Xaayda Gwaay Ngaaysdll Naay

3209 Oceanview Drive,

Queen Charlotte, B.C., V0T 1S0
Phone: 250-559-4900

Text-Messaging Enhanced Primary Care at Xaayda Gwaay Ngaaysdll Naay/Haida

Gwaii Hospital & Health Centre

Project Lead: Dr. T Morton

FEI Project Manager: Alissa MacMullin, MPH, MSc Student

Project Overview
The primary care team at Xaayda Gwaay Ngaaysdll Naay (XGNN) offers their patients
enrollment in a unique texting service. A web-based platform (WelTel) sends and receives,
organizes, and archives all texting conversations, permitting bidirectional patient-provider
communication. Launched in April 2017, this service is a novel approach in the context of
primary care locally and nationally. The primary care providers at XGNN want to understand
how this service impacts patient care. To begin to assess the impact, we conducted a timely
quality improvement (QI) project (phase 1) at this site. This report will summarize our quality
improvement outcomes. Findings in phase 1 inform phase 2 research activities.

The overall aim of phase 1 was to describe the use of this service over a 17-month period (April
2017 – August 2018). Questions explored included:
1. Who used the service?
2. How did patients and providers use this service?
3. What proportion of communication were charted and eligible for provincial incentive
payments?

Funding Agency
Doctors of BC’s Specialist Services Committee Facility Engagement Initiative (FEI) is the
primary funder of the technology, implementation, and quality improvement activities associated
with WelTel at XGNN. FEI is a provincial initiative supporting engagement between physicians
and health authorities, with the aim of improving the working environment and ultimately patient
care1.

Description of Setting
XGNN is one of two hospitals on Haida Gwaii located
in Daajing giids/Queen Charlotte, off the northwest
coast of British Columbia (see map). The new facility,
servicing 2600 patients, was opened in November
2016 and offers a full range of outpatient and
emergency care, in-hospital care (16 beds, 8 for long-
term care), and low-risk obstetrics. It is also a
Community Oncology Networked site with the BC
Cancer Agency, providing a full range of systemic
therapies for cancer patients.

1
For more information on FEI: http://sscbc.ca/physician-engagement/supporting-facility-based-physicians

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 Xaayda Gwaay Ngaaysdll Naay
3209 Oceanview Drive,
Queen Charlotte, B.C., V0T 1S0
Phone: 250-559-4900

It should be noted that cellphone use and reception is not ubiquitous on Haida Gwaii. Many
individuals in rural and remote B.C. still rely on landline phones or devices with WiFi connection
for communication. There is promise for greater connectivity on Haida Gwaii (Village of Port
Clements to see Telus connectivity in Spring 2019) and the North West.

At XGNN are 7 salaried physicians operating within 4 practices:

 Practice A: T Morton, C Shooner
 Practice B: G Horner
 Practice C: J Chrones, J Koopmans
 Practice D: T Pacholuk, S Van Osch

All practices at this site use an electronic medical record (EMR) known as Medical Office
Information System (MOIS). Each practice also has a Primary Care Assistant (PCA) with the
role of assisting the physicians with administrative duties. Their role in managing patient needs
via WelTel in conjunction with the practicing physician is evolving.

Description of Intervention
The WelTel platform is hosted via secure local server and meets all privacy and security
standards. Its impact on medication adherence and patient wellbeing has been assessed
through research in African and Canadian contexts2,3. Functions include system-generated
appointment reminders and check-ins delivered via text message, in which a patient receives
appointment details or the question, “How are things this week?”. Patients consenting to enrol in
the service can identify health concerns at any time, linking responses to a provider through the
web platform for triage
and advice (see image).

All conversations are

organized and archived
by date.

The platform sends out

weekly messages.
Responses are sorted
in the web interface for
providers to respond to
patients based on
need. Categories
includes:
- O.K.
- Not O.K.
- Unrecognized
- No Response

2
The Cedar Project WelTel mHealth intervention for HIV prevention in young Indigenous people who use illicit drugs:
study protocol for a randomized controlled trial. Available from:
https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-016-1250-3
3
Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a
randomised trial. Available from: https://www.sciencedirect.com/science/article/pii/S0140673610619976

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 Xaayda Gwaay Ngaaysdll Naay
3209 Oceanview Drive,
Queen Charlotte, B.C., V0T 1S0
Phone: 250-559-4900

Methods
The Project Manager, formally trained in evaluation & research, conducted the analysis.
Informal meetings with primary care providers and administration at XGNN guided the analysis
and outcome measures. Questions, data source(s), and outcome(s) are described in Table 1.
Findings were described at both the site level and the practice level.

Table 1. Questions and outcomes guiding QI project.

Question 1: Who used the service?

Data source: MOIS reports

 Age (average, range)
 Gender (M/F)
 Active, Inactive (attrition), Proxy Patients

Question 2: How did patients & providers use this service?

Data Source: WelTel conversational data

 Categories (deduced/induced) + counts
o DS – Data sharing & recording of patient results (e.g. blood glucose, pain scale)
o SAM – Symptom assessment & management
o AR – Appointment reminders
o RX – Prescription renewals & medication adjustments
o AS – Appointment scheduling
o O – Other (e.g. paperwork)

Question 3: What proportion of communication was eligible for provincial incentive payments?

Data Source: MOIS reports, incentive eligibility

 MOIS WT Encounters
 Response & non-response

Data sources included conversational data

stored in WelTel, as well as charted
information in MOIS (encounters,
demographics). An overview of conversational
data analysis is shown in Figure 1. During
analysis it became apparent that one
conversation may contain multiple types of
care and these instances within conversations
were accounted for.

Figure 1. Description of Analysis of Care

Conversation Data.

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 Xaayda Gwaay Ngaaysdll Naay
3209 Oceanview Drive,
Queen Charlotte, B.C., V0T 1S0
Phone: 250-559-4900

Results

Question 1: Who used this service?

Between April 2017 and August 2018, there were of 128 patients enrolled in WelTel. As of
August 13, 2018, 103 patients in Practices A through D were active (Table 2). At total of 25
patients texted “STOP” or asked a provider to remove them from the service (inactive). Inactive
patients are not fully removed from the system and can re-enroll at any time.

Table 2. Users of WelTel service at XGNN (Apr 2017 - Aug 2018).

Users Practice A Practice B Practice C Practice D TOTAL

# Active* 60 20 13 10 103
# Inactive 9 5 5 6 25
# Proxy Patients** 6 1 0 0 7

*Users are active if they were enrolled on final date of analysis (Aug 19, 2018).
**Proxy Patients - defined as individuals not enrolled in WelTel service that receives some form of care or health advice via a proxy (e.g. spouse or
next of kin). The proxy may be a primary caregiver or retains the only household cellphone.

Of the 128 users, 73% were female and 27% were male
(Figure 2, Table 4).
 Age: range = 16 – 84 years, median = 44
M  Male = 34, Female = 94
27%  Youth4 = 9

Users can act as a proxy for consenting patients in their

F household (proxy patients). These users are referred to as
73% proxies. There were a total of 7 proxies. The proxies were
either a parent (n=4) or spouse of the proxy patient (n=3).
Only one proxy was a male.

Proxy patients from practice A and B (N=7) had the following characteristics:
 Age: range = 13 – 67 years, median = 14
 Male = 4, Female = 3
 Youth = 4 or 57%

Table 3. Demographic information for users for all practices.

A B C D
Age Range 16 – 84 16 – 67 24 – 73 19 – 58
Median 46 41 45.5 34.5
Sex M 17 9 6 2
F 52 16 12 14

4
Youth ≤ 18 years of age

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 Xaayda Gwaay Ngaaysdll Naay
3209 Oceanview Drive,
Queen Charlotte, B.C., V0T 1S0
Phone: 250-559-4900

Informed by literature and practice, it was postulated that this modality of care would improve
patient management of chronic conditions in this particular population: cancer, hypertension
(HTN), chronic obstructive pulmonary disorder (COPD), congestive heart failure (CHF), and
diabetes mellitus (DM). However, voluntary enrollment in the service was open to all patients
and not contingent on a diagnosis of one or more of the chronic conditions of interest. There
were 50 diagnoses of these conditions among users (Table 3).
Table 4. Diagnosed chronic conditions of WelTel users.

Practice CA COPD CHF HTN DM Total*

A 3 1 5 15 12 36
B 0 0 0 3 2 5
C 0 0 1 3 2 6
D 0 0 0 1 2 3
3 1 6 22 18 50
*Total # of diagnoses ≠ # of users as many patients had more than one condition.
Abbreviations: CA = Cancer, COPD – Chronic Obstructive Pulmonary Disorder, CHF – Congested Heart Failure, HTN =
Hypertension, DM – Diabetes Mellitus, OTH = other diagnoses or no diagnoses

The number of users with one or more chronic condition was 39 (or 30.5%). A majority of users
(89 or 69.5%) did not have the diagnosed condition(s) of interest. Among WelTel users, HTN
and DM were most prevalent, with only 1 patient with COPD enrolled. There are 2600 active
patients at XGNN, with a total of 769 diagnoses of chronic conditions (HTN, CA, COPD, CHF, or
DM) (Table 5). Approximately 6.5% (50 out of 769) of diagnoses are captured in users of
WelTel.

Table 5. Diagnoses of WelTel users and patients at WelTel.

Diagnosis WelTel MOIS (Clinic) Total*

CA 3 124 121
COPD 1 83 82
CHF 6 43 39
HTN 22 350 328
DM 18 169 151
50 769 721

CA, COPD, CA, COPD, Over 17 months, the

7.0% 2.3% 6.0% 2.0% distribution of diagnoses
CHF,
9.3%
of these chronic
CHF, conditions at XGNN
DM, DM,
36.0% 12.0% (Figure 2) was similar to
39.5%
the distribution of users
registered in WelTel
(Figure 3).
HTN, HTN,
41.9% 44.0%

Figure 2. Chronic disease diagnoses Figure 3. Chronic disease

of 769 active patients at XGNN (Nov diagnoses of 50 WelTel users.
30 2018).
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 Xaayda Gwaay Ngaaysdll Naay
3209 Oceanview Drive,
Queen Charlotte, B.C., V0T 1S0
Phone: 250-559-4900

Mental health diagnoses (e.g. depression, bipolar disorder) were also captured and assessed
across the user population (n=29) for each practice:
 Practice A = 11
 Practice B = 8
 Practice C = 5
 Practice D = 5

Of the 128 users, 25 were inactive by the end of August 2018. Only 5 of the 25 inactive users
had a diagnosed chronic condition of interest. Reasons for attrition (inactive users = texting
“STOP” or asking to be removed from the system) included:
 Frustrations due to technical issues with sending/receiving messages;
 Acute care requirements were met and will reactivate for emerging needs;
 Felt uncomfortable receiving care via text and prefer other modalities;
 Expectations not met due to frequency of messaging (i.e. weekly);
 Texted “STOP” with no reason provided.
Question 2: How did patients & providers use this service?

There were a total of 6272 conversations5 between patients and providers between the weeks
of April 3 2017 and August 13 2018. A majority of responses were O.K., with 15% of
conversations requiring response (Figure 4).

Check-in Frequency & Type Over Time (Apr 2017 - Aug 2018)
600
# of Weekly Check-ins (monthly)

500

400

300

200

100

0
APR MAY JUN JUL AUG SEPT OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG
Total Check-Ins 43 140 294 448 340 338 460 387 402 520 430 410 513 414 409 518 206
O.K. 32 73 189 306 211 220 286 232 234 303 251 244 276 214 211 258 12
No Response 3 28 55 79 80 71 114 79 100 124 115 113 139 124 123 204 193
Care Conversation 8 39 50 63 49 47 60 76 68 93 64 53 98 76 75 56 1

Figure 4. Check-in Frequency & Type Over Time (Apr 2017 - Aug 2018).

5
Conversations – texts exchanged and sorted within one-week intervals in WelTel (Monday to Sunday).

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 Xaayda Gwaay Ngaaysdll Naay
3209 Oceanview Drive,
Queen Charlotte, B.C., V0T 1S0
Phone: 250-559-4900

Care conversations (defined as check-in’s requiring triage) were counted at weekly intervals.
Within a care conversation, there were multiple instances of care classified. Within 976 care
conversations, 1,063 instances of care were documented (Table 6).

Table 6. A Summary of the Instances of Care Provided to Active Users on WelTel (Apr 2017 - Aug 2018).

Practice A Practice B Practice C Practice D Total

Data Sharing (DS) 140 35 21 11 207
Symptom Assessment & Management (SAM) 195 48 28 26 297
Appointment Reminders (AR) 62 3 10 6 81
Prescription (RX) 98 20 5 7 130
Appointment Scheduling (AS) 137 29 30 33 229
O (OTH) 78 28 4 9 119
710 163 98 92 1,063

Definitions of each category and examples are provided in Table 8.

Question 3: What proportion of communication were charted and eligible for provincial
incentive payments?

All clinically important conversations in Weltel were copied into the patient health record, with a
unique identifying code “WT” created for purposes of auditing care provided via texting. There
were 664 WT encounters in MOIS. A WT encounter in the chart includes:
 Name of the person who communicated with the patient;
 Advice provided to the patient (communication/summary);
 Modality of communication (telephone or text);
 Confirmation that advice has been received.

Providing two-way medical advice via text message is billable as per the GP
Email/Text/Telephone Medical Advice Relay Incentive (G14078)6. It’s important to note that
providers at XGNN are remunerated as salaried employees and all but one practice are shared.
Nevertheless, the WT encounter can provide theoretical insights into billable instances of care in
accordance with G14078 eligibility criteria (Table 7).

Table 7. Theoretical WT Billable Encounters Documented in MOIS at XGNN.

Practice # of Total # of Eligible Services/Year Actual (WT) Billable Amount

Providers (WT)* Billed
A 2 400 428 400 $2,800.00
B 1 200 101 101 $707.00
C 2 400 84 84 $588.00
D 2 400 51 51 $357.00
Total 7 1400 664 636 $4452.00
*G14078 is payable at $7 per service, to a maximum of 200 per physician per calendar year. Assumed all WT
encounters within 1 calendar year.

6
GP Services Committee: Conferencing & Telephone Management Incentives, Revised January 2018.

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 Xaayda Gwaay Ngaaysdll Naay
3209 Oceanview Drive,
Queen Charlotte, B.C., V0T 1S0
Phone: 250-559-4900

Table 8. Definitions and Examples of Categories used in Conversational Analysis.

Category Definition Example

Data Sharing Data provided to patient and/or proxy patient at the

(DS) request of patients or prompted by provider. Includes OUTGOING: Your thyroid numbers are still high but MUCH improved. From 100, are now 24.1.
lab results or measures reported for self-management.

INCOMING: Pretty good just had back and chest pain I think that was from pulling up crab traps.
Includes health advice sought by the patient and
Symptom delivered by the provider that is specific to patient or OUTGOING: Are you still having chest pain?
Assessment & proxy patient needs and/or conditions (acute/chronic).
Management INCOMING: No it lasted for just over 24 hours.
(SAM)
OUTGOING: Hi xx, Can I call you to discuss the episode of chest pain you had? I'd like to get a little more
information.

Appointment Any reminder to patients that they have an SYSTEM: You have an upcoming appointment at January 10 at 02:30 pm
Reminder (AR) appointment at the clinic. Includes manual or
automated reminders.

INCOMING: Yes but I need a refill of my blood pressure medication

OUTGOING: The Bisoprolol?

Includes prescription refills and medication
Prescription adjustments. INCOMING : Yes please
(RX)
OUTGOING : Will refill for 3 months. Any possibility of popping in for a BP check at some point? Even
though we saw you, we haven't noted your BP since last Oct.

OUTGOING : Okay. Are you able to come to see Dr. Horner on call tomorrow? He has an opening at 3:30?
Appointment
Scheduling Includes clinic and specialist appointment requests. INCOMING : Yes, thank you
(AS)
OUTGOING : Great. I will book you in to see him tomorrow.

Other (O) Requests of hospital staff beyond medical care, but

are still duties of the healthcare system to complete INCOMING: Can you please send me dates and time of flu vaccine clinics
(e.g. requisition forms, clinic dates)

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 Xaayda Gwaay Ngaaysdll Naay
3209 Oceanview Drive,
Queen Charlotte, B.C., V0T 1S0
Phone: 250-559-4900

Discussion
Users

The initial hope for this service was to offer a new modality for chronic disease self-
management. However, enrollment did not just target patients with the conditions of interest, but
was open to all. A majority of those with the conditions of interest (HTN, COPD, CA, CHF, DM)
using this service have remained active. This could indicate satisfaction with the service, but
with this data we can only speculate user satisfaction and impact on health outcomes. Many
patients enrolled also had mental health diagnoses, and it may be worth exploring how this
platform assists the management of these conditions in particular.

Patients enrolled also used the service to proxy for family members, although the numbers were
small. Within NHA’s patient and family-centered care strategy, there is emphasis on including
patients and family members as equal partners alongside inter-professional teams in care
planning. Providers should consider that the provision of care via text message could involve
family members if proper consent is given. This option may be of primary interest to individuals
without access to a cellular device of their own or those who wish to assist their family members
with chronic or acute care needs at home.

Care Conversations

As more patients enrolled in the service, the total number of check-ins increased (Figure 2).
There is a very gradual linear relationship between total number of check-ins and the amount of
conversations requiring care. Whether enrollment was 45 patients or 128, the number of care
conversations was still fewer than O.K. and non-responses. Despite initial assumptions, the vast
majority of check-ins do not indicate a need for triage or medical advice. Alone, this data does
not fully capture impact on provider workflow, such as time spent triaging. However, it does help
to inform considerations among providers when designing appropriate implementation or scale-
up strategies.

Instances of Care

Symptoms assessment & management (SAM) and data sharing (DS) accounted for
approximately 47% of all instances of care. These are key components of chronic disease self-
management. SAM and DS through text are individualized and the two-way functionality offered
the patient or proxy the ability to ask questions for further clarification. DS with patients has
been done in innovative ways that extend beyond clinic visits or phone calls (e.g. online lab
results, medical devices that relay information directly to provider). These trends indicate that
bidirectional communication offers data sharing capability, using more ubiquitous technology
that patients are already familiar with.

Many instances of care were general advice, similar to the care one would receive from calling
the 8-1-1 Nurses Hotline. The providers would refer to 8-1-1 for after-hours assistance. This
could be of added benefit, improving awareness of related services through this modality.
Providers may wish to cite specific programs or integrate this information into broadcast
messages, all of which contribute to awareness, access, streamlining of services, and the health
literacy of the general public. It is not in the interest of providers to have scripted responses, but

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 Xaayda Gwaay Ngaaysdll Naay
3209 Oceanview Drive,
Queen Charlotte, B.C., V0T 1S0
Phone: 250-559-4900

“suggested responses” should be considered when training of providers in WelTel. This can
improve consistency, acceptability, and comfort levels for providers.

WelTel offers automated appointment reminders (AR) at various frequencies. As providers

became fluent with the system, they’ve increased the use of the reminder function. Some
patients have rescheduled their appointments after receiving reminders, opening up space in
the schedule for same-day emergencies.

Patients did ask for assistance with documentation (O) like requisition forms, or for assistance
navigating the health system (e.g. asking for clarification, names of providers, dates of visiting
specialists). These activities may be better suited for triage by a primary care assistant or
administrative positions. Based on the care model at XGNN, both providers and their assistants
can triage via text as appropriate. Adopting this approach at the clinic is in progress.

It’s important to note that while we can capture and quantify indicators that relate to improving
physical health, there are potential benefits, uses, and harms that are not so easily captured.
For example, one patient used the service much like a reflective journal, not seeking direct care
per se, but feeling a sense of security while using the service as their own therapeutic
intervention. Many patients also travelled and kept their primary care provider up-to-date on
their health status. This warrants further qualitative assessment. The diversity of users that
enrolled in the service supports both targeted enrollment to deliver specific types of care and the
merits of generalized enrollment. The diversity of need from the more generalized enrollment
showcased the ability for bidirectional communication to do more than what was predicted.

Charting & Billing

Charting all clinically relevant information in MOIS as a WT encounter avoided duplication of

records across platforms, was in accordance with best practices, and provided an auditing tool.
While text messages were sent/received/sorted in WelTel, triaging among providers is done
through alerts and flagging in MOIS.

Theoretical cost savings for fee-for-service physicians as per incentive billing seems prohibitive
if large numbers of patients are enrolled. For example, Practice A had the largest number of
patient users (n=69) and both providers in that practices have met their quota for billable
instances of care. Assessing cost-savings upstream (e.g. provider time, clinic or emergency
room visits avoided) may be more relevant.

Implementation Summary

Prior to launch in April 2017, a privacy impact assessment and a harmonized ethics review
through the University of British Columbia (UBC) were completed. The initial hope for this
platform was to conduct research, assessing effectiveness of the platform for chronic disease
management patients. The first iteration of use centred on our nurse practitioner managing all
incoming texts, responding or triaging for appointments as she felt appropriate. She enrolled
patients she felt suitable for texting, particularly youth and those with chronic mental health
needs. There was less interest for voluntary enrollment by patients with chronic diseases than
anticipated. The majority of patients currently active in Weltel were those she enrolled. Northern

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 Xaayda Gwaay Ngaaysdll Naay
3209 Oceanview Drive,
Queen Charlotte, B.C., V0T 1S0
Phone: 250-559-4900

Health supported this project by protecting time in her schedule for Weltel and for rapid-access
appointments she could schedule those needing urgent appointments.

With her departure at the mid-point of the pilot, the project lead (Dr. T Morton) took over primary
responsibility with the assistance by the clinic nursing team. Enrollment was halted as we trialed
different use case scenarios, with variable involvement of the nursing team, as most were
uncomfortable with the nature of care provided. In August, the provider alerted patients to a
temporary cessation of the service, picking up again at the end of summer (Figure 2). As the
other practices have observed its utility and benefit, there has been gradual evolution and
uptake on the part of the other physicians, such that 3 of the 4 practices (A, B, D) are now using
the platform to support care. Additionally, the primary care assistants of these practices are now
using Weltel for appointment scheduling and reminders, and for triage.

Successful implementation of WelTel at XGNN and understanding its use in primary care goes
beyond evaluating its use. A timeline providing an overview of past, present, and future activities
of various team members that have made considerable contributions to the launch and
sustainability of this service can be found in Table 9 of the appendix.

NHA Strategic Priorities

NHA’s Northern 5-Year Telehealth Plan emphasizes telephone and videoconferencing for live
direct interactions, as well as secure messaging to support team-based care. The two main
strategies of the plan are:
 Strategy 1: Use existing technology better
 Strategy 2: Create an enabling environment

Although their goals and strategies are not targeting mobile health (mHealth) patient-provider
interventions like WelTel, there is relevance (Table 10, Appendix). The evaluation of its
implementation as QI helps NHA to better understand barriers and enablers to use. Given the
lack of provincial policy around the use of mobile health digital health interventions in the
primary care setting, we consider this project as driving policy versus being policy-driven. This
project helps to foster enabling environments to expand Telehealth, and will contribute to the
rural and northern network of services.

Conclusion & Next Steps

Customizations to WelTel

Feedback from users informed changes to the platform that will improve its compatibility in this
context. The frequency of check-ins will be flexible, allowing the physician and patient to select
from daily, weekly, or monthly check-in options. There will also be an option for no check-ins,
suitable to patients uncomfortable with prompts or providers that may use this modality of
communication for care in other ways. Other functions that may be considered include the
videoconferencing capability between patient and provider.

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 Xaayda Gwaay Ngaaysdll Naay
3209 Oceanview Drive,
Queen Charlotte, B.C., V0T 1S0
Phone: 250-559-4900

Scale-up: Mills Memorial Hospital in Terrace, B.C.

In December 2018, Dr. D Jaworsky, Department of Internal Medicine, at Mills Memorial Hospital
in Terrace, B.C. will be using the platform to support patients on Hepatitis C or HIV treatment in
the northwest. The team at XGNN has provided support for this project. Dr. Jaworsky will be
using the next iteration of the WelTel platform as her implementation strategy requires the
flexible check-in options.

Phase 2: Research Activities

Quality improvement and research will better inform how this service impacts patient care.
The QI outcomes described in this report immediately inform the delivery of the service at
XGNN. In phase 2, more rigorous research will evaluate implementation and outcomes related
to patient care. Potential implementation and effectiveness research will be complementary,
emphasizing timely outcomes to improve site-specific delivery, while improving generalizability
of results:
 Dr. Morton is currently Primary Investigator (PI) of an effectiveness study approved by
NHA, FNHA, UBC, and community leadership. Recruitment is ongoing.
 Dr. R Lester (PI), co-founder of WelTel, and Dr. Morton are co-leads on an application to
Michael Smith Foundation for Health Research (MSFHR) Implementation Science Team
Program. They were awarded Phase 1 ($10,000.00) in September 2018 on a research
project to study the implementation and scale-up of the texting service in the northwest.
The deadline for Phase 2 is February 2019.
 Project Manager Alissa MacMullin (MPH) is a local research trainee engaged in both
projects as a Masters of Science student in Population and Public Health at UBC.

Questions or inquiries regarding this project and participation in future activities can be directed
at the Project Manager, Alissa MacMullin (alissa.macmullin@northernhealth.ca, 778-349-4219)
or Project Lead, Dr. Tracy Morton (tracy.morton@northernhealth.ca, 250-637-1846).

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 Xaayda Gwaay Ngaaysdll Naay
3209 Oceanview Drive,
Queen Charlotte, B.C., V0T 1S0
Phone: 250-559-4900

Appendix
Table 9. 2017-18 Timeline of Related Activities

2017  April 2017, launch of WelTel at XGNN following privacy impact assessment, operational approval,
& UBC Behavioural Ethics Approval.

 February 2018, Quality Forum conference, Vancouver (T Morton & Alissa MacMullin).

 June 2018, BCNPA conference, Nanaimo (L Corsie & D Duffy).

 August 2018, T Morton away. WelTel services stopped for 3 weeks, resuming week of Aug 20.

 September 2018, Michael Smith Foundation for Health Research (MSFHR) Implementation
Science Team Program Phase 1 grant was awarded to Primary Investigators Dr. Richard Lester
2018 of UBC mHealth Research Group and Dr. Tracy Morton for a research project to study the
implementation and scale-up of the texting service ($10,000.00).

 October 2018, WelTel finished customization of the platform to include variants of messaging
frequency (none, daily, weekly, monthly). Enrollment and care provision via WelTel expands to
include providers & PCAs from Practice B and D.

 December 2018, WelTel expands to include Denise Jaworsky (NHA Internal Medicine, Terrace)
Expansion a response to reviewers, pilot of WelTel within NHA beyond primary care providers
(specialists, NPs). Pilot data (April 2017 to August 2018) quality improvement analysis completed.

 Feb 2019, deadline for Phase 2 application for MSFHR ($500,000.00 over 3 years).
2019
 Spring 2019, TELUS connectivity for the Village of Port Clements, Haida Gwaii.

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Table 10. Aligning project activities with strategic priorities in the Northern 5-Year Telehealth Plan.
Goal 1: Make Telehealth Easier and
More Satisfying to Use
 Reduce barriers and workflow
disruptions and improve experience
of use for patients & providers
 Improve relationships among
interdisciplinary providers.
Strategy 1
Goal 2: Make Telehealth Easier to
Access
 Increase use among patients facing
barriers to accessing care
 Improve access to specialist and
sub-specialty care in remote and FN
communities

Goal 3: Make it easier to use, adopt, and
spread new tools and uses of Telehealth
 Develop reliable and adaptable
infrastructure and systems
 Create a better (well-known, easy to
use, and effective) pathway for
implementing and supporting new
uses and technologies
Strategy 2
Goal 4: Build a foundation for Telehealth
that works for the North
 Ensure that the Northern Telehealth
plan supports longitudinal care and
within that, optimal roles for primary
care providers and specialists
 Ensure Telehealth provides value by
assessing technology, risk,
processes and resource allocation
through the expanded triple-aim
lens.
 Ensure alignment of NH Telehealth
with policy and legislative
frameworks
Xaayda Gwaay Ngaaysdll Naay
3209 Oceanview Drive,
Queen Charlotte, B.C., V0T 1S0
Phone: 250-559-4900
Directly aligned with improving patient and provider use
and fluency of health technology.
May improve access to care from providers.
Offers providers another method to contact and care for
their patients that can save time and cost to health system.
Has engaged nurses, NPs, GPs, assistants, &
administrators at the site. FE initiative improves
accountability to provincial representatives and NHA.
Useful to a wide range of patients to improve access.
Will be trialed by Denise Jaworsky in Internal Medicine
(NW, NHA) to determine its use for specialist care.
Patients in remote and FN communities are engaged.
Privacy impact assessment assists decision-making for
similar technologies and their integration.
Implementation science (IS) research can identify context-
specific barriers and enablers, as well as culturally safe
pathways for scale-up, using validated IS frameworks.
Broader generalizability if trialed by NPs, GPs, and
Specialists in the region.
Technology is not limited to a single EMR or setting. It’s
non-profit and research affiliations assist in improving its
design and compatibility in Canadian primary care context.
A grassroots approach championed by GP that informs
Telehealth plan and requires minimal current financial
investment by NHA.
Usefulness extends beyond primary care providers to
specialists and clinics.
Aligns with triple health aim framework (health of
populations, patient experience, and reducing cost to
system).
Informs policy and decision-making. Alignment of its use to
national, provincial, regional, & local strategies.
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