Successful Models for Telehealth




Telemedicine and telehealth programs are generally more complex than their traditional on-site health care delivery counterparts. A few organizations have developed sustainable, multispecialty telemedicine programs, but single service programs, such as teleradiology and teledermatology, are common. Planning and maintaining a successful telemedicine program is challenging, and there are often barriers to developing sustainable telehealth programs. This article reviews some important aspects of developing a telehealth program, and provides two examples of currently operating successful model programs.








  • Telehealth facilitates continuing professional development and knowledge exchange across large distances and in hard-to-access locations, and is ideal for targeting international audiences and allowing health care professionals to share knowledge face to face without constraints of geography.



  • Planning and maintaining a successful a telemedicine program is challenging, and there are often barriers to developing sustainable telehealth programs.



  • The key to success of any telemedicine program is training and education.



  • Evaluation is core to the success of any telemedicine program—not only understanding benefits and limitations of technology, but how components work together as a whole system in conjunction with the user.



  • There is no single business model that will work for every program, but there are models for analyzing the costs and benefits of conducting telemedicine that are useful.



Key Points: S uccessful T elehealth M odels


Successful telemedicine programs that went beyond demonstration and pilot project efforts started appearing in the United States in the late 1980s and early 1990s, and many of them are still providing valuable services to a variety of patient populations. In the early days of telemedicine, the focus was mainly on providing services to rural or remote populations, and environments with special needs such as prison populations. Today telemedicine is much more far reaching and there has been substantial growth in areas such as urban, school, occupational, first-responder, and home telemedicine activities. It is impossible to review all of the successful telemedicine activities occurring today because they are extensive and varied. Instead, the authors present brief summaries of two very successful telemedicine programs that can serve as models for those interested in developing a new program or those with existing programs looking for ways to improve sustainability and increase their outreach.


When establishing a successful telemedicine program, it is important and useful to consider what others have accomplished and what precedents have been set. In particular, there have been significant efforts in recent years to establish standards and guidelines for telemedicine practices. Some of these are more technical in nature, describing the type of equipment that should be used and what the minimum performance standards are, whereas others are practice guidelines detailing how specific types of evaluations and examinations should be conducted in the telemedicine environment. For example, radiology has several technical and practice guidelines in place for digital image acquisition, storage, transfer, and display via Picture Archiving and Communications Systems (PACS) and teleradiology ; and the Society of American Gastrointestinal and Endoscopic Surgeons has guidelines for the surgical practice of telemedicine. The American Telemedicine Association has made significant progress in establishing both general guidelines for the practice of telemedicine and practice guidelines for specific clinical specialties. Although to date there are no established practice guidelines for teleotolaryngology, there have been some successful projects that can serve as practice models.


The arizona telemedicine program


The Arizona Telemedicine Program (ATP), funded by state funding and grants, was established in May 1997 to enhance health care delivery to medically underserved populations throughout the state using telemedicine technologies. The program was founded on 8 core policies, key of which were:




  • Creation of a single state-wide multiservice telemedicine program



  • Provide access to the program’s telecommunications infrastructure for all legitimate health care organizations in the state



  • Encourage the development of interoperability of all telemedicine facilities



  • Develop an open staff model for participation of physicians as service providers for multiple health care organizations



  • Promote best practice guidelines that are evidence-based and supported by clinical research



  • Operate the program as a virtual organization that would be inclusive and create incentives for all health care organizations to participate in a state-wide single telemedicine program.



At its formation, the founders of the program recognized that to be successful it would have to do more than simply offer teleconsultation services; the program would have to be a comprehensive entity that provided infrastructure, clinical services, training, and professional education ( Fig. 1 ). In terms of infrastructure, the ATP operates a private broad-band telecommunications network, the Arizona Telemedicine Network (ATN), which links more than 170 sites in more than 70 communities across the state. The network serves as an umbrella organization for 55 independent health care organizations located in such diverse settings as academic hospitals, community health centers, Indian Health Service facilities, the Department of Corrections, schools, and even patient’s homes.




Fig. 1


Components of a comprehensive telemedicine program.


Telehealth services have been offered in more than 60 clinical subspecialties, with teleradiology serving as the core service to approximately 25 hospitals and having conducted more than 1 million primary reads! The other subspecialties use both real-time videoconferencing (VTC) and store-and-forward technologies; at the hub site alone more than 15,000 teleconsultations have been conducted, with telepsychiatry as the main real-time application and teledermatology as the main store-and-forward application. In addition, more than 25,000 teleconsults have been conducted in the Department of Corrections since 1997, and it is estimated that 80% of the specialty consultations for the Arizona Department of Corrections are delivered directly into the prisons by telemedicine, thus avoiding tens of thousands of miles of travel by guarded prisoners every year. As an open service model, the ATN also connects non-ATP telehealth networks throughout the state; this includes several affiliated telepsychiatry networks in Arizona that have conducted more than 50,000 telepsychiatry patient sessions to date.


The key to success of any telemedicine program is training and education. Although telemedicine is really just another mode of health care delivery, there are some very unique aspects to it that must be considered. For example, not only must the users have some basic technological skills to effectively use the specialized equipment used in telemedicine ( Fig. 2 ), they also need to understand the limitations and benefits of those new technologies in terms of providing clinical information to the relevant users who need to render diagnostic decisions based on the data provided by those technologies. There are also “social” issues of which users need to be aware: how does one establish rapport with a patient over video, where should one look during a VTC consult to make eye contact (at the camera or at the monitor?), and do different cultures view teleservices differently (eg, Native Americans)? In addition, the authors have found that in many rural sites the turnover in health care personnel is very high, affecting the consistency with which services can be offered.




Fig. 2


A electronic stethoscope. Most health care providers new to telemedicine will not be familiar with the electronic stethoscope in terms of its operation or subtle differences compared with the traditional stethoscope, so hands-on training sessions include familiarization with these types of specialized technologies.


Training Programs for Telehealth Services


To combat this problem, the ATP offers bimonthly training programs with two options. The first provides an overview of telemedicine, covering everything from business aspects to technology. The second focuses on clinical applications. Both provide hands-on opportunities for participants to interact and use various telemedicine technologies and equipment. The training is free to individuals associated with Arizona programs and charges a nominal fee to out-of-state and international participants, contributing to the sustainability of the program overall. To maintain the lessons learned in these training sessions, the ATP also offers on-site follow-up training once a site acquires and installs its equipment, so that the users can familiarize themselves with the technology in the environment in which it will be used. Users are encouraged to renew their training on a regular basis to not only refresh their basic skills, but also to keep abreast of any changes in technology and practice standards and guidelines.


The ATP also provides approximately 500 hours annually of interactive continuing medical education and continuing education to participants in remote locations in Arizona and New Mexico using bidirectional video. Participants, who would normally be required to take costly trips, spending valuable time away from their practices to meet their annual educational requirements for licensure, are able to meet or exceed their requirement by participating in grand rounds from their own location, at their convenience, free of charge. Offerings across the network over the years have included grand rounds in ATP Clinical Care, Medicine, Psychiatry, Nursing, Geriatrics, Surgery, OBGYN, Pediatrics, Integrative Medicine, Public Health, Arizona Public Health Preparedness, and Informatics ( Fig. 3 ). Although these offerings do not provide income to the program, they do “advertise” the capabilities of telemedicine and the ATP to health care providers across the state, and often this is the first introduction to telemedicine that many providers have.




Fig. 3


Typical continuing education session conducted remotely over a telemedicine network. The audience is in the foreground and the guest lecturer (from Panama in this case) is seen on the monitor at the back. The lecture material can be displayed through a separate channel on the screen to the left of the video monitor for simultaneous viewing of the material and the speakers.


Evaluation of Telehealth Programs


Evaluation is key to the success of any telemedicine program. Not only is it important to understand the benefits and limitations of the individual pieces of technology to be used in telehealth consultations, but it is important also to understand how the various components work together as a whole system. One factor that many evaluations fail to take into account when doing evaluations in telemedicine is the user. Human factors in telemedicine applications are increasingly being recognized as an important evaluation parameter, but it is still a relatively forgotten component of the telemedicine encounter.


Aside from evaluating the technology and general practice of telemedicine, it is important for a successful program to assess itself on a periodic basis. There are no set methods to carry out such evaluations, but tools exist that can be modified or adapted to particular situations. Some of the basic information that can be tracked to assess program progress includes number of consults per month, number of real-time versus store-and-forward consults, referring and consulting sites, referring and consulting clinicians, case subspecialty, patient demographics (age, gender, major complaint), primary diagnosis, and primary recommendation. These key variables can be tracked and over time can provide a global picture about the status of a program, changes in case types and case loads, types of services being requested, and so forth. Keeping track of this type of information helps with program sustainability in the sense that it allows for better and more efficient staffing as well as more efficient use of services and personnel, and allows a program to make changes if significant trends in service loads and specialties are observed.


Skills of Telemedicine Staff


One of the challenges in sustaining a telemedicine program is not only having a core champion to promote the concept, but having the right people to support that concept and make the everyday running of the program efficient and effective. One of the ways to succeed in this is to have a set of established job descriptions for the key personnel of the program. For example, the job description for an ATP Rural Site Coordinator specifies that he or she must have experience of working in a medical practice environment including patient scheduling, and must have the ability to establish priorities according to preestablished policies and guidelines. The Coordinator also must possess good interpersonal skills and be comfortable in patient care settings, understanding the implications of patient confidentiality and privacy issues. He or she must have strong organizational skills and the ability to work with other health care providers, and have strong data-handling abilities. His or her responsibilities include: operating and maintaining telemedicine equipment; assisting the rural practitioner during the consult; collecting necessary transaction data including patient demographics and record information; participating in user group forums; collaborating in the development of protocols; overseeing integration of rotating medical students and residents in teleconsultation sessions; and working with the Evaluator to collect relevant assessment data. In addition, each job description indicates the chain of responsibility and who each person reports to.


Business and Operational Models for Telemedicine


The final key to success and sustainability of any telemedicine program is its business model. There is no single business model that will work for every program because every program offers different services, operates in different environments, and is reliant on different amounts of external funding (eg, grants). There are, however, several publications detailing several business models and/or analyzing the costs and benefits of conducting telemedicine. The ATP has developed a virtual organization connecting organizations throughout the state of Arizona. It uses a membership formalized through legal contracts in a shared-cost model to capitalize on economies of scale (an application services model or ASP) by sharing services at lower costs. Sharing services across multiple health care organizations can contribute to success and sustainability. Fig. 4 shows the basic components of the ATP ASP business model.




Fig. 4


The membership/business model for the Arizona Telemedicine Program.


In Fig. 4 , each layer supports the layer(s) on top of it. The vendor services layer represents the physical infrastructure of the network (eg, leased T-1 and T-3 telecommunications lines). The infrastructure layer contains the actual telecommunications infrastructure once installed. This layer represents services that support the basic ATP structure including telecommunications, marketing services, funding support, and grant writing. It is the foundation of the program and is the core of what all clients obtain when they become a member. The operational services layer includes the daily operations: clinic operations, equipment installation, practice management, training, transcription, billing, and reimbursement.


The operational services level includes actual services supported by or supplied by the program, including health care provider services, clinical protocol development, continuing education, quality assurance and quality control, credentialing, licensing, and legal. Finally comes the client layer; clients can be patients, payers, or businesses that use the various services supported by the program. Once members, the clients can choose (and pay for) those services they want. For example, an organization may choose to use the clinical services for teleconsultations but may have no need for distance education services, so they pay only for one and not the other. In this way the model is very flexible and clients need to purchase only those services in which they are interested. It also allows clients to maintain their traditional patient referral patterns. Clients may choose to purchase, for example, access to the telecommunications infrastructure but not the clinical services operated by the ATP hub site. Instead, with the telecommunications link they can connect to their existing specialty-referring site if it is on the network. Thus, the ATP model is referred to as an open network whereby individual sites can connect with each other rather than with a central hub facility only. This membership-based ASP business model has provided a steady revenue stream for the program which, when combined with revenue from clinical services reimbursement and external funding for equipment upgrades and special projects, has contributed to the sustainability of the program for nearly 15 years.




Baycrest telehealth program


Health care is a common language of need that transcends culture, religion, and nationality, and is vital to the advancement of any society. One of the limiting factors influencing health care delivery worldwide, but particularly in the developing world, is the availability of skilled professionals to serve society in meeting its health needs and goals. Telehealth, a developing medium that facilitates continuing professional development and knowledge exchange across large distances and in hard-to-access locations, is ideal for targeting international audiences and allowing health care professionals to share knowledge face to face without constraints of geography.


Accordingly, the Peter A. Silverman Global eHealth Program (PASGeP) was established in 2005 to create an international telehealth network with Canadian, Israeli, Jordanian, and Palestinian sites. A major goal was to help build bridges to peace in the Middle East through health care initiatives, building on the pioneering work of the Canada International Scientific Exchange Program (CISEPO) and its accomplishments over the past 2 decades.


The PASGeP was launched with the signing of a Memorandum of Understanding among Baycrest, CISEPO, the Department of Public Health Sciences at the University of Toronto, and the Peter A. Silverman Center for International Health, Mount Sinai Hospital. The program was designed to test and evaluate a telehealth-based continuing education program for use in promotion of cooperation and knowledge exchange within the network of regions in partnership with CISEPO. Since 1995, CISEPO has brought together Israelis, Jordanians, and Palestinians around the common goal of enhancing health and promoting cooperative dialog. Its activities range from numerous continuing education events, to subspecialty surgery, to community hearing screening centers that have assessed hundreds of thousands of infants. The CISEPO partnerships involve a 3-part approach to partnership development anchored by health care service, research, and policy-related health promotion.


For the pilot project, each Canadian and Middle East site installed telehealth equipment suited to their local needs and capabilities. Baycrest, which serves as the hub, received additional television equipment to allow for broadcast-quality production capabilities, and assumed the production and coordination responsibilities. The telecasts have emphasized a series of programs involving a core collaboration of Canadian, Israeli, Jordanian, and Palestinian sites using “on the ground” infrastructure and relationships, and established relationships within the CISEPO network. Regional hospitals equipped with videoconferencing equipment outside the collaboration covered by the Memorandum of Understanding also participate in the programming. The University of Toronto City-Wide Behavioral Neurology Rounds, Co-Chaired by Dr Morris Freedman and Dr Sandra Black, were selected as the series for the international program. The Behavioral Neurology Rounds are broadcast weekly to Toronto sites using the Ontario Telemedicine Network (OTN), while the international broadcasts occur once per month during the academic year.


The cross-border programming is designed for academic continuing professional development, international relationship building toward cooperation, and demonstrating the power of health care as a common language to bring people together. The PASGeP has appointed telehealth directors to plan the content and oversee local coordination of the series. The directors for the Middle East are also the 3 CISEPO Program Directors: Dr Yehudah Roth (Israeli program), Dr Ziad ElNasser (Jordanian program), and Dr Ziad Abdeen (Palestinian program). For Canada, the telehealth initiative is coordinated by Dr Morris Freedman, Tim Patterson, and Andrew Ignatieff.


Programming


The telecasts are accredited as a group learning activity as defined by The Maintenance of Certification Program of The Royal College of Physicians and Surgeons of Canada. This accreditation, while being relevant for Canadian participation in the program, is also important to the international audience as a means of enhancing the credibility of content. In addition to seeking accreditation, the programming aimed to implement television-quality production levels to make the telecasts more seamless. The rationale for such emphasis on production quality was that technical/production problems or lack of preparedness detract from the audience’s engagement with the content and medium.


The topical focus of the telecasts is centered on neurobehavioral impairment including exploration of issues pertaining to Alzheimer disease, frontotemporal dementia, and cognitive impairment due to Parkinson disease. Programming typically involves case presentations with live participation from either patient and/or family in person or via telecast. This approach enables the telecast audience to interact with the audience and provide feedback to the attending physicians about possible diagnoses and treatment prospects. Remote sites are not allowed to videotape the programming, due to patient confidentiality. Fostering interaction, rather than providing simple didactic instruction, is an essential component of building relationships between the sites and enhancing the format’s knowledge transfer potential. Anecdotally, the rounds’ participants have commented that the patient presentations focus their attention and empathy on the common humanitarian aspects of the case—the diagnostic and management challenges and the need to alleviate suffering in each patient and family. This focus seems to suspend geographic and political barriers, as the attendees collaboratively solve problems and learn together.


A program script is prepared for each telecast, allowing all sites to be aware of the flow of the program so that they can be prepared for the interactive discussion periods; this was viewed very positively by program coordinators at each site. The Chair of the series, based at Baycrest, has responsibility for coordinating the content for the international program. This role has served as a platform for promoting learning and teaching on the art and science of providing education through the telehealth medium. Some pivotal lessons include learning about where to stand in relation to camera positions, awareness of camera angles, and methods to invoke and provoke discussion from the remote sites to encourage interaction.


Production


Baycrest television production capabilities were upgraded through the PASGeP initiative to include:



  • 1.

    Two-camera shoot with the ability for multiple camera shots


  • 2.

    A monitor for the Chair and presenter to see the remote sites and maintain eye contact with participants at these sites


  • 3.

    Microphones in the ceiling so that the Baycrest audience (local) can conduct a dialog with the presenter without having to repeat the question to the remote audiences


  • 4.

    Constant monitoring of the bridge (described below) to allow for the intricacies of health care programming.



This equipment made for a strong production base of operations that could accommodate large local audiences and deliver a quality program.


Resolve Collaboration Services was hired to accomplish the international bridging, and OTN bridged the Toronto, Ontario sites. Bridging services allow for multisite interaction. These technical capabilities facilitate a smoother production that allows the audiences to concentrate on the content rather than on the production inadequacies.


Monitoring and Evaluation Framework


A framework and methodology for evaluating the impact of international telehealth programming was developed to guide the evaluation and monitoring activities. The first step in this process was the development of a program logic model, which maps out the inputs, activities, and expected outputs, and planned outcomes associated with the goals of PASGeP. The logic model outlined the purpose and scope of the program in simple terms, and was used to frame the evaluation and monitoring efforts and to assist in program communications ( Fig. 5 ).


Apr 1, 2017 | Posted by in OTOLARYNGOLOGY | Comments Off on Successful Models for Telehealth

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