WELCOME :)

This

Collaborative Blog

is

brought to you

by....

Group A

Bloggers

Maxine Bernard

Margaret Devries

Leisa Faulkner

November 2009
Athabasca University
MHST 602
Professor : Jack Yensen

The Future?

Is this the future of health care?

Positive or a negative?

Presentation Outline

Objectives

Definition

Identify specific strategy

Goals

Background information

Role and scope of practice

Skill set of the provider

Status and progress across Canada

Benefits and limitations for patients

Benefits and limitations for health care providers

Summary

Future trends

Recommendations

Discussion questions

Links to websites

References

Objectives

1. To provide an overview of telehealth and describe the practice of videoconferencing.


2. To identify the competencies, roles and standards required in the practice of videoconferencing.


3. To descibe a specific videoconferencing application.


4. To highlight the benefits and limitations of videoconferencing.


5. To identify videoconference opportunities as a method to support rural populations


6. To suggest recommendations and identify future trends.

A tip.... when using any of the links, to easily re-enter the blog, simply click on your back button/arrow.

Introducing.......

Telehealth is increasingly evident in every Canadian province and territory. Factors contributing to the growth of telehealth in Canada include; increasing technological capacity, the perceived need to deliver specialty services to rural and remote communities, and the need to reduce the isolation of health professionals in remote areas through continuing health and medical education. A number of barriers, however, continue to inhibit the widespread adoption and implementation of telehealth including an insufficient infrastructure, and a lack of standards. For our presentation we will be focusing on videoconferencing.

Please click on the video below to view videoconferencing in action. *Note be sure your volume is ON.





Recommended Readings (...of course there are readings!)
Please do come back to us... remember after enjoying the reading, click on your back button/arrow to return easily to the blog.


1) Benefits of telemedicine. http://www.ortcc.org/PDF/BenefitsofTelemedicine.pdf

2) Implementing telehealth to support medical practice in rural/remot regions: what are the conditions for success? http://www.implementationscience.com/content/pdf/1748-5908-1-18.pdf

3) Telehealth Law-Regulating Telehealth in Ontario-Next step in the transformation agenda http://www.medicine.mcgill.ca/Ruis/Docs/telesante/Telehealth_feb06.pdf

Only for those who want to read even more....
4) Assessment of Videoconferencing in Canada http://www.cadth.ca/media/exsum/telehealth_tr_e.PDF

Telehealth Defined

Definitions:

Telehealth – delivery of health care from a distance

• Originally used to describe administrative or educational functions related to telemedicine. Now used as umbrella term to describe all possible variations of health care services using telecommunications


• Many forms of telehealth including telemedicine, tele-education and nursing telepractice.


• Defined by Industry Canada’s Advisory Council on Health Info-structure as “the use of information and communication technology to deliver health and health care services and information over large and small areas. (CNA, 2000)
  

Telemedicine is a subset of telehealth. It includes many sub specialties using live videoconferencing systems. It is the direct provision of clinical care via telecommunications i.e. diagnosing, treating or following up with a patient at a distance.

Telecommunication – currently 4 modes including:
1. voice only i.e. ordinary telephone
2. video/images i.e. digital pictures
3. data exchange i.e. keyboard/mouse operations)
4. virtual contact i.e. videoconferencing

The Telehealth Practice of Videoconferencing

Videoconferencing:

Videoconferencing (VC) is the real-time transmission of voice, data, and video images between two or more users at some distance from one another (Noorani & Picot, 2001). Examples include performing assessments and engaging in patient teaching. According to Winters & Winters (2007), VC also allows televistation to occur. There are five different types:

1. teleassessment (active remote assessment)


2. telemonitoring (generally minimally intrusive using sensor and measurement devices)


3. telesupport (goal of the encounter is to provide support for patients and/or providers i.e. emotional support


4. telecoaching (support and instruction for a prescribed therapy are conveyed)


5. teletherapy (actual interactive therapy)
   

Variety of levels of sophistication in these videoconferencing systems are available. (Winters & Winters, 2007)

VC is the most frequently used communication strategy for telehealth applications in Canada (Noorani & Picot, 2001). Health professionals use VC systems for remote diagnosis and therapy, clinical consultations, education and training, and administrative/business functions.

There are a variety of software applications and hardware technologies available to support videoconferencing applications. They can be as simple as using a regular desk top computer and linking into existing telephone lines or as complex as using specialized equipment. Regardless of the equipment there is generally a video monitor, VCR/DVD device, patient examination cameras, microphone and various other attachments to facilitate examination such as an otoscope or dermascope. Microsoft Office live meeting is one software application that has been used in a telehealth application in Ottawa Ontario. Polycom has developed hardware for use specifically with Telehealth applications including screen/cart stations, probes and stethoscopes. http://www.polycom.com/solutions/industry_solutions/healthcare/index.html (examples of telehealth technology- please click on the arrow on the video below. *note: ensure your volume is on)

Samples of telehealth education applications http://www.rohcg.on.ca/education/video-audio-e.cfm (click on this link, several examples available. *Again - click on the back button/arrow to re-enter the blog, we don't want to lose you!)

Other software applications are also available to enhance the videconference assessment process and can be used for specific patient populations. For example Motion Analysis Software is available to assess the patients gait and mobility and assist the provider in determining a plan of care and patient progress.
http://www.medical-motion.com/default1.htm (sample video of motion analysis software- click on video on website, then click on video.)

Goals of Videoconferencing

Usage Goals:

1.) Videoconferencing capabilities allow health care providers to engage in virtual face-to-face encounters with patients or other health care providers (Winters & Winters, 2007)
2.) To decrease resource usage
3.) To improve treatment compliance

4.) To provide the additional support of specialists for patients and health care providers improving accessibility (Ho & Karlinsjky, 2004)

5.) To provide additional learning opportunities for professional development of rural physicians/health care providers to improve patient satisfaction and quality of health care services available (Winters & Winters, 2007).
6.) Significant cost savings and satisfactory or improved outcomes have been reported when comparing telehealth approaches with traditional care for chronic disease management

Background Information and Statistics

Background:
In Canada, telemedicine and telehealth experiments date from the mid to late 1950s, and telehealth has been operational in at least one province, Newfoundland, since the 1970s. Canadian telehealth programs are producing increasing numbers of peer-reviewed articles,
evaluation reports and other documents.(Noorani & Picot, 2001).

• Patients, families, nurses and health care providers are faced with accessing and negotiating health care services with limited resources in countries where vast geographical landmasses exist (Sevean et al, 2008).


• Telehealth and telemedicine have been used to provide quality health care for tens of thousands of patients worldwide over the last decade.


• Currently used in rural areas, school districts, home health settings, nursing homes, Native American communities, NASA space missions, cruise ships, prisons and the military (Brown, 2005).


• Critical nursing shortage exists (Winters & Winters, 2007). Use of telehealth technologies may be a useful strategy to extend the availability of nurses without imposing additional burden (Winters & Winters, 2007).


• Health care environment is experiencing an influx of telehealth technologies that allow patient monitoring and management of chronic health problems, predominantly in the home (Winters & Winters, 2007). Examples of remote telehealth remote monitoring devices include pulse oximetry, HR, BP, etc…


• Telehealth technologies provide opportunities to meet the rapidly growing needs of consumers and healthcare providers. Many in need of services do not have access to high-end technologies (Winters & Winters, 2007).


• Lowest level of technology needed to carry out a task should be used.


• Telehealth technologies are altering conventional methods of providing patient care (Sevean al, 2008)


• Telehealth technologies have been heralded as the answer to providing care to those populations due to geographical limitations that do not have access to specialized care
  
  Please click here for... Rural Population Statistics
  
  

Nursing in the Telehealth era

Role of the Nurse in Telepractice

“RN’s continue to identify and/or respond to evolving needs of the public and to health system trends and issues. To assure they remain effective in meeting the needs of current and future clients, RNs are embracing new roles in areas such as policy development, advocacy, telehealth and primary health care”. (CNA, 2002)

Definitions (as defined by Canadian Nurses Association)

Telehealth: “the use of information and communication technology to deliver health services, expertise and information over distance”. (CNA, 2007)

Telepractice: “A nursing specific application of telehealth that includes all client-centred forms of nursing practice and the provision of information, conferences and courses for health care professionals occurring through, or facilitated by, the use of telecommunications or electronic means”. (CNA, 2001)

“As champions of primary health care, nurses play a major role in maximizing the benefits of health care technology, including ensuring that nursing telepractice is used safely, appropriately and ethically.” (CNA, 2001)

• Nursing telepractice is recognized as being within the scope of nursing practice by all Canadian nursing jurisdictions.


• Consistent with philosophy and approach of primary healthcare
  
• Potential to enhance application of the five principles of the Canada Health Act (Comprehensiveness, universality, portability, accessibility and public administration)


• Guided by code of ethics for Registered Nurses


• Subject to relevant legislation


• Should be part of an integrated health care service to enhance but not replace existing health care services


• To improve access to care


• Encourage appropriate use and efficiency of health care services

Principles for provision of safe, competent and ethical telepractice

• Establish a therapeutic nurse-client relationship


• Incorporate the nursing process (client assessment, planning, implementation, evaluation and documentation)


• Applicable to telepractice-provision of information, referral, education and support


• Document all telehealth nurse-client interactions with date and time of call, name, telephone number and address of client, information given and any follow-up or referral information provided.


• Evaluation of telehealth strategies

Competencies, Skills, Accoutabilities and Standards of Practice

Nursing Competencies

• Require specialized nursing knowledge and skill (beyond an entry level nurse)
  
• Strong clinical knowledge (specialized knowledge and skills depending upon client population served)


• Strong assessment skills


• Strong (exceptional) communication skills


• Strong critical thinking and evidence-based decision making skills


• Competencies related to technologies being used


• Determine appropriateness of the specific technology in use in meeting the specific patient needs


• Strong documentation skills


• Computer skills and data collection


• 3-5 years experience in variety of acute and/or community settings

Underlying principles

• Consider cultural, spiritual and psychosocial needs and preferences


• Obtain informed consent
  
• Maintain security, confidentiality and privacy
  

Standards impacting Telepractice

• Code of Ethics for Registered Nurses


• Professional Practice standards


• Relevant legislation
  
• Practice guidelines of the province/territory in which they are a registered nurse and practicing (regardless of where the patient is located)

“Nurses are obligated to determine whether they have the required competencies for nursing telehealth practice. Also as with all nursing care, nurses practicing telehealth services are expected to practice within their scope of practice; that is, they carry out only the activities they are competent and authorized to perform”. (CNA, 2007)

For an example of provincial nursing guidelines check out the following document from the College of Registered Nurses of Nova Scotia "Telenursing Practice Guidelines" by clicking on the follwoing link: http://www.crnns.ca/documents/TelenursingPracticeGuidelines2008.pdf

Locus of Accountability
Nurses engaged in telehealth are considered to be practicing in the province or territory in which they are located and currently registered, regardless of where the client is located. This model endorsed by CNA is believed to be the most cost effective and efficient for regulatory bodies to implement and to be in the best interest of both clients and nurses.

During Telepractice interaction the nurse must: (to support accountability)
...Inform the client of name, professional designation, provincial or territorial regulatory body and place of work

Shared Responsibility in supporting Professional Practice Environment:
By employers, governments, regulatory bodies, professional associations, educational institutions, practitioners and the public

“Nurses engaged in telehealth have an obligation to advocate for systems that promote the safe, competent and ethical delivery of telehealth services and to act when client care is compromised”. (CNA, 2007)

Standards

Accreditation Canada has developed standards that enable assessment of the components of the organization that support quality and safety in the delivery of telehealth services. The standards are based upon five key elements of service excellence: clinical leadership, people, process, information, and performance.

There are six subsections within the standards:

• investing in telehealth services
• engaging in prepared and proactive staff
• purchasing and maintaining telehealth equipment and networks
  providing safe and appropriate services
• maintianing accessible and efficient clinical information systems
  monitoring quality and achieving positive outcomes
  

For a complete overview of Accreditation Canada Telehealth Standards please click on the following link:
http://www.accreditation.ca/accreditation-programs/qmentum/standards/telehealth-services/

Status of Telehealth Across Canada

Status of Telehealth Across Canada :

Telehealth application is expanding across Canada at an incredible rate including VC. Noorani & Picot (2001) discussed eight provincial Telehealth projects in their "Assessment of Videoconferencing in Canada" document, who use videoconferencing to provide health care and continuing health and medical education. The provincial and territorial programs discussed were Alberta, Newfoundland, Nova Scotia, Ontario, Quebec, Saskatchewan, Northwest Territories and Nunavit. For more extensive reading refer to the document link in the suggested readings section of the blog.

In comparison, Ho & Jarvis (2006) provide a more extensive look at the status of telehealth across Canada. Telehealth, including VC has expanded to all provinces and territories with only Prince Edward Island and Newfoundland not having a provincial Telehealth network.

For a summary of the Clinical Telehealth Activity in Canada by province and territory review the summary table by clicking on the following link: http://docs.google.com/Doc?docid=0AWPdIyKwA_pBZGZqYjN2aGJfNGdrZHB2cGdk&hl=en

Telehealth strategies make up the most projects in progress per province across Canada with the exception of Saskatchewan and PEI. For a quick look at the status of Telehealth click on this link http://www.infoway-inforoute.ca/lang-en/ and click on map at bottom of the page.

Infoway announced new funding allocation of 500 million in the 2009 Federal budget for e-health projects. As of March 31/09 Infoway has approved 283 EHR projects across Canada. Presently there are 173 projects in progress of which 44 are Telehealth Initiatives.

Benefits and Limitations of Videoconferencing Telehealth for Patients

Benefits

• reduce travel time and number of trips to medical appointments
• reduce travel costs: such as gas, meals, accommodations, parking, air fare
• reduces trips in heavy traffic and bad weather
• reduces time away from work and families
• increase rural patients access to specialist and advance health care
• may allow for easier access to second opinion
• allows patients opportunity to receive care at home vs. hospitalization
• receive care in community and with those they know
• quicker access to specialists
• allows for face to face interaction with specialist
• increased patient satisfaction
• can avoid transfers of care from rural to urban centres
• reduces/eliminates long wait in waiting rooms to see specialists and exposure to infectious diseases
• improvement in health with closer monitoring

Limitations

• access to equipment to facilitate video teleconferencing
• availability of technology applications - is high speed Internet available in their location
• experience of use with technology
  

For a complete list of benefits and limitations with references click on the following link:

http://docs.google.com/Doc?docid=0AWPdIyKwA_pBZGZqYjN2aGJfMmNoZnJkbWQ2&hl=en

Benefits and Limitations of Videoconferencing for Health Care Professionals

Benefits

• access to specialist opinion and expertise, assessment, and teaching
• faster access to a second opinion
• reduces isolation of rural physicians
• saves time and reduces errors
• can be used for information sharing/consultation prior to transfer from rural to urban centre for seamless patient care
• can be used for follow-up visits improving continuity of care and patient teaching
• used as initial consultation with specialist to reduce wait times
  increased access to a wide range of services and specialists in remote areas
• allows for not only verbal but visual cues which enhance the interpersonal relationship
• increased adherence to medication regimens
• may increase time to review patient information and therefore time with patients
• provides new possibilities for continuing education and training for isolated or rural practitioners
  

Limitations

• initial and ongoing costs for technology applications
• quality of bandwidth may affect assessment and may not be sufficient for some speciality care
• lack of knowledge or comfort level with the technology and orientation time
• may reduce the number of specialist in remote areas
• reduced ability to perform physical assessments reduces "hands on" clinical practice
• dependent upon the skill of the health acre provider to do the physical examination
• employer or employee responsibility for maintaining qualifications

For a complete list of benefits and limitations with references click on the following link:

http://docs.google.com/Doc?docid=0AWPdIyKwA_pBZGZqYjN2aGJfMWdqaGdxeGc4&hl=en

Example of a Telehealth Video Conference Application in Canada

The Physical Rehabilitation Distance Communication Initiative















The Initiative:

• A Telehealth program that uses the Information Highway to provide remote consultation and continuing education services in Eastern and North Eastern Ontario through videoconferencing application
• Nine health care facilities partnered (1997 to 1999) cover approximately a 1000 Km range
• The result, implementation of a successful and sustainable video conference system to support physical Rehabilitation services

Key concepts of the program:

• clinical assessment, treatment, community outreach, education, administration, computer configuration, network administration, software development, multimedia development, research/evaluation, communication/information dissemination, shipping/transportation, project management

Outcomes:

• implementation of communication systems, validation of video conference approach, improved clinical video conference techniques, development of continuing education methods

Fundamental principle:

• to provide services at the right time, at the right place and at the right cost

Objectives:

• setup the community sites currently serviced by the Terry Fox Mobile clinic for distance communications
• Train the community staff how to use the communication system
• Provide on-line access to rehabilitation educational content that is applicable to rural communities
• Organize a regular, on-line consultation schedule for each site

The Technology used:

• Internet based technology was used to complete all consultations and educational sessions
• The system worked over regular telephone lines, the Internet, or a computer network
• Besides connecting to any site that had reliable telephone service, the low bandwidth conferencing system had low purchase and low maintenance costs
• Core communications software used was Microsoft Net Meeting (a standards-based video and data conferencing package that runs on any 32 bit Windows operating system)
• Net Meeting is free and is a standards-based video and data conferencing package
• The tools included were: Live-Video and Audio Conferencing, Whiteboard, Chat, File transfer, Program Sharing, data conferencing security features
• Project implemented in 1999—upgrade with Windows 7 to new software—Net Meeting replaced by Microsoft Office Live Meeting
• Motion Analysis software was used to enhance the video conference capabilities by enabling assessment of patient mobility and gait
• The system was easy to implement, easy to maintain, cost effective, and sustainable

Clinical application:

• Physical rehab consultations completed for communication disorders, foot care, gait problems, orthotics, prosthetics, upper extremity weakness, and wheelchair prescription
• Consultation time was 40 minutes
• Through an evaluation component of the program is was determined all clients were comfortable with the Telehealth consultations
• Once implemented the communication systems were self-sustainable by the rural communities
• Continuing education application included: web pages, handouts, slides, overheads, CD-ROM, Net Meeting Whiteboard and notebook computer projector

Challenges included:

• equipment funding from some hospital’s operating budgets, staff changes in the community, physician funding for video conference consultations

Funding from Telecommunications Access Partnerships (TAP) was essential for providing Telehealth technology in small communities.

For final report on this telehealth inititaive click on the following link:
http://www.irrd.ca/telehealth/distfile/rpt1999.pdf

Future Trends

Please click ... "The Doctor Is In" - Video Detail - The Video Lounge to view what the general public is seeing on TV commercials (please note - this was retrieved Nov 12, 2009).


· Critical care areas with cameras and monitoring devices to remotely monitor critically ill patients in a number different of hospitals to one centre, as there is a decreased number of internal/critical care specialist also acts a second opinion or back-up

· Uses for Bluetooth technology for medical devices - increase access and mobility

· Increase in virtual communities for health care providers - support for isolated health care professionals

· Increased use for home care agencies - monitor patients from afar, weekly visits via videoconferencing

· Remote monitoring for chronic health conditions, such as, diabetes, COPD, CHF - link with nurses and physicians for monitoring and teaching
(Wolbring, 2008)

· Could be used with pandemic flu outbreaks to reduce contact

Recommendations

• Educational support for health care professionals to increase knowledge and comfort level with technology


• Development of pan-Canadian professional regualtions to support video conferencing telehealth between provinces


• Be the driver of technology change, rather than adapting to existing technology


• support expansion of bandwith quality throughout Canada


• Encourage increased access to patients and health care providers


• Expansion/updating of programs as technology evolves


• Advocate for physician remuneration consistent accross Canada
  development of nationally approved standards for training of professionals


• Committment at the government level for long term funding to support sustainability of the program


• Need to conduct quality outcome studies to evaluate clinical and cost effectiveness


• Development of guidelines for planning, implementation, user training and program sustainability over the long term
  
  
  

Summary

Telehealth strategies have the ability to enhance patient satisfaction and outcomes during the health care experience and transcend barriers related to access to health care. The patient is at the center of the strategy and if fully supported by human and financial resources and strong policy development there is the potential for improved patient outcomes, efficiency in service delivery and greater satisfaction for the health care provider. Although telehealth and videoconferencing strategies continue a slow evolution there promises to be a bright future as one of the many E-Health initiatives as it grows, develops and becomes engrained in day-to-day practice.

Discussion Questions

1) What are key challenges in implementing a telehealth videoconferencing application (thinking about organizational change and medico legal issues)? What can you do in your area of work to support telehealth videoconferencing?


2) What future trends do you forsee in the area of videoconferencing?

3) Discuss the status of physician remuneration for telehealth services in your province and how it compares across Canada. What are the potential implications for Telehealth services in your area?

4) Discuss the potential implications of teleconferencing strategies for rural populations. Consider the provinces with the highest rural populations in relation to the number of implemented Telehealth strategies.

Web sites of Interest

Canadian Society of Telehealth http://www.cst-sct.org

Telehealth Canada blog for providers and organizations http://telehealthcanada.blogspot.com

Ontario Telehealth Newtwork http://www.otn.ca

American Telemedicine Association http://www.americantelemed.org

Association of Telehealth Service Providers http://www.telemed.org

Canada Health Infoway http://www.infoway-inforoute.ca

References

Accreditation Canada (2009). Telehealth services. Retrieved October 10, 2009 from http://www.accreditation.ca/accreditation-programs/qmentum/standards/telehealth-services/

Canadian Nurses Association (2002). Discussion Guide for The Unique Contribution of the Registered Nurse. Retrieved October 15, 2009 from http://www.cna-aiic.ca/CNA/documents/pdf/publications/unique_role_rn_e.pdf

Canadian Nurses Association (2000). Telehealth: Great potential or risky terrain? Retrieved October 15, 2009 from http://www.cna-aiic.ca/CNA/documents/pdf/publications/Telehealth_November2000_e.pdf

Canadian Nurses Association, Position Statement, (2001). The Role of the Nurse in Telepractice. Retrieved October 15, 2009, from http://www.cna-aiic.ca/cna/documents/pdf/publications/ps52_role_nurse_telepractice_nov_2001_e.pdf

Canadian Nurses Association, Position Statement, (2007). Telehealth: The Role of the Nurse. Retrieved October 15, 2009 from http://www.cna-aiic.ca/CNA/documents/pdf/publications/PS89_Telehealth_e.pdf

Canada Health Infoway (n.d.) EHR Progress map. http://www.infoway-inforoute.ca/

Fincher, L., Ward, C., Dawkins, V., Magee, V., & Wilson, P. (2009). Using telehealth to educate parkinson’s disease patients about complicated medication regimens. Journal of Gerontological Nursing, 35(2):16-24.

Gagnon, M., Duplantie, J., Fortin, J., & Landry, R. (2006). Implementing telehealth to support medical practice in rural/remote regions: what are the conditions for success? Implementation Science 1:18. Retrieved October 10, 2009 fromhttp://www.implementationscience.com/content/1/1/18

Health Canada (2005). First Nations, Inuit, and Aboriginal: telehealth. Retrieved October 15, 2009 from http://www.hc-sc.gc.ca/fniah-spnia/services/ehealth-esante/tele/index-eng.php

Ho, K., Karlinsky, H., Jarvis-Selinger, S., & May, J. (2004) Videoconferencing for telehealth: Unexpected challenges and unprecedented opportunities. British Columbia Medical Journal. Vol. 46, No. 6. Retrieved October 27, 2009 from http://www.bcmj.org/videoconferencing-telehealth-unexpected-challenges-and-unprecedented-opportunities

Institute for Rehabilitation Research and Development (2000). The Physical Rehabilitation Distance Communication Initiative. Retrieved Oct 5, 2009 from http://www.irrd.ca/telehealth/distfile/rpt1999.pdf

Leimig, R., Gower, G., Thompson, D.A., & Winsett, R.P. (2008). Infection, rejection, and hospitalizations in transplant recipients using telehealth. Progress in Transplantation, 18,2, 97-102.

McCarty, D. & Clancy, C. (2002). Telehealth: Implications for social work practice. Social Work, 47 (2), 153 -161.

National Initiative for Telehealth Framework of Guidelines. (2003). http://www.ehealthstrategies.com/files/telemed_canada_guide.pdf

Nursing Now Issues and Trends in Canadian Nursing. (2001). What is nursing informatics and why is it so important. Retrieved Oct 10, 2009 from http://www.cna-aiic.ca/CNA/documents/pdf/publications/NursingInformaticsSept_2001_e.pdf

Perceived Risks of Using Telehealth by Community and Proposed Solutions (n.d.). Retrieved October 20, 2009 from http://www.fp.ucalgary.ca/telehealth/Canarie%20-%20Final%20Report,%20June%202002/Appendix%20A%20-%20Analysis/04-ABC%20Analysis%20Table%20One.pdf

Roine, R., Ohinmaa, A., & Hailey, D. (2001). Assessing telemedicine: a systematic review of the literature. CMAJ, 165(6), 765-771.

Seavean et al (2008). Patients and families experiences with video telehealth in rural/remote communities in Northern Canada. Journal of Clinical Nursing, 18, 2573-2579.

Telehealth Association of Ontario. (n.d.). Retrieved October 5, from http://www.ehealthontario.on.ca/ehealth.html

Telehealth News. (n.d.). Retrieved October 10, 2009 from http://telehealth.net/

Telemedicine Association of Oregon (2004). Benefits of telemedicine. Retrieved October 15, 2009 from http://www.ortcc.org/PDF/BenefitsofTelemedicine.pdf

Telemedicine Information Exchange. (n.d.). Retrieved October 20, 2009 from http://tie.telemed.org/

Winters, J.M. & Winters, J.M. (2007). Videoconferencing and telehealth technologies can provide a reliable approach to remote assessment and teaching without compromising quality. Journal of Cardiovascular Nursing, 22(10), 51-57.

Wolbring, G. (2008) The future of telehealth, medicine and care. Retrieved October 5, 2009 from http://www.albertatelehealth.com/library%5CWolbring.pdf