Telehealth networks have become well-established everywhere from rural Montana to the Australian Outback during the past decade. The foundation of telehealth is videoconferencing technology that allows clinicians to contact sick or injured patients across long distances.

The Northern Ontario Remote Telecommunication Health (NORTH) Network has expanded telehealth beyond its videoconferencing origins. The organization operates an IP-based digital system. The system can deliver a range of services to clinicians and their patients throughout the Canadian province, which is larger than France and Spain combined.

Jonathan Linkous, executive director of the American Telemedicine Association, said the NORTH Network is a telehealth innovator and well ahead of similar U.S. networks. It not only operates one of the most active telehealth networks in North America, Linkous said, but also one of the most diverse. In addition to doctor/patient videoconferencing, the network supports electronic health records (EHRs) and a provincewide diagnostic imagery system.

Ontario's geography forces medical care to be either costly or innovative. The province has 12 million people in 415,000 square miles. In comparison, France and Spain are home to about 100 million people.

Prior to the launch of the NORTH Network in 1998, Ontario spent $20 million on air ambulance services. Although air ambulances solve the distance problem, they don't address the delivery of time-critical medical care, such as the NORTH Network's Telestroke service, which telehealth networks can provide.

Dr. Edward Brown, executive director of the NORTH Network, said stroke victims need treatment within hours to alleviate blood clots in their brains.

But medical personnel can administer the anticlotting drug only after consulting a neurologist. "If you give the wrong person this drug, it can be dangerous" because of the potential for hemorrhages, Brown said.

Emergency physicians in North Bay and Sudbury use the Telestroke service to contact neurologists at hospitals in Toronto, which is about 250 miles south of those two Ontario cities. But the network provides more than long-distance consultations, Brown said.

Remote neurologists can receive CAT scans and view them during a videoconference with emergency room physicians.

If an off-hours consultation is necessary, Brown said, neurologists can connect to the network at home. He said that without access to the telestroke service, patients and clinicians in distant areas would not be able to easily obtain the life-saving clot-busting drug.

The NORTH Network handles other diagnostic imagery, too, Brown said. The network is one of the largest Picture Archiving and Communications Systems that support filmless radiography and connect doctors in remote communities with radiologists in metropolitan hospitals, he said.

The network serves 190 locations in Ontario. The organization upgraded to IP from an ISDN-based network in 2002. Network connections to many of those locations run at speeds of 1 megabit/sec, while some of the smaller, remote locations have 400 kilobits/sec connections, said Ron Riesenbach, the NORTH Network's chief information officer.

Riesenbach said the 400 kilobits/
sec rate is good enough to support diagnostic imagery applications, although it could take 15 minutes for an X-ray to be transformed. But that's still faster "than putting film in an air courier pouch."

Brown said the switch from ISDN to IP has given the NORTH Network the flexibility to support primary care nurse practitioners, EHRs and home health care.

Remote consultations account for the bulk of the NORTH Network traffic. The network supported 25,000 consultations in May, with a 100 percent annual growth rate. The NORTH Network serves 1,300 family physicians and 750 specialists who work in more than 80 fields and connect to more than 150 hospitals.

Riesenbach said the switch from ISDN to IP has cut costs and increased the network's usefulness. Brantz Myers, director of enterprise marketing at Cisco Systems Canada, which supplied much of the NORTH Network's infrastructure, agreed. An IP-based system produces much lower network costs, Myers said. IP networks also easily support encrypted transmissions, which are essential for health care networks, he added.

IP-based networks are also easier to manage and monitor, Riesenbach said. Monitoring tools allow network managers to zoom in and check the health of devices on the network, including the equipment that supports videoconferencing.

The NORTH Network developed its Telehealth Service Manager program in-house to manage the system's registration and scheduling, Riesenbach said. This Web-based application is already on its second generation, he said.

Using the network and those tools, the NORTH Network can provide big-city medical care to people living in some of the most remote parts of North America, Brown said. The network has lowered the cost of patient and physician travel and introduced new services that ensure quality health care, Brown said.