The potential of telemedicine: barriers, incentives and possibilities in the implementation phase

Between 1998 and 1999, the Swedish Institute for Health Services Development (Spri) evaluated three applications in which specialist competence was being accessed via telemedicine. The results indicated that these kinds of application can be cost-effective in an organization well adapted to new technology and that telemedicine can improve continuity of care for patients. However, the new technology was seldom supported by the old organization and better education and technical support are needed. In a study called 'Incentives and Implementation', the Federation of Swedish County Councils interviewed people in Swedish health-care with a lot of experience of telemedicine. The interviewees agreed that telemedicine was likely to affect the whole structure of health-care. Peripheral competence was expected to increase and referral patterns to change, as well as the functions of the personnel and the hospitals. New working conditions and methods of work were expected to be made possible by telemedicine and health-care was expected to become more process oriented, partly because patients are likely to be more demanding and better informed. To be able to utilize this potential, health-care managers will have to show more interest in and commitment to telemedicine. Old organizational patterns must be called into question and be developed along with information technology and telemedicine. It is also important to give priority to training in telemedicine for physicians and nurses.     

The future of telemedicine--take the organizational challenge!

Implementation of telemedicine has not been as rapid as was expected in the 1990s. Diffusion of technologies can be complex and is known to be influenced by many factors. Organizational problems are crucial for the future of telemedicine, but have been gravely underestimated. When a telemedicine service is established we have a virtual organization. Internal organizational consequences of telemedicine are very common and more effective use of the technology is likely to require organizational changes. For different applications of the technology there are similarities, and differences, in internal organizational consequences. Organizational matters connected with telemedicine are dealt with in a new book, The Organizational Challenge for Health Care from Telemedicine and E-health, the full text of which is available via the Internet. In the book, solutions are outlined for common organizational problems in telemedicine. Managers must actively lead organizational changes. Replacing simplified optimism with realism may be very important for the future of telemedicine.     

Organizational readiness for telemedicine: implications for success and failure

The use of telemedicine brings about change in health-care organizations and opens up new possibilities for service delivery. The organizational environment is often crucial in determining whether or not telemedicine applications will be successful. To examine the concept of 'organizational readiness for telemedicine' as a factor to explain why telemedicine initiatives succeed or fail, the results were used of interviews with key informants, conducted in two studies: the Alliance for Building Capacity project and the National Initiative for Telehealth guidelines project. The data indicate that organizational readiness for telemedicine is a multifaceted concept that is related to planning and the workplace environment. A greater understanding of the factors within organizational readiness could help to avoid costly implementation errors. 'Readiness' needs to be systematically assessed and is important for long-term success.     

Learning in organizations working with telemedicine

To investigate learning in telemedicine, qualitative interviews were conducted with 30 people working with telepsychiatry, teledermatology, a telepathology frozen-section service and tele-otolaryngology. More than 80% of the respondents said that they had learnt something new by using telemedicine. Most frequently the participants improved their knowledge of the specialty in which they were involved, but this was not the only way in which they learnt. The learning did not necessarily change behaviour, as two-thirds of the respondents felt that the learning had not permitted them to perform tasks for which they had previously needed assistance (although this varied somewhat with the type of telemedical work that respondents were engaged in). Two-thirds of respondents thought that something more could be done in telemedical work to promote their own learning, which shows the clear potential for learning by telemedicine. Learning could be promoted further by extending the use of the technology to other applications. To start working with telemedicine, initial instruction seems to be sufficient--a more extensive training programme appears unnecessary. In future, as many applications of telemedicine are implemented, health-care organizations may become important arenas for learning and leaders will have to focus on learning. The results of the present study clearly showed that working with telemedicine produces learning.     

Implementation of telemedicine: the problem of evaluation

In the UK, few telemedicine applications have endured beyond the trial phase. It is commonly said that lack of evidence is responsible for the lack of implementation. This assumes that evidence will lead to implementation. Studies show that this is naive, especially in organizations like health-care systems, which are characterized by professional dominance. Furthermore, other research indicates that the nature of the changes experienced by clinicians in telemedicine experiments is sometimes limiting compared with conventional practice. This presents a dilemma for evaluation since it cannot reliably take place until a particular technique has become stable and accepted into the daily routine. A programme of selected case studies is recommended to develop knowledge of how telemedicine can become a taken-for-granted part of medical care.     

Legal issues relating to telemedicine in Canada's publicly funded health-care system

The advent of telemedicine poses new legal challenges for Canada's health-care system. Although telemedicine increases access, it does not fit easily into Canada's traditional one-tier approach to health-care. Cross-border telemedicine services may inadvertently contribute to a two-tier system. The current legal system will have to be adapted to accommodate changes instigated by cross-border telemedicine.     

Transaction costs economics as a conceptual framework for the analysis of barriers to the diffusion of telemedicine

Telemedecine has been talked about for more than 20 years, without it entering daily use with any success. Based on transaction costs economics, the present analysis of the exchange relationships between health care producers highlights certain characteristics of the current technical and legislative context, which leads to transaction costs. It also demonstrates that the introduction of telemedicine shifts the costs associated with agents' opportunism from patients to health-care producers themselves. All these costs may be considered nowadays to thwart the use of telemedicine. It is argued here that the Public Authorities and professionals of health care could act upon telemedicine in two fields: (1) intervention in the institutional environment aims notably at better defining the property rights of telemedicine, and so constitutes an unavoidable means of encouraging health-care producers to invest in new technology; and (2) implementation of organisational forms and mechanisms susceptible to regulating such telemedical relationships between health care producers-given the present institutional environment-constitutes an essential means for overcoming the immediate barriers blocking the diffusion of telemedicine.     

Human factors considerations in implementing telemedicine systems to accommodate older adults

The number of older adults is increasing, and telemedicine has the potential to improve their access to health care. Telemedicine systems have been shown to benefit older adults by increasing peer support interactions, providing health-care access to older adults in rural communities, reducing the cost of health care, increasing exercise, reducing pain and depression, and, perhaps most important, improving functional independence. However, older adults may have different needs from other users when interacting with telemedicine systems, because of age-related changes in perceptual, motor and cognitive abilities. The design of telemedicine technologies should, therefore, capitalize on older adults' strengths while minimizing their weaknesses. The field of human factors has much to offer in optimizing interactions between older adults and telemedicine technologies. Future research should take advantage of human factors methodologies to best design telemedicine technologies for an older population.     

The potential for telemedicine and telecare in Deptford

We carried out a study to explore the potential of telemedicine and telecare to improve health-care for the population served by a health centre based in Deptford in south-east London. A wide range of potentially useful telemedicine and telecare applications was identified, nine of which could provide some immediate benefit. Other requiring new approaches to the delivery of care involved some reengineering of services. Some suggestions focused on the need to integrate information technology with service provision. Other suggestions raised strategic questions, the most important of which concerned the routes of access to health-care.     

Telemedicine in the work site: a study of feasibility, and patient and provider satisfaction

We examined the use of telemedicine for improving access to care in a work-site clinic. A prospective study of 100 patients was conducted over a four-month period in a work site that housed 700 employees. Sinusitis (10 visits), upper respiratory tract infections (9 visits), otitis media (9 visits), hypertension (9 visits) and back pain (8 visits) were the most common reasons for the visits. In 99 visits, clinicians were of the opinion that the telemedicine visit felt similar to a face-to-face visit. For most of the visits (67), patients strongly agreed or agreed that telemedicine had a positive effect on their relationship with the health-care provider. The otoscope, microscope and stethoscope telemedicine peripherals were important in aiding diagnosis (and ruling out other causes) in about 55% of the visits (upper respiratory tract infection, sinusitis, otitis media, cough, sore throat, nevi, rhinitis and ear wax related concerns). The ability for the patient to watch their ENT examination and see any associated abnormalities was appreciated by many patients. Physicians, nurses and patients were capable of using the technology with little training.     

Organizational and environmental factors affecting the utilization of telemedicine in rural home healthcare

In the last five years, home health agencies have become increasingly interested in telemedicine as a potential means to meet the future healthcare needs of their aged and chronically ill clientele. This case study examines the organizational and environmental conditions that affected the implementation of a telemedicine program in one rural home healthcare organization. Several factors restricted the utilization of telemedicine, including Medicare's Prospective Payment System and corresponding documentation (Outcome Assessment and Information Set), the organization controlling grant funding for the program, and several environmental factors. Findings suggest that in rural communities, older homecare patients may have less opportunity to benefit from telemedicine. The study demonstrates the importance of environmental and organizational factors when implementing a telemedicine program. Recommendations are offered for home healthcare organizations considering development of telemedicine programs.     

Putting the 'tele' into health-care effectively

Although the introduction of new technologies has been successful and become accepted practice in many areas of industry, traditional methods have tended to prevail in health-care. Telemedicine has been adopted by enthusiasts who recognize the potential benefits of a 'global health service'. However, the more widespread introduction of telemedicine requires considerable organizational change in the way health-care is delivered. More evaluation is required of clinical outcomes, organizational effects, benefits to health-care providers and users, and quality assurance.     

Benefits and drawbacks of telemedicine

Telemedicine is a vast subject, but as yet there are limited data on the clinical effectiveness and cost-effectiveness of most telemedicine applications. As a result, objective information about the benefits and drawbacks of telemedicine is limited. This review is therefore based mainly on preliminary results, opinions and predictions. Many potential benefits of telemedicine can be envisaged, including: improved access to information; provision of care not previously deliverable; improved access to services and increasing care delivery; improved professional education; quality control of screening programmes; and reduced health-care costs. Although telemedicine clearly has a wide range of potential benefits, it also has some disadvantages. The main ones that can be envisaged are: a breakdown in the relationship between health professional and patient; a breakdown in the relationship between health professionals; issues concerning the quality of health information; and organizational and bureaucratic difficulties. On balance, the benefits of telemedicine are substantial, assuming that more research will reduce or eliminate the obvious drawbacks.     

Telemedicine in the future

Telemedicine can provide a compelling alternative to conventional acute, chronic and preventive care, and can improve clinical outcomes. In the industrialized world, it is likely that telemedicine will continue to move healthcare delivery from the hospital or clinic into the home. In the developing world or in regions with limited infrastructure, telemedicine will mainly be used in applications that link providers based at health centres, referral hospitals and tertiary centres. The future of telemedicine will depend on: (1) human factors, (2) economics and (3) technology. Behaviours related to technology affect change at the individual, organizational and societal level. Personnel shortages and decreasing third-party reimbursement are significant drivers of technology-enabled health care in the industrialized world, particularly in the areas of home care and self-care. We can safely assume that developments in mobile communications, sensor devices and nanotechnology will alter the way that health care is delivered in the future. The growth and integration of information and communication technologies into health-care delivery holds great potential for patients, providers and payers in health systems of the future. Perhaps the most difficult question to answer, however, is 'When will telemedicine become part of the standard of care?'     

Impact of IT on health care professionals: changes in work and the productivity paradox.

Health care organizations are under increasing pressure to become more efficient while at the same time maintaining or improving the quality of care. Information technology (IT), with its potential to increase efficiency, accuracy and accessibility of information, has been expected to play an important role in supporting these changes. We report the impact of patient care information systems on health care professionals in five community hospitals. The study framework incorporated both quality of care in Donabedian's elements of structure-process-outcome and Grusec's three levels of IT impact: direct substitution, proceduralization and new capabilities. The study results suggest that, for specific tasks, IT increased efficiency and productivity--a single employee was able to complete more tasks. However, this produced other consequences not predicted. Participants noted this change did not 'free up time' to spend with patients, but meant there were potentially more opportunities to provide services and more tasks to complete. Other effects included: reduced job satisfaction as more time was spent on the computer; less frequent interactions with patients and for shorter duration; and an increasingly 'visible' accountability as performance was easily monitored. There were also changes in roles and responsibilities as the computer enabled tasks to be carried out from a number of locations and by a variety of personnel. When innovations are introduced into organizations there are both expected and unexpected consequences. Increased awareness of the interactive relationship between computer users and the technology helps organizations better understand why results do, or do not, occur. One must look beyond just simply increasing productivity by replacing manual tasks with automated ones, to examining how the changes influence the nature of work and relationships within the organization.     

School-based telemedicine: teachers', nurses' and administrators' perceptions

In 1997, a telemedicine project began in Kansas which brought health-care directly into elementary schools using interactive video-links. The project initially involved four schools, but was expanded to cover 10 schools, including two middle and one high school. We examined the organizational issues related to telemedicine links to schools. Specific attention was paid to the perceptions of the nurses, teachers and key administrators. The research involved analysing archive data and interviewing participants in the project from the schools and the medical centre. The results showed the difficulties in delivering health-care, especially by telemedicine, to under-served urban children. However, the data also revealed that these can be overcome. Once they had experienced it at first hand, almost all concerned began to see telemedicine as an effective and important asset to the delivery of health-care.     

An evaluation of satisfaction with telemedicine among health-care professionals

A survey was conducted among non-doctor health-care professionals in six rural counties in Missouri. The purpose of the survey was to establish baseline data to evaluate the effect of changes in the health-care sector, especially technology changes, on the job satisfaction, career satisfaction, relationships and communication activities of health professionals. The survey included three rural counties in which integrated telecommunication and interactive video telemedicine services were being installed, but before significant activities had begun, and three comparator counties without substantial integrated telecommunications infrastructure and telemedicine services. During a one-month study period, 1108 questionnaires were distributed. The total response rate was 50.1% (n = 555). Of the respondents, 30.3% indicated that technology in health-care was having a large effect on their work, although only 18.2% indicated that telemedicine and telecommunications were having a large effect. No systematic differences were found among the health professionals in the two communities at the time telemedicine equipment was being installed.     

A systematic review of the methodology of telemedicine evaluation in patients with postural and movement disorders

We reviewed the methodology used in telemedicine research concerning patients with postural and movement disorders. Literature searches were performed using various computerized databases through to October 2005. Twenty-two studies met the criteria for review. Two broad models of telemedicine delivery were represented in the literature: (1) telemedicine between health-care professionals at each telemedicine site (n=16) and (2) telemedicine between health-care professionals and a patient at a remote site (n=6). Disparate research methodologies were used to investigate these two models. Most studies were limited to investigating the technical feasibility and acceptability of a telemedicine service rather than focusing on the overall effect of introducing the telemedicine service into routine health care. Nonetheless, it is possible to conclude that telemedicine is acceptable for both patients and professionals when used in rehabilitation. Since the two models of telemedicine evaluation tend to explore different outcomes (diagnostic accuracy versus health status), it is recommended that separate methodologies should be used. In contrast to evaluations of telemedicine model 2, randomized controlled trials appear to be less valuable for telemedicine model 1.     

Can managed health care help manage health care-associated infections?

Managed-care organizations have a unique opportunity, still largely unrealized, to collaborate with health-care providers and epidemiologists to prevent health care-associated infections. Several attributes make these organizations logical collaborators for infection control programs: they have responsibility for defined populations of enrollees and for their overall health, including preventive care; they possess unique data resources about their members and their care; and they are able to make systemwide changes in care. Health care-associated infections merit the attention and effort of managed-care organizations because these infections are common, incur substantial illness and costs, and can be effectively prevented by using methods that are unevenly applied in different health-care settings. Both national and local discussions will be required to enable the most effective and efficient collaborations between managed care organizations and health-care epidemiologists. It will be important to articulate clear goals and standards that can be readily understood and widely adopted.