health and the Provincial Data Network, which to the international ISDN or H.320 world via MBTelehealth holds the distinction of creating offers a wide band, local area network that BRI (Basic Rate Interface). This is literally our a pioneering effort in what has become an enables secure links, point to point, or multisite gateway to videoconferencing equipment in important advancement in health care, video- conferences to 24 sites in Manitoba. other provinces, the United States and Europe. over-internet teleconferencing. The To communicate to Europe at high bandwidth, A key element in achieving an effective network an advanced E 1JT1 format bonds (23)-64 MBTelehealth network is a Canadian leader in is the use of a Multi-site Control Unit (MCU). the use of a Province wide Local Area Network kilobyte lines to enable wide band 1472 kbps This computer-based hardware, in concert with transatlantic conference quality. (LAN) H.323 Internet Protocol (IP) devices called a "Gatekeeper" and a "Gateway," videoconferencing system, which includes provide increased flexibility and capabilities In the four sites where the next generation PDN interoperability with H.320 PRIJBRI systems for our videoconferencing network. With our is not yet distributed, we currently utilize satellite for both provincial, inter-provincial and Cisco Systems MCU, up to 15 sites can technology on both Ku and C bands to international videoconference links. - accomplish 384 kilobytes- per accomplish our l&. These sites are: Churchill, second (kbps), two way Leaf Rapids, Lynn Lake and Berens River. communication, linked These sites are up-linked J down-linked by together simultaneously, satellite transmission carriers at MTS as well using high quality fiber- as an earth station at Health Sciences Centre. optics and wide band IP This interoperability adds an extra layer of technologv through comvlexitv in terms of technologv and VPN's (Virtual private troubleshd~tin~efforts, but offers Networks). The MCU communication to distant Health Care Centres uses both voice activated that are not reachable via the Provincial Data and continuous presence Network. In certain cases the various ) (quad screen) formats to technologies come together to provide access provide large or small to even more distant sites in Northern Canada. conferences. The IPNC In the case where a Specialist Provider in Winnipeg requires a link to a patient in Rankin Inlet, for example, MBTelehealth partners with these remote communities in Nunavut via a combination of satellite and ISDN lines, traveling a distance of over 15,000 kilometers. in documenting the (difficulties that have been diagnostic menus, remote monitoring and wiring encountered ateach of our Telehealth sites. schematics. This has reauired a constant Where quality issues were a large undertaking learning curve, as a variety of unique problems in the first few months, it's now very rare to and situations come to light. The Technical see the quality of a session compromised by resource position requires detailing and packet loss or video jitter. As a result of the understanding a vast array of problems from partnerships with the RHA's and the facilities blown fuses and defective wiring to dealing and infrastructures within them, our reliance with network issues that affect large areas. on the cooperation of the IT Managers and support personnel was very important. For Bill Evans and Ken Babb, most of these facilities the dedicated bandwidth Technical consultants to the network and use of QoS was somewhat new ground.

Troubleshooting Because the majority of MBTelehealth site coordinators did not have a technical The role of the Technical Resource Coordinator background, it quickly became evident that requires acting as an information conduit for training in use of the Telehealth equipment and the Site Coordinators and our technology the peripheral equipment such as the digital

=.-nroviders....-- and vendors.. --- We.' - have fnrmed-----A-- nlirlI---- Nikon cameras. Elmo document cameras and working relationships with the various technical electronic stethoscopes, would be an important support departments, Manitoba Telecom element in providing vital information to the Services, engineers and government agencies. health care providers. To address these needs, we offer assistance through telephone, internet Our challenge is to maintain a high degree of and the videoconferencing equipment. This technical competency, while striving to allow continuous, on-going support is augmented by the telehealth sites to be as active and effective site coordinators / site assistant workshops that as possible. Very early on, we learned the are offered at our Winnipeg facilities. importance of QoS, or Quality of Service, which provides dedicated bandwidth, controlled As MBTelehealth videoconferencing equipment, latency and jitter by shaping network traffic fiom both Tandberg and Polycom are in regular and tagging packets for efficient routing. In use, we find there is a certain amount of collaboration with our engineering consultants, maintenance required, and it has become we worked closely with Manitoba Health and necessary to have a thorough understanding of 1 MTS to track down problems in the quality many aspects of technical usage, including seen during videoconferences. We quickly learned how to track down problems and how to characterize the effects we observed. A Technical Problem Report has been effective

Telehealth facilitates family involvement Use of the telehealth network, especially for Few impacts have been seen on the scope in patient care. continuing education and administrative use, of professional practice. has in some regions enhanced linkages Generally, the MBTelehealth network is among health professionals and agencies During the evaluation period, the providing another way to access the same both within and among regions. MBTelehealth network produced estimated services that were already available in-person savings of approximately $1.1 million by rather than increasing access to services From the RHA administrators' point of view, eliminating Gavel-related expenses. people could not reach before. telehealth has been implemented and managed effectively. Overall, the MBTelehealth network has been Local physicians' use of the telehealth very successful in increasing patient and network to access specialist clinical care can The decision to coordinate the network community access to needed, quality care, be enhanced. centrally with MBTelehealth site fostering linkages among practitioners and coordinators situated in the RHAs has carried throughout the health care system, and Provision of continuing education through more advantages than disadvantages. becoming integrated into existing patterns telehealth has been very successful, with of service delivery. strong uptake across the province. Continuing education through telehealth seems to particularly benefit non- physicians and physicians in rural Manitoba when compared with those in northern Manitoba. Continuing professional education through telehealth has three main impacts: - reduced necessity to travel - development of closer ties among practitioners, increasing a sense of community and support - improvements in the quality of care l delivered to patients. 1 Telehealth contributes to work satisfaction for professionals and may contribute to i recruitment and retention in some cases. Telehealth both saves and adds time to i service delivery. h Overall Utilization by Stephanie Gibcmon. MCE Fiscal Year 2002-2003 Newor-k Education Specialist

Continuing Medical Education (CME) For physicians located in rural practices, perceptions of professional isolation, restriction from clinical support services and lack o available CME opportunities, has been manifested in overall job dissatisfaction and termination of rural practice. The CME MBTelehealth program was designed in partnership with the University of Manitoba CME Department to encourage small grc'UP - -4 learner-centered interaction recognizing the April May June July Aug. Sept. Oct. Nov. Dec. Jan. Feb. Mar. knowledge, skills and affective experience:S that Total Number of Sessions: 2,034 need to be shared among rural and north1ern physicians and with their specialty collezigues in Winnipeg and Selkirk. The CME projel ct has Utilization by Type of Session demnnstrated------an-- - increasing- - - level nf corn fort ------(3 -- . ------(by Fiscal Quarter 2002-2003) with the technology as a two-way uuu communication tool. The following comments I I were voiced by physicians who contributed to 500 I H April - June U the telephone survey that was conducted at the n July - September concluiion of the spring 2002 term: October - December k-4 "don 't count headsfor two years; too important I January - March I to help with qualz$cations" "wejust love it" "very impressed with the whole system" 'pel it was the perfect structure with the latest updated knowledgepom the Health Sciences" CME Module Development & Attendance Following the clinical priorities identified in the January 2002 Needs Assessment, eighteen modules were developed during the three terms, (3). The response to the initial needs assessment "The positive response from the physicians is Spring 2002, Fall 2002 and Winter 2003. as well as the first three months of modules has rewarding" been very positive. The interactive media has Emergency Medicine: The Emergency Airway, permitted the use of mannequins for technique "I thinkjust talkingface-to-face (with the rural A Review of Arrhythmias, Emergency demonstration, the display of equipment and physicians) for even a short time makes you feel more like you are working as a team and Toxicology, Trauma Care, Pediatric product types, the presentation of current " Emergencies, Emergency Resuscitation research and the discussion of local techniques "that has to be b bene~itfor Mental Health: Acute Psychotic Agitation, and nursing challenges. Research Mood Disorders, Delirium, Dual Diagnosis, CME & CNE Facilitator Orientation & Two presentations based on this pilot project Anxiety Disorders, The Mental Health Act Assessment were made at the Canadian Association of Dermatology: Topical Medication, Acne, Skin In order to provide consistency and quality Continuing Health Education Fall 2002 Cancer, Eczematous Rashes, Psoriasis videoconferencing facilitation, all faculty conference; "Facilitating Physician Learning Community Development: A Pilot Project using Issues for International Medical Graduates: members have participated in a videoconferencing workshop. Conducted as a Internet Protocol Videoconferencing" and a Current Issues in Licensing, Legalities and workshop, entitled "CME Videoconferencing Legislation multi-point videoconferencing simulation, the following objectives are covered: Facilitator Preparation." A research proposal has been accepted by the Society for Academic Over the three terms of the CME program, - to familiarize facilitators with the capabilities Continuing Medical Education for support of overall attendance has increased. The number and limitations of the videoconferencing research on learning community development of "return" learners has grown throughout the equipment and network, and in videoconferencing networks. A presentation project and attendance patterns for the individual has been accepted for the Canadian Association communities have also strengthened. The - to supply facilitators with pedagogical of Continuing Health Education Fall 2003 observation of the participation by of the 'allied hmeworks and resources for videoconferencing conference: "The Network within the Network: health professionals' lead to the development module development and delivery. CHE Fractal Identification in Telehealth of the Continuing Nursing Education program -- .- - - - Developments". - L L11 LIV*" l*,"UUlVU UIV UUUVYUVU V, bIIV YUUVUC."l. and a program tor Mental Health workers. Development of education programs for other Coordinator in order to provide the opportunity allied health professions are under consideration. for facilitators to refine their content presentation and to receive feedback on their facilitation Continuinx Nursing Education skills. These assessments have been requested by the facilitators who consistently express their CNEModule Development & Atkdance commitment to the learning experience and - - A needs assessment conducted during the their pleasure with the videoconferencing format. The facilitators' perspectives have summer of 2002 identified clinical topics for l been sought in order to help to refine the the rural nursing communities. The 18 rural i orientation process. Their comments regarding sites have been grouped into six communities, their learning process as faculty of the pilot which receive one of 13 modules, once every project include: third week, throughout 2003. The modules include wound management (4), emergency "We learned@om each other while designing (3), palliative (3) and cardiac rhythm review the program" MBTelehealth has come a long way in a very short time. Primarily a clinical based network, MBTelehealth has attracted 51 specialties with by Irene Pare; Winnipeg Site Coordinator more than 100 specialists providing MBTelehealth was also working closely with consultations to clients throughout Manitoba the Ontario programs through requests for Prior to commencing employment with and North Western Ontario. One needs only to consultative services from the North Network be present during a clinical session to see how MBTelehealth in June 2002, emphasis to suecialists in Winnipeg,. ~articularlvfor was on obtaining the services of the patients have welcomed the opportunity to weekly clinical and educational see a specialist over the network. Clients remain specialists and their clinics to sessions with Dr. Fran Edye to five support consultative requests f?om within an environment in which they are most First Nations communities within comfortable, usually with family close by, and rural and northern communities. the North Network. Seventeen specialists at Health can access the consultation without having to Sciences Centre had begun I entered the world of telehealth travel. It is always a pleasure to be present using telehealth in scheduled with awe and soon learned that during a session with a specialist who then clinics or on an ad-hoc basis and the advantages of telehealth receives a true sense of telehealth, the genuine education had developed in six would only be bound by gratitude shown by the patient, and understands specialty areas. A working group imagination and the reluctance of how this could be a benefit to their practice. had been put together at St. Boniface specialists to adapt their current way Many specialists recognize the challenges and General Hospital for the development of providing health care to patients have adapted their practice to make the of a telehealth program sites and a in rural and-- remote. - areas of technology work in their own set of medical records workflow Manitoba. circumstances. Some rural based specialists are now setting up clinics to provide service within developed. Selkirk Mental .l . Health Centre purchased rneir own regions. videoconferencing Telehealth has been in use in Manitoba for less equipment and than two years and "the word is out." While commenced providing there is no specified process in place to attract educational and new providers, they have been identified and mnnmiltntiv~CPW~PPC approached in different ways. Patients now contact their specialists or the local Site Coordinator to see if telehealth could be a possibility instead of traveling. Presentations have been made to various providers to give an overview and to generate an interest in how telehealth can fit into their practice. Once a provider has agreed to participate in telehealth, a meeting is set up with the staff to develop the workflow process. Health service providers have begun to provide HEALTH SC monthly educational seminars on autism spectrum disorders. In order to take knowledge to the point of care, renal health, mental health, public health, ontology, as well various health care rounds, have all begun accessing telehealth. Televisitation has been used infrequently fiom Winnipeg sites to date but there have been inquiries fiom many rural and remote sites. One particular televisitation session was most memorable between Nunavut and Winnipeg. The staff became emotional while witnessing the joy and excitement of the children here in Winnipeg and family members in Baker Lake seeing each other. MBTelehealth has continued to expand by entering a partnership with Cancercare Manitoba. At present, there are nine locations within the MacCharles site that can be linked to use telehealth. The oncologists and other Munitoba Health Minisrer Duvid Chomiak oflcialb opens the Network February, 2002. health care professionals have been very quick to adopt the use of the technology for clinical as well as educational uses.

TOensure the specialist has the most comulete -~t- is-- ---an ever-evnlvino- . -- . - . y--....-.,nrncecs tn"enciire the examination p&ible over distance, seveial needs of the patient and provider are met - either providers, which has allowed their physicians peripheral diagnostic devices have been made in a clinical setting, case conference or discharge to access Manitoba specialists regularly. available at the rural and remote sites. Digital planning. Although, not all specialties have Meetings have been held to develop a workflow cameras provide close up pictures of various embraced the concept of telehealth, process to ease the process for patients, referring disease processes. To ensure the best possible MBTelehealth staff will take advantage of the physicians and the North Network scheduling l image and to expedite the clinical encounter input generated fiom the success of the existing office. for the provider, MBTelehealth has also specialties to encourage participation. purchased patient examination cameras. These Since starting in the position of Winnipeg Site While MBTelehealth is primarily a clinical Coordinator there have been challenges and ! cameras are so impressive that one specialist stated that the image was better than that which network, educational sessions that ultimately rewards. As a nurse, I truly believe telehealth could be seen with the naked eye. Electronic enhance patient care are considered a priority is a way of providing health care that is here to stethoscopes and otoscopes are also available as well. Regular Continuing Education sessions stay. To save patients and families time and for specialist consultations. are provided to rural and remote sites. Mental travel when they are ill can only be a win-win situation.

Berens Rivf:r was the first telehealth site Primarily the telehealth program in Berens established in Manitoba -in fact it was River was used for providing support to the hnctioning a1 bout 14years ahead of the rest high number of diabetic clients in the of the networlc. A satellite communication link community. As the satellite link was to Room was put in plsIce between the Health Sciences CE130, Children's Hospital in Winnipeg, it Centre and Bc xens River in the spring of 2000 was necessary for Diabetes Educators, Karen utilizing Ku Band Satellite. A Site Coordinator, Omichinski and Sharlene Thompson, from Josephine Be1-ens, was hired to provide support North Eastman Health Authority, to travel to to the networlk activities. Josephine recently Winnipeg to provide consultative services. completed tht :Health Care Aide program in Josephine would sometimes drive to client's Gimli. When MBTelehealth was developed, homes in the community to ensure they were the Berens Ri ver site was included in the able to attend these sessions. Other clinical network. activities included dermatology, infectious disease disorders, mental health, and foot care clinics. Education on foot care techniques was also offered through the foot care specialist with the Northern Medical Unit. There have been some ongoing challenges to During the time the equipment was not effectively working, there were several phone meetings with Lilly Gompf, Dr. Iris McKeown, Jason Steele, Keith Berens and several other staff to develop a plan to provide more clinical services to the community. These services will include increased diabetes education and support, dermatology, genetic counselling, wound care management, renal health, speech language pathology, FASIFAE assessment and treatment, and mental health applications. Plans are undenvay in 2003 to connect Berens River telehealth to the rest of the network. This is very exciting for Berens River as well as for the whole of the network for a number of reasons. Berens River staff will then be able to access ongoing continuing education sessions that are currently available on the network and access specialists in various locations. North Eastman Health Authority will be able to utilize the connection between Pine Falls and Berens River to support intraregional activities. The diabetic educators will save the 1-112 hour drive into Winnipeg, often in adverse driving conditions, to provide support and ongoing and believed in the technology and its Even though this program has been in existence education and treatment, as the sessions will capabilities even without having seen it since 2000 it has not experienced its potential, be initiated from Pine Falls. consistently work well. The nursing team has which will be seen in the upcoming year as helped to identify areas where telehealth will Berens River becomes fully integrated into the Health care centre staff support the program in complement the care provided to the community MBTelehealth network. Berens River. Josephine Berens has worked to members. Dr. McKeown has always taken time develop the program amid many challenges and out from busy clinics to attend and contribute changes to advocate for the clients in the to the planning sessions and has identified community. Support has also been provided by several clients to refer to physicians on the Keith Berens and Lilly Gompf, Nurse in Charge. provider list, asking if they could be seen over They have been active supporters of the program telehealth. stated that now he only needs to book off one The direct benefit to client care truly hit home primary health care delivery model, hour instead of at least four. This benefits the during a particular clinical visit where the client MBTelehealth will continue to play an intricate clients, as the employee is now available for was sitting in a room with his wife, his and important role in prescribing to this model the three hours, previously used to travel, to Community Cancercare Nurse, physician, and as demonstrated by the aforementioned example. perform ultrasound services. ~~TeleheilthSite ~oordinat01--at~oundry Trails Health Centre, while seeing and speaking MBTelehealth site coordination at BTHC is Central Region is large geographically so to his specialist who was in an office in shared by two of us, who are nurses, and regional meetings require a significant amount Winnipeg. During the visit, treatment options combine this role with our RHA-Central MB of travel time and time away fiom the worksite. were explained and discussed, CT Scan images Inc. Staff Development positions. The role of With telehealth located in Boundary Trails and were reviewed, and a plan for follow-up was Site Coordinator offers ongoing challenges and Portage District General Hospital, travel time arranged. What a true picture of total health career enhancement. We are proud to be part is cut in half for some employees. Examples of care delivery! The client was extremely pleased of the MBTelehealth team. regional committees, that have utilized the with the process. As the region moves to the technology include, Pharmacy and Therapeutics, Health Information Services, Library, and several Accreditation Teams. There are also employees who participate in provincial

Requests for clinical referrals and for providers infection control, regional administrative nurse and why telehealth is a wonderfd addition also continue to increase. Requests originate meetings and interviews, as well as fire and to health care. A telehealth link to the University from specialists, family physicians, nursing paramedics. of Alberta's Stuttering Institute, really made staff and allied health personnel, with the me think about the great opportunities and majority of requests coming from the clients A turning point for the Brandon site was with potential that telehealth has. who live in the community or surrounding areas. the introduction of the electronic stethoscopes, which many of the providers in Brandon had At the Brandon Regional Health Centre, many 'l The Brandon site has been involved with been requesting. These stethoscopes will individuals and departments have been Continuing Medical Education and Continuing positively impact on the specialties of supportive of telehealth. Rod Pohl, Information \ Nursing Education, through MBTelehealth. nephrology, cardiology, pre-operative admission Technology, has been very supportive in Those who have attended have spoken very clinic and pediatrics, to name a few. promoting telehealth, and has invited me to positively about the experience and have enjoyed attend monthly I.T. meetings to keep current the interaction with the presenters and the ability All clinical sessions have been really positive. on the latest progress in Electronic Health to interact with other health care professions at Each time I am involved I sense the client and Records. Trinda Rabe and Vicki Gagnon as other sites. Physicians from Minnedosa and family reactions to telehealth overwhelmingly provide back-up telehealth coordination, and Hamiota have taken the opportunity to attend positive. Most comment on how great they have been wonderfully reliable and supportive. these sessions as well. Along with the Brandon think telehealth is and how much time and Carol Manson-McLeod, Clinical physicians, they have expressed appreciation money they have saved by not having to travel. Redevelopment, has shown support for the for the opportunity to receive credits for Clients have been able to bring along family program and saw that telehealth was placed continuing education without having to travel and support persons who otherwise may not within the new facility among the other hundreds of miles. have been able to attend with them because of outpatient clinics. Telehealth will also have childcare and work responsibilities. the opportunity to access another conference Grand Rounds through MBTelehealth have Oncology clients have benefited from the room in this facility. Dr. Wilson and Jean Jack included, ultrasound, radiology, pathology, have been the primary administrative supports internal medicine, psychiatry, breastfeeding and services of telehealth service. Many of these clients are already very tired and fi-agile. Their for MBTelehealth at the Brandon Regional ethics. These have been verv well received and *. U-..l+h .,...... ~C~ILIILCIILIC. attended. satistaction m not havlng to spend the day traveling to Winnipeg is evident. Bringing a Midwife Peer Review educational sessions have family together to discuss cancer treatment been successful and have saved a lot of travel. options over the telehealth link reminds us of These sessions have provided the midwives how intricate the health care decision making with the opportunity to have the peer support process can be. Advocating for the client is to discuss cases of interest for learning and probably the most rewarding part of my position. teaching purposes. Holding a hand to comfort someone who has just received bad news and being able to share Administrative meeting sessions which have good news with another person is why I am a occurred to date through the Brandon telehealth site include, travel health, renal, oncology,

he other end of the link increased my Administrative use of the network in the Region One of the first connections fiom Dauphin was 3dence. Throughout the session the parent's has proven beneficial as administrative staff with Sick Children's Hospital in Toronto. Prior -eciation that their child could be seen in from both centres can meet without someone to telehealth, the family and child had to travel phin without having to travel to Winnipeg having to make the two hour drive, sometimes twice a month to Toronto to be seen for pre- evident. in uncertain weather. Administrative use has surgical assessment. Now they were able to included meetings of the mental health team, have some of these appointments over the need and potential for clinical and information technology team, dietary, telehealth link. The relief and excitement of inistrative services between Swan River physiotherapy and the regional emergency the parents at the completion of the session was and Dauphin was identified early in the program. medical services. evident when they expressed their pleasure and In recognition of this, I worked with Cindy awe at the ability to visit a physician in Toronto Bettesworth, Site Coordinator in Swan River, Physicians within Dauphin were very excited without having to leave home. The little girl to develop a process for provision of these about the prospect of having continuing thought it was "pretty cool" the television talked services between the communities both to reduce education opportunities. Prior to telehealth, back to her. client travel and that of the specialists. It was Grand Rounds had been available via the ISDN felt that MBTelehealth could support Dr. legacy equipment on a per request basis. Access I thank the Dauphin Hospital Foundation for Sukhbir Sandhu's weekly trip to Swan River to other educational activities was limited. The their financial support of the establishment of to follow-up on clients in that community. It broad range of topics being presented has the telehealth program in Dauphin and to the made me very proud that Dr. Sandhu and Dr. attracted physicians, medical residents and other Parkland RHA administrative staff for their Pieter Willemse both came on board and health care professionals. ongoing support. Thanks to Tami Chapin, Dauphin became a consulting centre as well as Information Technology, for being one of the a referring centre. Presently, Dr. Sandhu holds Education is also available for patients and champions of telehealth in the community and S clinics in Dauphin every Tuesday and every families. Several children in Dauphin are for ongoing support of the program. I second Thursday. This is a real advantage to affected with autism. After speaking with appreciated working with Cindy Bettesworth, the Region, the clients and to Dr. Sandhu as he parents and learning of their feelings of isolation Site Coordinator Swan River, who provided can now continue to provide services to both and desire for education and support fiom other me with program and personal support in the communities plus reduce the amount of travel parents and caregivers, it was great that development of our regional programs within -. . . telehealth cniild nffer them this nnnnrhnitv .m-- . . ... direction. ana was always availame to solve problems such as sound proofing and lighting. Dean There has been a large demand administratively Duncan, Network Administrator, solved any to lower medical travel costs and from this the technical glitches from the Churchill end. The Northern Patient Transportation Program Board of Directors, especially Chairman Bob Thegreatest success of the MBTelehealth committee was formed to address issues Penwarden, are all champions of telehealth and site, in the Churchill Regional Health Authority, surrounding health care transportation, including RHA management are always supportive of thus far, has been the continuing education the use of telehealth. Administrative meetings telehealth activities. sessions. Attendance has been very good overall fiom the Churchill RHA have primarily centered and comments have been positive. Even the on opportunities for recruitment and interviews. Telehealth has been a challenge and learning first experience as a cascade of Winnipeg (which experience. I appreciate the trust and provided Churchill with a 6-inch square viewing Televisitation has not been used but it is independence that comes with this position. area) was appreciated by the public health nurses anticipated that this service could best be offered My goal is for patients and clients of the who attended. to clients from Nunavut who are in Churchill Churchill RHA to see telehealth as something for extended stays. they can use for their own benefit and as a common sense alternative in quality health care In January 2003, the Churchill telehealth site provision. took part in a telehealth week. Over forty staff InSeptember 2001, Nancy Miller, Manager has been very positive. In Gillam, physicians, of Health Programs, Gillam General Hospital, the community mental health worker and clerical approached me to ask if I would be interested staff request telehealth services, which is in the Telehealth Site Coordinator position for evidenckd by the increase in clinical sessions. Gillam, and subsequently I was hired as a casual Psychiatry, pre-surgical assessments and employee for MBTelehealth, Winnipeg dermatology comprise of the majority of Regional Health Authority. In October 200 1, consultations to date. Site Coordinators continue Site Coordinator Orientation was held in to work on developing further referral patterns Winnipeg, where we met fellow site between Thompson and Gillam in addition to coordinators and orientated to MBTelehealth psychiatry and pediatrics, which are already in and the videoconferencing equipment. place. Equipment arrived in Gillam on December 11, 2001 and the first connection was with Recently, I was able to provide a telehealth and Thompson on January 20,2002. otoscope demonstration for Dr. hid, an ENT specialist from Thompson. I was practiced and The Regional Telehealth Grand Opening was ready to show him a healthy eardrum but was held over the link, in conjunction with taken by surprise when he asked me to look in Thompson, Leaf Rapids and Lynn Lake, on the mouth and nose. Dr. Anid has since April 25,2002. Winnipeg connected to requested to have some of his patient I

Thompson, Gillam and Leaf Rapids for the first appointments scheduled over the telehealth link. 4 half and then Leaf Rapids wasdropped and Lynn Lake picked up, as only one of these two Telehealth has provided improved access to satellite sites can be linked at any one time. It health care that would have otherwise not been was so exciting to see the split screen where possible due to financial and time constraints we could view four sites at one time. individuals face. It is much better for patients to be able to come into the telehealth office in There were numerous telehealth sessions Gillam for a consultation rather than having to between Gillam and Thompson to test the travel to Thompson or Winnipeg. In some equipment and internet protocol lines. Watching cases, particularly in psychiatry, patients would the second hand of a clock was useful in not have attended the appointments if it had determining the freeze time at a far site. Using meant out-of-town travel. Additionally, the a digital camera to display what was seen on education and administrative sessions which this end and then transferring the image to have been well attended enable staff to Winnipeg over the link, was valuable and proved participate in training and on committees that successful in resolving problems on more than would not be possible if we had to travel. one occasion. As knowledge and awareness grows, the use Feedback from the clients of telehealth, patients, of Telehealth will continue to expand to better families, nurses, physicians, other health care serve the health care needs of our population. professionals, and administrative participants m ~keHealth Centre, in Killarney, session involved an individual with severe lriety of uses of the innovative arthritis who was spared an arduous three-hour th network in Manitoba. Clinical, trip to Winnipeg for a ten-minute consultation md administrative demonstrations with a specialist. The individual was very h sessions have been offered to grateful not to have had to travel and stated roviders, the public, to service they would not have gone to see the specialist I local clubs. if travel was involved. That session was followed closely by a televisit between a lsers have consulted with grandmother and a newborn granddaughter. ts, vascular surgeons, neurologists, The grandmother's reaction to seeing her new nd wound management specialists. granddaughter for the first time was th is presently half way through heartwarming. The grandmother would not :ries of Continuing Medical have been able to see her son, daughter-in-law ssions that are offered every two and granddaughter for several months if the physicians in Killarney. A variety telehealth network was not available in ging from emergency medicine to Killarney. to mental health, have been In the beginning days of setting up the telehealth :Continuing Nursing Education site in Killarney, the maintenance department ugh MBTelehealth has recently (Morley, Charles and Ron) played a major role urrently offers education in in helping with moving, painting and renovating. lalliative care and wound Kerry Neely of Future Soft was helpfid and management. The present Nursing Education

.-S . . A knnwledaeahle-- .. - in the---- -L-"."-A".LV"inctallntinn nfV' rnhl~WUU" tn'V program will run every three weeks through five rooms in the Health Centre. Penny December 2003. Sorensen, Chief Executive Officer of the MBTelehealth has supported administration by Assiniboine Regional Health Authority has been providing the opportunity to attend meetings a great supporter of telehealth in the Region. using the network, thereby saving both time The Killarney Foundation generously provided and travel. MB~elehealthkso uses the network a grant for $15,000 to the Region and to for ongoing Telehealth Site Coordinator MBTelehealth for the initial start up costs in meetings and for regular administrative meetings Killarney. with all the Regional Health Authorities to As the Site Coordinator in Killarney, I have provide the latest information on MBTelehealth enjoyed being part of this new program for and to provide the RHAs with a forum. health care delivery to residents of Manitoba. Through one of the early clinical sessions (Plus I get to play with all sorts of high-tech provided, it became very clear to myself that gadgets). It has been a very rewarding year the telehealth network would be of great benefit and I am looking forward to the future with to all the residents of Manitoba. This particular MBTelehealth.

Site Coordinator in the fall of 200 1 and remained sessions are greatly appreciated, as it is very in the position until moving away from the difficult and expensive to travel from the community in May 2002. The,Polycom community to take part in continuing education. Viewstation equipment was delivered to Lynn Provision of educational opportunities may Lake Hospital in January 2002 and David Allen have an impact on recruitment and retention of (TecKnowledge) and Liz Adair travelled there staff to these Northern sites, allowing staff to in laniiay 2002, MBTelehealth provided a remain current in their health care practice. 'the equipment and training to the e hospital. Renovations had been Administrative usage has bccn limited in thc .n operating room theatre that was no Region by the inability of having more than use and an IP drop was put in to one satellite site up at one time. There is always n area for clinical and non-clinical competition for the satellite between Leaf Rapids lections between Lynn Lake and other and Lynn Lake that necessitates one centre :re extremely difficult at the beginning being connected over the satellite with ns were experienced with quality of Thompson, Gillam, and the other centre joining 'transmission, difficulty connecting in by teleconference. atellite and fiequent dropping of calls There have been few clinical sessions in Lynn lected. MBTelehealth worked with Lake but plans are in place to work with the ial staff and Vancouver Teleport the Northern Patient Transportation Program to rovider, to recti* the problems. identify clients who could benefit from seeing ;atisfactoryconnection was the Grand a specialist over the telehealth network rather ~f the Burntwood RHA sites on April than having to travel. It is planned that consults m Lake have been 25,2002. The Site Manager, Cathy Leahy, will soon start between Lynn Lake and a number of along with Seonaid Merasty, took over planning Thompson specialists. There will soon be :tions and quality of the event and were in Lynn Lake to set up consultation services available in the Region 1Polycom camera the call. The event went well with all sites in for pediatrics, ENT, mental health and surgical Lake Hospital had assessment. As the facility is also the centre the Burntwood RHA being able to connect " ...... 7 ,.- . * to be replaced, which left the centre without a without a problem. ~eonaidMerasty was hired lor inpatient care between Leaf Kapids and camera for a period of time. The local physicians into the position of Site Coordinator. Cathy Lynn Lake, it will be advantageous to look at have been somewhat hesitant to utilize the Leahy is now the Manager, Health Care discharge planning and coordination between equipment for consultation and a marketing Programs for Lynn Lake and Leaf Rapids and Lynn Lake and Thompson. plan is being developed to approach this problem continues to be a strong supporter of telehealth An occupational therapy aide recently moved and increase local physician use of the network. at both sites. into the community and it is hoped support for Lynn Lake is one of four telehealth sites in the There continues to be episodic problems with her can be provided over the telehealth network Burntwood Regional Health Authority and is satellite connections to the community but by the physiotherapist in Thompson. one of three sites that have satellite services service has improved. Educational activities (the others being Churchill and Leaf Rapids). have been provided to physicians and nursing Lori-Ann Van De Woestyne, was hired as the staff and are attended as the staff is able. These

Successes have included: establishment of Snow Lake, upgrading clinical and educational regular fetal alcohol syndrome diagnostic clinics rooms, establishing teleradiology services, and case management meetings, continuing integrating telehealth into the NOR-MAN education, speech therapy services and mental Primary Health Care Initiative, establishing health utilization - especially psychogeriatrics telehealth for Saskatchewan residents served and child and adolescent treatment. by Flin Flon General Hospital, and promoting the Blue Cross Employee Assistance services. Challenges have included: acceptance and utilization by NOR-MAN physicians, as well Examples where access to clinical services via as quality of telehealth rooms requiring MBTelehealth has made a significant difference: upgrading for telehealth. A post-laryngectomy cancer patient in Flin Flon Future priorities will include: expanding services was feeling overwhelmed by the impact of with Cancercare Manitoba and the Manitoba disease, as well as surgery and radiation Renal Program, establishing services to support treatments. The patient was frustrated and diabetes care, extending telehealth services to discouraged about whether speech would be regained. The MBTelehealth network was able link to the Winnipeg-based Speech Therapist to provide more frequent and regular speech therapy sessions. The increased frequency of therapy and the fact that the patient could remain in the community close to family and friends seemed to provide a greater sense of control over the situation. The patient became much more motivated and optimistic and was able to make good progress towards regaining speech. A probation officer in Flin Flon contacted MBTelehealth about a 19 year-old client who was in custody in The Pas awaiting sentencing for a second offence. Several people involved with the case suspected that fetal alcohol syndrome was a factor in the young client's history, but there was no diagnosis and no fhnding to transport the client to Winnipeg for assessment. The probation officer was concerned that without assessment the justice system would have no option but to impose a jail sentence. The NOR-MAN RHA Mental Health Service and the Fetal Alcohol Syndrome assessment was assessed via telehealth by the Pain and recommendations. They also assured the patient team at Children's Hospital linked from Symptom Control Clinic at Cancercare that they were available via telehealth on an Winnipeg to The Pas for the diagnostic Manitoba in Winnipeg. In the patient's ongoing basis for follow-up. Later, the family interview. The telehealth link allowed the condition, travel to Winnipeg would have been doctor said that it was a complex case and that participation of the client's adoptive parents, very difficult and expensive. The patient was he appreciated the support from the Winnipeg justice, the NOR-MAN psychologist and Mental brought to Flin Flon hospital by ambulance for team. He also said that regardless of how much Health team, and physicians in Winnipeg the appointment, and was accompanied by their difference the appointment made to the patient's (including three visiting FAS experts). In the spouse, the NOR-MAN Palliative Care symptoms, the family felt they had received the end the client was released from custody and Coordinator, and family doctor. The Winnipeg best care available and that they appreciated is now living in supervised housing in Flin Flon team, which consisted of two physicians and a being able to consult the outside expertise. and attending high school. Everyone involved, pharmacist, spent 70 minutes with the group in including the judge, felt this was a far more Flin Flon and was able to make several constructive and cost-effective resolution of the case. A cancer patient in The Pas was scheduled for post-operative follow-up with the Oncologist in Winnipeg. The prognosis was poor, the patient had some difficult treatment decisions to make and was in need of emotional support. It was arranged for the patient's two adult children to be present with the Oncologist in Winnipeg while the patient and spouse with the chemotherapy nurse from The Pas hospital linked over telehealth. The session was positive for the patient, the family provided emotional . .

not have to try and transport the clic ent to the Last, but certainly not least, the reason the city for the appointment. The time from when position became so inviting, is due largely in the client left from and returned to tlle personal part to our one and only rural supervisor, Liz care home was approximately one-lhalf hour Adair. Liz has been the twinkle throug-hout and compared to an all day trip to the city. Providing the reason this Site Coordinator decivded to try care as close to home as possible is a something new. When this position was commitment MBTelehealth is able to fulfill. advertised it was at a time when there was a need for a change, and it was almost like it was Many individuals were instrumentsl in meant to be. Liz's enthusiasm and ability of establishing the MBTelehealth locat.ion at Pine persuasion peeked my interest and she has Falls. North Eastman Health Authority 'S continued to be a motivating force behind the Information Technology team, Ron Drabyk, MBTelehealth team. The caliber of specialty Jeffery and Patty were instrumental in the services on board and the unified keenness of installation of lines in the building smd getting all the service providers sold the program. - the Pine Falls site on line with the r est of the *- telehealth family. The maintenance crew made All the MB Telehealth team have been up of Alan Tardiff, Tim and Brian we re essential instrumental in making this program the success in getting the clinical area established, which that it is today. Some of the Site Coordinators included painting and furniture col1ecting. and myself have had interesting discussions on North Eastman Health Authority skiff, Judy what we got ourselves into. Some of us have I laughed until there were tears running down Coleman, Rhonda McIvor, Brigette Budgell, our cheeks. Telehealth is definitely an area of Ev Palanuk and Wendy Tardiff wer,e all the future, where information and knowledge he position of MBTelehealth Site Coordinate-K ciinnnrtiw= in ~ctahlichinrrthe nrnm --, UUy,V. CL. V ALL VVCUV~VLA~~ ,,,,.am is available at the point of care, and most r Pine Falls began in November 200 1. A parameters within the facility. We cannot a1 office area was selected in the Pine importantly, where we make a difference in exclude the MBTelehealth Central Office staff someone's life. I feel very fortunate to be a part Health Complex and telehealth sessionLS that have always "been there" and provided a of such a positive, effective and essential health egan in early spring 2002. Clinical activities wealth of support and information to our sites. care service. date have included, dermatology, pre- an(1 ost-operative pediatric surgical sessions, ez e and throat (ENT), mental health and hysiotherapy. The majority of clinical activi as been in dermatology and pediatric surgic consults. Each and every opportunity to set the specialist over videoconferencing equipme has been a positive experience for all clients One particular case involved a client with Alzheimer's disease who was living in the juxtaposed personal care home. A referral h been made to the ENT specialist and the client family were especially grateful that they dic KTelehealthhas been operational at Portage at Portage Hospital for 20 years, working as a District General Hospital since January 2002. registered nurse in various areas. The telehealth Since that time many changes have occurred needs assessment from 2001, identified some and much new ground has been broken. Louise resistance among healthcare providers, in using Lusignan originally held the position of Site telehealth for specialist consultation. Hiring a Coordinator for MBTelehealth at Portage nurse into the position was done with the plan Hospital before moving to Winnipeg. Louise that clinical services would be established, and coordinated the equipment setup, and arranged is slowly showing some success. and hosted the MBTelehealth Open House on May 17,2002. The majority of telehealth use to date has been for administrative purposes. Portage Hospital On September 16,2002, I started in the position and Boundary Trails Health Centre are the two of Site Coordinator. I have been an employee regional centers in RHA Central MB, Inc. Much administrative activity occurs between the two progresses and the technology is rapidly There has been a network of people in the facilities and the telehealth sites in these centres forgotten. As a patient advocate, I can see how Portage area who have helped to establish the have facilitated many meetings. Because of the these clinical sessions are a positive experience telehealth project at portage Hospital. The vastness of the region - some 18,500 square for the patient. As a nurse, I am able to reinforce Facility Director, Dr. Doug Kinley promoted kilometers, traveling time and expenses have the information that the provider has given to the project from the start. Associate Facility been reduced significantly. the patient after the session is complete. In my ~irector,Pat Nodrick continues to be very - last pre-operative clinical consultation, blood supportive. Dr. John Hedden has shown much Portage Hospital, as the northern centre in the work was arranged to be done before the client interest and was the first Portage physician to region, serves a population of approximately left the hospital and saved the patient and family request a clinical session. Recently a telehealth 40,000. Neighboring facilities include: a 150-kilometer future trip. presentation was held for the Portage Clinic MacGregor and District Health Centre, Seven nurses, sanctioned by the physician group. Regions Health Centre, St. Claude Health Another wonderful use for MBTelehealth has Hopefully the interest shown by the nurses will Centre, Notre Dame Health Centre, Lorne been our continuing education sessions. continue to generate clinical activity. Memorial Hospital, and Cartier Health Centre, Continuing Medical Education initially received as well as the variety of Long Term Care a lukewarm response but has sold itself over Daisy Dowhy, Coordinator of Central Plains facilities. Portage Hospital is also in relative time with good planning, excellent speakers Cancer Care, has been an advocate of telehealth proximity to Neepawa Health Complex and and relevant topics. These sessions have also and took part in the telehealth evaluation. A Tiger Hills Health Centre. All of these facilities provided the physicians with an opportunity to telehealth presentation made during a recent have clients and staff who could benefit from be exposed to telehealth. Seeing telehealth in Central Region Stakeholder meeting generated the services MBTelehealth can provide and action is probably my very best marketing tool! much interest from business people and have been included in the marketing plan for community leaders alike. the Portage Hospital MBTelehealth site. Continuing Nursing Education has been a bonus to the nurses in the area. With the nursing Personally, I have found the position of Site The clinical service side of telehealth is slowly shortage, it has been difficult for nurses to attend Coordinator with MBTelehealth to be both increasing with a great number of the referrals education sessions where travel is required. interesting and challenging. My initial fears originating from the facilities surrounding Telehealth has brought these education sessions with the technical aspects have been overcome. Portage. St. Claude, Neepawa and Seven to the nurses. Excellent speakers and relevant I used to consider myself "remote control Regions have been the greatest users. All topics with lots of advance notice have made illiterate," and now can manage at least two clinical sessions have been very positive and these sessions very successful. Introduction of remotes at any given time and even cope well patients state that they enjoy the undivided the Quarterly Ethics rounds and the City Wide with the digital camera. It is anticipated that attention they receive from the specialist and Ultrasound rounds has also helped to meet some the Portage site will be a recipient of some of appreciate the convenience and proximity of of the education requirements for other the exciting clinical tools that will be available renovation of an old nursery, whic :h would five children from one family and their guardian, become the primary clinical room With adjoining who were all scheduled to see a dermatologist office. In total there are four roor ns supplied for a skin disorder. The appointment was a with Internet Protocol drops for telc ehealth, with success with a diagnosis made and treatment two of them designated for clinic;11 activity. ordered. The guardian stated that if they would On May 1,2002, amid a late spring; snowstorm, have needed to travel to Winnipeg for the the Grand Opening was held whic:h was very appointment they would not have made the trip. successfbl and attended by staff, t he Board of Directors, local politicians and the :public. As Site Coordinator, I see that MBTelehealth is a success story in Russell. The program The first official telehealth activity 2it the Russell provides for more opportunities for continuing site was a Continuing Medical Educ ation session education with less travel. Continuing Nursing held in April 2002. The physician s regularly Education has been offered since January 2003. attend these sessions, pleased that 1they are able As a registered nurse on staff, I know there is to access education in their home facility, and a real need for education in the Region and are developing relationships with S;pecialists in telehealth is providing the required education larger centres through the telehealth program. in all areas. The Russell facility has a One of the physicians even attends the education Chemotherapy Unit and is scheduled to have a sessions when he is on vacation d 3ys. Hemodialysis Unit by the end of 2003. Cancer Care Manitoba is using MBTelehealth to provide Clinical sessions commenced in May 2002. The education for Chemotherapy staff throughout majority of clinical sessions have been primarily the province. Chemotherapy and dialysis dermatology, with other sessions involving YUCIVIILUnati~ntc &l1V. ILL hav~IIU V V th~CllV ronoh;l;hrVUYUVIIILJ tnLW t-~ppi~~~IVUUIV V pediatrics, infectious diseases and surgery. education and attend follow-up appointments Additionally, employees of the Region have through the telehealth link. been able to access the Blue Cross Employee Assistance Program by telehealth. All clinical The success of telehealth in the Region is thanks MBTeleheaIth in Russell is located in the activity has been successful. Clients praise the to the staff of the Russell District Health Centre. Russell District Health Centre, an active acute program, commenting about the importance of Administrative, medical, nursing and support care facility. This site was selected by the being able to attend these appointments at or staff has all supported the program since its Marquette Regional Health Authority for its close to home, and are amazed at the quality of beginning. Regional Health Authority staff, activity and distance from Winnipeg. The transmission and often comment, "that it is just especially Information Technology and Russell District Health Centre is a 3 l-bed facility like being in the doctors office." One client, a Administrative staff, has provided information that employs five family physicians. farmer, who was able to attend two separate and support to the program and myself as Site follow-up appointments with an infectious Coordinator. Finally, the Regional Health The videoconferencing equipment arrived in disease specialist, found this extremely valuable Authority Board of Directors is comrnended Russell in January 2002. Renovations had been as the appointments were scheduled during the for their decision to develop a MBTelehealth made in preparation for telehealth, including busy harvest season. Another session involved program in the Region and Russell. consults between physician teams both within for optimum health care delivery. A procedure Manitoba and out-of-province, and simple conducted over the link to replace a voice box, procedures including prosthetic voice box allowed the client to remain in their home replacement as well as enterostomal therapy community and attend the wedding of a management. grandchild. I As a Winnipeg RHA site, health care Observing interaction between physicians who professionals at St. Boniface provide and have spoke on the telephone but have never participate in education sessions both within met each other prior to a clinical session Winnipeg and throughout the Province conducted on the network, reinforced the need (ultrasound rounds). The telehealth network for peer support of the health care community facilitates teaching of medical students in general. Transfer of knowledge and expertise (cardiology rounds), peer support (Midwifery was provided to nursing staff in Thompson Peer Review Group), transfer of knowledge through an enterostomal therapy session. (Cancercare infusion pump therapy) on a Telehealth connectivity from St. Boniface and provincial basis. As well, St. Boniface was one Health Sciences Centre is instrumental in of 352 sites to participate in a historic allowing clinicians flexibility within their international conference, the American Joint schedules. Committee on Cancer Staging. Since the introduction of MBTelehealth by St. Boniface has successfully used point-to- Winnipeg RHA, St. Boniface General Hospital point and multi-site settings to conduct has embraced the program as a way of reaching committee and administrative sessions. The those patients who receive care fkom this tertiary MBTelehealth network supports the link care site. The support from administration by connectivity from St. Boniface to the provincial between Health Sciences Centre and St. the Executive and Associate Directors of data network was established and operable in Boniface as professionals provide support to Clinical Programs, Dr. Michel Tetreault and May 2002. The open house was held on Regional initiatives and are able to remain on MS Doreen McMorris, enabled MBTelehealth September 10,2002, conducted jointly by the site (cardiology, oncology, pathology, renal). to make inroads with all clinical areas at the rable Dave Chomiak, Minister of Health site. The Information Technology department anitoba, Dr. Brock Wright, Chief Medical While statistics clearly indicate increasing use worked diligently to ensure the infrastructure cer for Winnipeg Regional Health Authority, of telehealth at St. Boniface General Hospital, required to connect MBTelehealth to the d Dr. Michel Tetreault, Executive Director they cannot relay personal stories that further provincial data network received priority. The inical Programs for St. Boniface. the development of this program. Bringing a Surgery Program, Dr. Mark Taylor, has provided family together over the telehealth network to space to facilitate sessions from a variety of Clinical sessions in keeping with the aim of the discuss cancer treatment options with a rooms. Recently an 85-seat theatre in the network, have increased steadily at St. Boniface. physician remind us how intricate the health Education Building was wired. The growth of Provision of health care by physicians, nursing care decision making process can be. MBTelehealth at St. Boniface General Hospital staff, and allied health professionals account Assurances to the provider that the client and continues to be supported and nurtured by the for approximately 48% of the telehealth sessions family fully understand the consequence of the planning and integration of this service into provided through this site. Examples of these treatment available and supports the client, future endeavors. sessions include, consultations and follow-up, family and their health care community to allow led over The Centre has also been involved in the dental Continuing Nursing Education series where in the nurses at SMHC take part in the education sessions broadcast from Winnipeg.

:nt teams Tele-Administration-much committee work lams, takes place at SMHC, some of which involves what travel to many regions throughout the province. :SMHC With telehealth, staff are able to link to many orts to regions, thus decreasing travel. Having telehealth at SMHC has meant many are able positive things to the Centre. The main nt and advantage has been to clients receiving services services over telehealth. In one particular difficult .S after session a translator was required at both telehealth sites as the client's parents spoke Cree. Additionally, the client was deaf which viduals required the translator at SMHC to translate to who are being referred to SMHC's Extended the social worker who then wrote out what the Treatment Program or Rehabilitation Program. parents were saying to enable the client to know SMHC is able to link with the referring -. . . ,- ., ." . * what was being said. Initially it was difficult community to gain runner mrormation on tne having many individuals involved in the client or to assess them using telehealth, rather communication process, but the joy on the client than the client having to travel to SMHC for and parents faces was worth every minute of assessment. the session. It was difficult to end the session, Tele-visitation for Families - as many of the as neither party wanted to say goodbye. Selkirk Mental Health Centre's telehealth site clients are away fiom their families for extended has been operating since March 2002. The SMHC's Medical Director, Dr. Jack Kettler, periods of time, telehealth can provide them was instrumental in SMHC becoming involved Grand Opening was held on May 8,2002. As with the opportunity to visit on a regular basis. the only Provincial Mental Health Centre in in the telehealth initiative, along with the Manitoba providing long term treatment and Tele-Education for Health Care Providers - assistance from the Interlake RHA which care, many of the individuals receiving treatment educational sessions have been provided on a provided support, including Network at Selkirk Mental Health Centre are a long way regular basis to all telehealth sites in Manitoba, Administrator, Sanela Maric, being available from their home communities. With the use of through Continuing Medical Education services to ensure equipment is operational. My position the telehealth equipment, we have been able to for physicians. Several of SMHC's psychiatrists as Telehealth Site Coordinator for the Centre enhance the recovery process for many of the have been involved in providing these sessions. fits well with my position as Community Liaison Coordinator for SMHC.

comprise the Swan Valley Health Facilities MBTelehealth has made tele-psychiatry a major organization. player at the Swan River site. Since October 2002, the Parkland RHA Psychiatrist from The catchment area includes many outlying Dauphin, has utilized MBTelehealth to provide towns, rural municipalities, First Nations a weekly clinic plus two additional clinics communities and unorganized territories with monthly. Currently, the compliancy rate of the over a 60-mile radius from Swan River, and clients is 90-100% per clinic, with all

tntnlinu---A-- an estimated population of 15,000. D ----- participants stating they would continue to use Currently, eil;ht physicians provide medical telehealth, and remarkably, some stating they care from Sm ran River with minimal in-person preferred telehealth to in-person consultations. specialist services provided to the Valley. In addition, other tele-psychiatry interactive MBTelehealt.h has made a significant positive uses have included case conferencing and impact on thc :health care users of the Valley. discharge planning with health professionals The telehealth needs assessment report was from Winnipeg and Brandon. compiled in 14ugust 200 1 and MBTelehealth Another major player has been the education was introducled to the Swan River area in component that telehealth has provided. Regular, November 2(10 1. The initial primary uses for biweekly Continuing Medical Education the equipmerit included administration and sessions for physicians have been attended on education, W ith minimal clinical sessions average by 40% of the doctors with favorable scheduled. TIoday, however, the focus has evaluations of the content, technical delivery, changed witl:I the majority of the sessions etc. This enhances the in-house education -- -- *.. scheduled foir specialist and clinician sessions, with presenters traveling from Welcome to Swan River Valley, a thnvmg consultations. Winnipeg, are provided for on a monthly basis farming based community, riestled uicturesauelv . . between Porcupine and Du Provincial Park ranges of 7 Manitoba. The town of SW 476 kms northwest of Win northwest of Dauphin and of Brandon with neighbori cities of Regina and Saskal away. Hosting a populatia people, an estimated 15% ( age 65. Within the town of! the Swan Valley Hospital, facility within the Parklanc Authority. Other non-devo operating within the Valle: Valley Lodge Inc., Swan F Home and Benito Health Cc physicians, management, board members, Swan Vallev Health Facilities Foundation Inc., committee members, local government officials, and the health care consumer has attributed to the exponential growth of MBTelehealth in Swan River. As a Nurse and most importantly, as MBTelehealth Site Coordinator, I cannot explain the satisfaction felt when a terminally ill patient reaches for my hand, in a gesture of thanks after they have had a telehealth consultation with their oncologist. Prior to the advent of telehealth they had to make flight arrangements to see the same physician they can now see without leaving the comforts of their home community and without the emotional, physical, and financial hardships of travel. In a very short time, MBTelehealth has become an integral, key component of health care Telehealth team members fly to Swan River to initiate discussions on site development, spring 2001. deliverv for residents of the Swan River Valley. I am confident the future of health care within this community will achieve many positive Mental Health staff have been provided with the province. Travel was avoided and the outcomes with the continued and imperative topics directly affecting their commitment optimal outcome was achieved in the most time use ,fthis technology. towards ongoing education. MBTelehealth has efficient manner. There have been major accomplishments by will be starting clinics in the spring of 2003. telehealth in Thompson. Living in the North The psychiatrist in Thompson frequently sees I has its disadvantages when it comes to provision patients in Lynn Lake, Leaf Rapids and Gillam of health care. Historically it has been necessary utilizing telehealth and recently started providing to travel to Winnipeg for specialty services not services to clients in Churchill. provided in Thompson. At times, people are required to take very lengthy bus rides to get During the past months the following clinical ~intmentsin Winnipeg, only to turn sessions have been provided in Thompson: travel back that same night. These Dermatology (Adult and Pediatric) :sult in lost working time, need for Genetic Counseling rangements and the risk associated Cardiology ng, particularly during the winter. ovision of telehealth clinics many Neurosurgery E can be avoided. Psychiatry (Thompson to outlying areas) Pediatric Surgery ore specialties are coming on board. Infectious Disease will be holding monthly pediatric Enterostomal Therapy e areas of Leaf Rapids, Lynn Lake which will avoid patient travel Wound AssessmentManagement :entres into Thompson. The ENT Employee Assistance Program rhompson has come on board and The pediatricians have utilized the link from LUL ullly 1U1 IIIyS~Il, mpson site as well. The amount sessions have increased greatly months. nenmlon in ~ugust md found the g to begin with. wen hook up my hard to believe that his. The learning is peripherals has g. Each time you the VCR, document me time, you really ished something. Ionnnc x~rhnn+h;nnr( I Ilk1 k IIU V k Vkkll DVII1k kIIUllkll5kD W Ilk11 Ullll~J do not go as planned, but even troubleshooting can be fun - provided it is not in fiont of a room. full of people! having the ability to keep current in their profession. MBTelehealth has provided these professionals with a link to peers for case conferencing and education. I am really looking forward to the future of MBTelehealth in Thompson. The possibilities for this service are endless. Each day interest by community members and staff is increasing. There is a real sense of accomplishmentwhen we are able to work with people to accommodate their requests and in the process increase our knowledge and capabilities. Dr. Moll' Seshia, Dr. Leigh Wincott, WanyeBoyce & Dr. Anne Nwehuhe in the nursery in Thompson General Hospital, Thanks to Site Supervisor, Liz Adair, for all her support since I commenced in this position. the nursery in the Thompson General Hospital sessions have included meetings, interviews It has been wonderful to have her so close by. to the neonatal intensive care unit at Health and orientation sessions to staff in the outlying I also need to acknowledge Pearl Morris, Site Science Centre. A cable has been ordered to areas. Coordinator during the first year of i connect a monitor to the equipment in the MBTelehealth development. Pearl has always Thompson unit.Once this has arrived, the MBTelehealth, Thompson site, has been very been there when I needed her help or was feeling 1 equipment will be left in the nursery during all successful in its endeavors to date in the a bit unsure of myself. Central Office staff in k hours. Staff has been trained and are very excited Burntwood Regional Health Authority. Both Winnipeg have been very supportive and patient about the availability of this support. staff and community have been given access to with me. I think I talk to them more that all services close to home that would not otherwise the other site coordinators combined. I am very Provision of education sessions has greatly have been possible. It is wonderful that people gratefbl to be part of such a super team! benefited the people in Thompson. Continuing are able to just "come to the clinic' and drive Medical Education and Continuing Nursing back home in minutes without all the challenges Education sessions are being held, not only to trips to the city would result in. My position ..7 . -- 1 'P m 1. - .1 . lnompson mom W mpeg, our.uom I nompson 1s very rewaraing m tnat people are nappy to to the outlying sites. It is difficult for health be at home. This is very new technology to care professionals to travel to education sessions some people and reactions have been very in Winnipeg and to have these sessions available positive. Even the children think it is wonderful on their doorstep has been wonderful. thatihat they can talk to the TV and it responds. Individuals are often able to leave their duties It's like a game -they can duck under the table for a short time and "run7'"run" down the hall to and say "Can you see me now?" participate. Recruitment of health professionals to the North Administrative usage of MBTelehealth prevents has always been a challenge. There is a feeling travel in many circumstances to Winnipeg, Leaf of isolation from peers, particularly when they Rapids, Lynn Lake and Gillam. Administrative are a lone specialty. Also, there is fear of not - AK-U TUA I . I \\n

' ASHERN BERENS RIVER BOUNDARY TRAILS *BRANDON CHURCHILL FLlN FLON *GILLAM KILLARNEY LEAF RAPIDS LYNN LAKE NO RWAv HOUSE PINE FALLS PORTAGE LA PRAIRIE RUSSELL* SELKIRK ST. BONIFACE STEINBACH *SWAN RIVER* THE PAS THOMPSON

1 Designed by: ?BJ?C Biomedical Communications, Health Sciences Centre, www.hsc.mb.ca/bmc Room 536 - Fifth Floor TEL: 204 1975-7755 John Buhler Research Centre FAX: 204 / 975-7787 p'?'-f-4,: :-ra 1 1 .F... , 715 McDermot Avenue www.mbtelehealth.ca Winnipeg, Manitoba R3E 3P4 CANADA