Rebekah Jamieson
HealthNet, Canada
Community Health Centers (CHCs) are providing essential health and social services to many communities across Canada, and this function is becoming more vital as provinces concentrate on cutting costs and developing more economic and efficient alternatives to the current health care system. Community Health Centers are community-based organizations focused on primary care, disease prevention and health promotion. CHCs work closely with their communities to assess basic needs, and they often serve high-risk populations that normally have problems accessing health services, such as aboriginal groups, the homeless, new Canadians, and rural populations. The more than 300 Community Health Centers across Canada provide a wide range of services that promote physical, economic, and social health in their communities. More than half of all CHCs are located in rural or remote areas.
Community Health Centers currently serve over 13 percent of the Canadian population, but this number rises as CHCs are increasingly viewed as viable, cost-effective health care venues. While Quebec has a highly evolved system of CHCs employing over 15,000 people, Prince Edward Island and New Brunswick are only now carrying out pilot projects to assess the appropriateness and efficiency of Community Health Centers as health provision models for these provinces. Meanwhile, the demand for services provided by CHCs is clearly increasing. Saskatchewan is in the process of creating over 60 new CHCs throughout the province, and British Columbia's health reform plan also supports the development of more CHCs there. Numerous rural hospitals are being closed and converted to Community Health Centers, while larger hospitals are reducing services, often aiming their overflow at CHCs. In addition, many community agencies that CHCs normally work with, such as crisis centers, employment agencies, and seniors' organizations, are being threatened or eliminated by government cutbacks, further expanding the need for Community Health Centers in Canadian society.
Despite this need and the apparent success of Community Health Centers, they are among the most underserved health provision groups in the country. In urban communities, CHCs are often overlooked by larger health-care institutions because they are smaller organizations, though they may serve large populations. Community Health Centers must be allowed to participate, especially in restructuring and strategic planning discussions, in order to contribute their unique perspectives. One serious problem within CHCs that reinforces this inequality, however, is a lack of funding and resources, particularly in the area of technology. In the "Information Age," health care institutions are realizing the importance of using information technologies to increase efficiency and improve services. Larger organizations are often able to find the necessary funding and equipment for such activities, either internally as a result of redistribution of budgetary and physical resources, or externally through government programs and corporate sponsors. In contrast, smaller organizations like Community Health Centers usually have limited budgets that they must use for direct patient care, particularly in rural areas. As a result, many CHCs do not have some of the most basic communications tools that are taken for granted by larger institutions. In Nova Scotia, for example, most of the rural CHCs do not have fax machines. Community Health Centers in Canada must be given the necessary tools to continue providing quality health and social services to their communities, wherever those might be. This is one of the goals of the HealthNet Community Access Pilot.
The HealthNet Community Access Pilot is a collaborative project initiated by the Network Services Development Group (NSDG) of Industry Canada. The NSDG team is led by Rebekah Jamieson, a consultant to NSDG, who coordinates the HealthNet CAP and is responsible for community health organization liaisons and overall project management. Strategic inputs are provided by Michael Pluscauskas (HealthNet coordinator and consultant to NSDG) and Andrew Stephens (General Manager, NSDG).
The main goal of the HealthNet Community Access Pilot (CAP) is to expand and evaluate the use of information technologies (Internet) in Community Health Centers across Canada by developing user-friendly tools and resources to facilitate access and familiarization to the Internet. HealthNet CAP attempts to educate and provide participants with appropriate tools to help them begin developing Internet systems and policies within their own context. The initial test phase of the project ran from September 1995 until March 1996, with nationwide expansion expected to take place in 1996-1997.
As described above, Community Health Centers are an important part of Canada's health care system. CHCs need useful tools that will facilitate efficiency and allow workers to provide better services with fewer resources. Communications technologies like the Internet may be able to assist in this process, improving the ability of CHCs to share resources and information, access current medical databases and clinical resources, consult with other professionals around the world, and increase technical skills.
Community health centers are suitable starting points for introducing Internet technologies to communities, particularly in rural areas. A CHC is often one of the central service agencies in a community, serving a diverse and sometimes large population. CHCs also have a strong commitment to their community and were created in part to raise public awareness of issues involving people's physical and social well-being. By evaluating the experiences of a few CHCs, it is hoped that the HealthNet Community Access Pilot can help act as a model for increasing the use of the Internet in CHCs across Canada, based on the challenges and successes of the initial test group.
A combination of community partners and corporate sponsors have been involved in the first phase of the HealthNet Community Access Pilot. Sponsors supporting the project include the Ottawa-Carleton Health Information Network (an initiative of the Royal Ottawa Hospital), which has provided free Internet access to local CHCs, Gandalf Technologies and Bell Canada, which have supplied an ISDN line and hardware to connect one CHC's LAN to OCHIN, and the Community Access Program of Industry Canada, which provided funding to hire the HealthNet CAP Coordinator.
Community Health Centers participating in the project include Carlington Community and Health Services (Ottawa, Ontario), Merrickville District Community Health Center (Merrickville, Ontario), Somerset West CHC (Ottawa, Ontario), Sandy Hill CHC (Ottawa, Ontario), and Pinecrest-Queensway CHC (Ottawa, Ontario). Interest has also been demonstrated by other CHCs across the country, such as in the North West Territiories, New Brunswick, Saskatchewan, and Quebec.
As of March 1996, over 35 new users in 5 Community Health Centers in the Ottawa area were taking part in the initial pilot phase of HealthNet CAP. User-friendly training sessions have been held, and effective training materials, online resources, and software recommendations have been developed. The Ottawa-Carleton Health Information Network (OCHIN), a municipal Wide Area Network created by five local hospitals to share information infrastructure costs, supplied free Internet access to all CHCs in the area, which greatly helped to encourage participation. Both rural and urban CHCs have been taking part in the project, and many more are interested in becoming involved. Various awareness-raising activities have taken place, such as the preparation of an article for the Association of Ontario Health Centers' newsletter and participation in national and international conferences.
Early in 1995, two Community Health Centers in the Ottawa-Carleton area indicated an interest in participating in the HealthNet Community Access Pilot. Funding and personnel became available in September 1995, at which time work began on the project.
From the beginning, emphasis was placed on collaboration and appropriate use of the technology. It was understood that the Internet is not a panacea, but it may be able to enhance the services already provided by CHCs. By providing Centers with Internet access and useful tools to help them become familiar and interested in the technology, it was felt that CHCs could then decide for themselves how they wished to apply these tools within their organizations.
Ultimately, the success or failure of the project was dependent on the CHCs, thus it was felt that the project should be user-directed and evaluated. Throughout the initial pilot phase, feedback from users was encouraged and documented in order to learn from the experiences of the participants. Informal group discussions as well as some written surveys were used to gather feedback. As more Community Health Centers became involved, lessons were shared based on prior experiences, resulting in more effective programs for new users.
The focus of training was on providing the basic tools needed to understand and use the Internet. Because most of the users had little or no previous knowledge of the Internet or computers, it was important to de-emphasize the technology in order to eliminate fears and encourage use. This helped to encourage participation by individuals who would not normally gain Internet access. By assessing the users' background knowledge at the beginning of training, it was possible to permit the users themselves to guide the speed and content of the sessions. This approach worked well and was positively received by the new users; when polled, most participants felt the program was "very useful" to them.
The HealthNet CAP Coordinator has been working closely with various Community Health Centers since September 1995, facilitating the appropriate implementation and use of Internet tools within these centers. As of March 1996, over 35 new users in 5 Ottawa-area Community Health Centers were participating in the project and providing feedback. Further training sessions are planned for April 1996. Resources developed for use by CHCs across the country include a training program outline, a basic training manual, an on-line World Wide Web resource that includes starting points and helpful hints for new users, and other support resources.
People participating in the project come from a wide range of professions, and most had little or no prior experience with the Internet. Participants include physicians, nurses, administrators, health planners, medical secretaries, physiotherapists, community developers, personnel and finance coordinators, and executive directors. This adds to the value of the project, as a broader cross-section of CHC workers is able to understand and benefit from this new technology. It is also interesting to note that the majority of participants in the pilot phase were women. About 70 to 80 percent of current Internet users are men, so it is important to help women become aware of the available tools so that they can benefit and a balance can emerge.
Response to the HealthNet Community Access Pilot has been positive. Although there are some challenges in applying the Internet to CHC workers' professional lives, most feel that solutions can be developed to overcome these impediments.
Throughout the length of the HealthNet Community Access Pilot, users were asked to provide input and feedback to help evaluate the project. By maintaining a continual record of the progress, challenges, and successes of the pilot, it was hoped that the lessons learned could be shared with other Community Health Centers across the country as they move into the area of information technology. The following is an examination of some of the main benefits and barriers to participation, based on the experiences of the initial test group.
Most users felt that participation in HealthNet CAP was worthwhile and envision using the Internet in both their personal and professional lives in the future. Improved communication and access to information are the direct benefits experienced by new users, although their exact use of the Internet varied. More indirect benefits perceived or experienced as a result of using the Internet include increased efficiency (e.g., less "phone tag"), less duplication of activities between CHCs, and reduced costs associated with travel and long-distance calls and faxes. All these can ultimately benefit the clients of CHCs, since increased efficiency and access to information may result in quality services despite more limited resources.
One physician participating in the project enjoyed the benefit of increasing his knowledge and skills base as a result of the HealthNet Community Access Pilot. In an e-mail message, he wrote, "Thanks for the project--it made me feel part of the future and less of a dinosaur!!"
Despite the lack of previous Internet experience, most users were able to quickly and effectively make use of various Internet tools as a result of training and encouragement. E-mail was used to communicate with colleagues, participate in professionally relevant discussion groups, set up meetings, collaborate on documents, and receive electronic publications. The World Wide Web provided valuable research capabilities, and many users were able to find extensive Web resources that they applied to their professional lives. Useful materials on a wide range of topics (nutrition, personnel issues, breastfeeding advocacy, community development projects, specific clinical problems, etc.) were accessed via the Web. A number of users also used telnet to connect to their local FreeNet accounts.
There were numerous challenges facing interested users wishing to participate in the HealthNet Community Access Pilot. In most cases, technical problems were a major barrier, although the exact problem for each individual varied. Some people had no technical difficulties at all, while others were plagued with software glitches, modem problems, and other such impediments. A few users had little knowledge of computers, so even the most minor errors caused great frustration and discouraged use. Lack of equipment was also a large technical barrier, since participation for some people depended on the existence of a home computer. The Merrickville CHC did not have one suitable computer to set up in the Center, which delayed its progress significantly.
Despite the various technical challenges, innovative solutions have been developed to overcome the majority of these problems. Other challenges that may not be so easily overcome include:
Of course, in most cases, lack of financial resources is the largest barrier to the participation of CHCs in the area of information technologies. In considering most of the challenges listed above, funding could help to overcome them. Since it is not likely that additional funding will be made available in the near future, CHCs wishing to benefit from the Internet must work together to leverage all available resources in order to develop adequate solutions to these challenges.
Some new users of the Internet feel that it is not only important for CHCs to apply these technologies to their organization, but essential. Many large health care organizations are in the process of restructuring and using information technologies to increase efficiency with fewer resources. Community Health Centers must not be left behind, particularly when there are so many potential advantages. Peer groups often act as the best voice for change, thus we have listed some of the ways in which CHC workers themselves envision the Internet being used by Centers across the country:
Many useful lessons have been learned as a result of the HealthNet Community Access Pilot. As mentioned above, many of the challenges facing users who participated in the pilot phase indicate potential problem areas for other CHCs. The most important lessons from this project include:
It is estimated that between 150 and 300 full-time jobs could be created over the next year as a result of the HealthNet Community Access Pilot. As the demand for Internet training, consulting, and Web page development increases in Community Health Centers, people will need to be paid to carry out these activities. To meet this need, current employees could be trained to provide these services internally, new employees could be hired, or external consultants could be paid on an as-needed basis.
The first option of training current employees will result in capacity-building within Community Health Centers. By providing workers in CHCs with useful Internet skills and knowledge, they will be better prepared to access internal resources to develop appropriate solutions to their information and communication needs. In the past, most CHCs have relied on external computer consultants to provide key technical services. This has had negative impacts in a number of areas. By understanding the implications of Internet technologies, Community Health Centers will have more control over decisions related to this important area. This may also reduce the amount of money spent on inappropriate, unnecessary consulting services.
It should be noted that higher-end Internet expertise may still be required by Community Health Centers. One way of creating jobs while lowering the cost of these services for CHCs might be to consider hiring young people who are just emerging from the university to work within the CHC, rather than high-paid computer technicians. The under-25 age group is one of the most experienced in the area of Internet technologies and could provide both technical skills and an interest in community development (e.g., outreach programs). Many young people have a broad range of relevant skills that could be used by CHCs, and their innovation and enthusiasm could be great benefits.
In addition to the creation of jobs, benefits of the expansion of the HealthNet Community Access Pilot include:
Depending on the resources available to a particular Community Health Center, the challenges in accessing the Internet and participating in the HealthNet Community Access Pilot vary. Some Centers are well equipped with computers and technical support, while others remain technically disadvantaged. Despite the differences, however, there are some common challenges for most CHCs.
The major barriers facing Community Health Centers wishing to participate in the HealthNet Community Access Pilot appear to be lack of equipment (computers, modems, telephone lines), lack of local Internet access, lack of technical expertise, and lack of training resources. Rural CHCs face particular difficulties due to long-distance telephone rates. Both financial and human resources within CHCs are limited, further magnifying the perceived barriers.
Fortunately, in most cases, cost-effective solutions can be found to overcome these barriers, partly by developing strategic partnerships and leveraging available resources. Training resources and some technical support have been developed through HealthNet CAP and could easily be shared with CHCs across the country. The HealthNet CAP Coordinator could act as a resource person for Canadian CHCs in coordination with provincial representatives, providing useful tools, contacts and expertise as required. Various arrangements could be explored to provide CHCs with necessary equipment, and Internet access solutions can be developed by working with existing infrastructure. Whatever the end solutions, it is important to leverage all available resources in any given area, keeping in mind the goals of reducing costs and providing comprehensive patient care.
The human infrastructure for such a program is already being assembled. Various individuals and groups of Community Health Centers have been contacted and are interested in implementing Internet systems within their organizations, although further connections must be created and reinforced. Letters of interest are being collected on behalf of CHCs across Canada. Participation and communication among both grassroots organizations and larger, national bodies involved in policy-making must be encouraged.
In addition to solving the technical and human infrastructure challenges of a nationwide HealthNet CAP expansion, there are many ways in which Community Health Centers could be encouraged in their movement towards the increased use of information technologies. The support and resources already provided by HealthNet CAP could be extended in conjunction with provincial support mechanisms, such as representatives from the Association of Ontario Health Centers and other such organizations. These groups could play an important role in encouraging dialogue within each province, leveraging resources and sponsors, and addressing the needs and desires of their constituents regarding the Internet. Training programs and technical support are other important services that could also be provided or organized by provincial CHC organizations.
Community Health Centers require open-minded, supportive environments in which to learn about the potential benefits and uses of the Internet. Partners and sponsors should constantly be sought after who might be interested in helping CHCs overcome initial barriers to participation (e.g., by lending equipment, sharing Internet access costs, etc.). Management within CHCs must not impede progressive-minded workers interested in exploring technology options. CHCs that are already connected to the Internet could help encourage other Centers in their activities through a sort of "buddy" or "twinning" system. Online discussion groups on a variety of topics could also facilitate communication and information-sharing between Community Health Centers, in addition to more traditional means of relating their experiences (e.g., print newsletters, telephone calls).
Other factors that could help facilitate CHCs' involvement on the Internet include the provision of financial or technical support for Centers with limited resources, such as rural CHCs. Many practical barriers, such as a lack of equipment or training resources, could easily be overcome with the help of some financial aid, though without help, these barriers are often insurmountable. Such assistance might be provided by provincial governments or private-sector partners.
Nationwide expansion of HealthNet CAP services will take some time to fully complete. It is expected that by the end of October 1996, at least one urban and two rural CHCs per province could be participating in the project. The following is a proposed action plan to indicate how this expansion might be realized.