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by John Chenery

In a remote Nova Scotia fishing village late one spring evening, a copiously refreshed resident emerged from a waterfront bar, took a long walk on a short pier and ended up in the Atlantic jammed between the pier and a fishing boat.

Badly banged up, he was taken to local hospital where the two family doctors called to attend him were concerned that he might have sustained broken ribs, internal injuries, maybe even a broken neck or a fractured skull. All the victim could tell them was that it hurt - a lot.

Just a few years ago, the doctors' first move would have been to stabilize the patient and get him to the trauma center in Halifax as quickly as possible, involving either a lengthy road journey or an expensive flight on the air ambulance. Today, thanks to a pioneering public-private partnership (P3) between the provincial health department and TecKnowledge Healthcare Systems Inc., things are simpler, with benefits to the patient, the physician and, not least, to the province's cash-strapped health system.

TecKnowledge is a leader in the burgeoning field of telehealth - the use of communications and information technology to deliver healthcare services and information over large and small distances. Telehealth is quickly emerging as one of the fastest growing segments of Canada's multi-billion-dollar healthcare industry. An estimated 400 Canadian companies are now active in the business - projected to top $1 billion in sales this year.

In the case of the accidental swimmer from Nova Scotia, the province's advanced telehealth network, the most comprehensive in Canada, allowed the local doctors to rapidly send x-rays and other test results to radiologists and trauma specialists in Halifax. The expert diagnosis: no serious injuries, no need for an emergency dash to the city; have him spend the night and sleep it off.

Long distance diagnosis is now an everyday occurrence in Nova Scotia. All healthcare facilities with inpatient beds - 41 in all - are linked in a network that is costing the province $8 million to install and operate for three years. "We've surprised a lot of people," said Linda Weaver, TecKnowledge's co-founder and Chief Technical Officer. "Nova Scotia isn't exactly famous for being progressive."

The system allows doctors in remote areas to refer difficult cases to any physician in the provincial healthcare system, including specialists at the principal teaching hospital in Halifax. Physicians can see and speak with the faraway patient through videoconferencing while x-rays, photos, video clips and other relevant materials are digitized and transmitted. The telehealth unit can also be hooked up to devices such as ultrasound monitors to complete the diagnostic package.

Weaver said that the project was born four years ago in response to growing problems among the province's rural physicians. "They were overworked, overwhelmed and they were leaving their practices. It was clear to the decision-makers in the provincial health department that something had to be done and telehealth was one component of the plan."

Instead of trying to establish and operate the network itself, the department went looking for a private sector partner. They discovered TecKnowledge. Founded in 1993 by Weaver and Dorothy Spence, former clinical engineers in the provincial health system, the small Dartmouth-based company provides telehealth solutions to the healthcare community.

"It came down to some forward-thinking people within the public sector as well as political leaders realizing that something needed to be done and they didn't have the expertise to do it," said Weaver. "They were willing to break down the barriers between the public and private sectors to make it happen."

Weaver firmly believes that telehealth is one activity that must be undertaken as a partnership because of its complexity and the need to consider the requirements of all the parties. Nova Scotia has installed a governance structure that is led by the health department and brings users - physicians and hospitals - to the table with the operators before decisions are made and implemented.

Weaver feels that there is still strong resistance in some parts of the public health sector to the growing involvement of private companies in providing services. "There is a very real fear that the private company brings with it a different set of objectives, which is true, of course. Businesses want to stay in business; they have to be profitable. But that doesn't have to be the only driving force."

Ten years ago, most telehealth activity was funded almost exclusively from the public purse. But as the industry has grown, so have the involvement, participation and investment from the private sector.

The main driver fueling the ongoing telehealth boom has been the explosion of information technology and telecommunications at a time when the healthcare industry was increasing its use of computers and telecommunications. But much of the recent growth and even stronger prospects for the industry arise from its potential to maintain quality healthcare in an environment where federal and provincial healthcare spending has been stagnant or declining. Add to that an aging population, increasing demand for equitable access to healthcare services for residents of isolated communities and the increasing demand among the general population for health information of all kinds.

In a detailed analysis of the telehealth industry, Industry Canada said remote consultation needs (telemedicine) or distance health and continuing medical education drove early projects. Today, fewer than 30 percent of projects are based on telemedicine. Most startups now focus on integrated health networks, of which telemedicine may be a component. One of the major features of the current telehealth scene in Canada is the growing involvement of private companies. Continued growth would require close partnerships between the customer/purchaser/user and system or service providers. "…In many countries like Canada, these entities are located in separate public and private domains, but good working examples exist where the best of both sectors partner successfully," the analysis noted. "The best telehealth projects combine the expertise of health users with the best suppliers of technological innovations."

Dr. Mamoru "Mo" Watanabe, president of the Canadian Society of Telehealth, agrees that, if telehealth is going to proceed and achieve its potential, the public and private sectors are going to have to learn how to work together in partnerships.

"It's a relationship that is still difficult because the partners are so different in their philosophies and their approach," he said. "The private company will always tell you that they want to make a profit but that it is not the driving force, but it really is. They are driven by quite different objectives. And because there is a difference in culture, there is a different understanding of how the sectors work. You need to spend a lot of time just working out what people mean when they say certain things. We're all speaking English and using the same words but you soon find out that the words mean very different things in the different sectors."

Adding to the tension is the long-running and increasingly heated debate over private firms offering clinical services - a development seen by many as the beginning of the end of Canada's public health system.

"Admittedly, this is not a very well considered reaction because in Canada at this time private delivery of clinical services through telehealth is not what is driving its development," said Watanabe. "But these days anything that involves a public-private partnership in the health field tends to make people wary."

There are problems enough without that kind of misunderstanding. Watanabe said that with the notable exception of Nova Scotia, the record of health departments and private firms working together on telehealth projects is not good. "Virtually all the provinces have experienced problems, sometimes serious problems in making these partnerships work," he said. "It certainly has not been an easy relationship and there are still a lot of difficult transitions to be made if we are to overcome the culture clash at work here."

Nevertheless, most provinces have telehealth networks in greater or lesser stages of development. Alberta's we//net resulted from a strategic alliance of Alberta Health with IBM and Ernst and Young to provide project development and quality assurance services. The partnership ensures that alberta we//net is primarily private-sector built with appropriate advice and guidance from government and the public sector health authorities, with additional input from medical professional associations and healthcare providers.

In Quebec, development of the Interregional Telemedicine Network would not have been possible without input from the private sector, said Dr. Andre Lacroix, an expert on telehealth at the University of Montreal.

Toronto's Hospital for Sick Children has pioneered many different telehealth applications working with a range of companies including Bell Canada, Adcom Electronics, Teleglobe and Sony.

Ask Linda Weaver the secret of TecKnowledge's success in Nova Scotia and she doesn't hesitate. "An awful lot of telehealth projects that have been started in Canada and elsewhere have been straight technology-push. That means companies coming in with complex and expensive technology that doesn't match what needs to be accomplished. We came at the problem from the opposite direction, co-developing and co-designing the system with the clinical people who would be using it. So you arrive at solutions based on what is needed, not what is technically possible. And you iron out potential areas of conflict as you go along."

John Chenery has worked as a journalist and editor for national newspapers in Australia and the UK. Before moving to Toronto from Costa Rica, he was Director of Communications with the Earth Council.

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