Success factors for telehealth—A case study

PURPOSE

To present the lessons learned from an evaluation of a comprehensive telehealth project regarding success factors and evaluation methodology for such projects.

METHODS

A recent experience with the evaluation of new telehealth services in BC, Canada, is summarized. Two domains of clinical applications, as well as educational and administrative uses, and the project environment were evaluated. In order to contribute to the success of the project, the evaluation included formative and summative approaches employing qualitative and quantitative methods with data collection from telehealth events, participants and existing databases. The evaluation had to be carried out under severe budgetary and time constraints. We therefore deliberately chose a broad ranging exploratory approach within a framework provided, and generated questions to be answered on the basis of initial observations and participant driven interviews with progressively more focused and detailed data gathering, including perusal of a variety of existing data sources. A unique feature was an economic evaluation using static simulation models.

RESULTS

The evaluation yielded rich and detailed data, which were able to explain a number of unanticipated findings. One clinical application domain was cancelled after 6 months, the other continues. The factors contributing to success include: Focus on chronic conditions which require visual information for proper management. Involvement of established teams in regular scheduled visits or in sessions scheduled well in advance. Problems arose with: Ad hoc applications, in particular under emergency conditions. Applications that disregard established referral patterns. Applications that support only part of a unit's services. The latter leads to the service mismatch dilemma (SMMD) with the end result that even those e-health services provided are not used. The problems encountered were compounded by issues arising from the manner in which the telehealth services had been introduced, in particular the lack of time for preparation and establishment of routine use. Educational applications had significant clinical benefits. Administrative applications generated savings which exceeded the substantial capital investment and made educational and clinical applications available at variable cost.

CONCLUSION

Evaluation under severe constraints can yield rich information. The identified success factors, including provision of an overarching architecture and infrastructure, strong program management, thorough needs analysis and detailing applications to match the identified needs should improve the sustainability of e-health projects. Insights gained: Existing assumptions before the study was conducted: Evaluation has to proceed from identified questions according to a rigorous experimental design. Emergency and trauma services in remote regions can and should be supported via telehealth based on video-conferencing. Educational applications of telehealth directed at providers are beneficial for recruitment and retention of providers in remote areas. Insights gained by the study: An exploratory approach to evaluation using a multiplicity of methods can yield rich and detailed information even under severe constraints. Ad hoc and emergency clinical applications of telehealth can present problems unless they are based on thorough, detailed analyses of environment and need, conform to established practice patterns and rely on established trusting collaborative relationships. Less difficult applications should be introduced before attempting to support use under emergency conditions. Educational applications are of interest beyond the provider community to patients, family and community members, and have clinical value. In large, sparsely populated areas with difficult travel conditions administrative applications by themselves generate savings that compensate for the substantial capital investment for telehealth required for clinical applications.

A randomized controlled trial of telephone calls to young patients with poorly controlled type 1 diabetes

OBJECTIVE

To determine if scheduled telephone calls from a pediatric diabetes educator to children who have type 1 diabetes improve hemoglobin A1c (HbA1c) level, hospital admissions, diabetes knowledge, compliance, and psychological well-being.

RESEARCH DESIGN AND METHODS

A randomized controlled trial of 123 young subjects (mean age 11.9 yr, 69 male) with type 1 diabetes (mean duration 3.65 yr). For 7 months, the intervention group held bimonthly 15-30 min scheduled supportive telephone discussions. The primary outcome was change in the HbA1c level. Admission rates and changes in diabetes knowledge, psychological parameters, compliance, and patient perception were measured.

RESULTS

There was no significant difference between the treatment and control groups either before or after the intervention. The mean HbA1c level in the control group increased from 8.32 to 8.82% and in the intervention group from 8.15 to 8.85% (p = 0.24). Both groups showed an increase in admissions of 0.2 per yr (p = 0.57). There was no improvement in diabetes knowledge (p = 0.34), compliance, or psychological function. The intervention group viewed their contact with the clinic as more helpful (p = 0.003). Analysis of family function did not reveal subgroups with statistically significant differences. A mean of 13 calls was made to each subject at a cost of 36 Australian dollars per child per month.

CONCLUSIONS

Scheduled bimonthly phone support does not improve the HbA1c level, admission rates, diabetes knowledge, psychological function, or self-management but is perceived by patients as helpful. Further study into the effects of more frequent but shorter periods of support for patients experiencing specific difficulties is needed.

Telehealth services to improve nonadherence: A placebo-controlled study

The objective of this study was to test whether a telehealth intervention could improve the compliance with continuous positive airway pressure (CPAP) by patients with sleep apnea. These patients had been nonadherent for the initial 3 months of therapy even after receiving the initial standard and then supplemental audiotaped/videotaped patient education for adhering to CPAP nightly. The materials and methods included a randomized testing of experimental and placebo interventions. Interventions were delivered by nurses to two groups in their homes by telehealth over a 12-week period. The placebo intervention was used to control for Hawthorne effect, time and attention influences and the novelty of having telehealth in the home. Results following the telehealth interventions were that significantly more patients in the experimental group 1 (n = 10) than the placebo group 2 (n = 9) were adhering nightly to CPAP (chi 2 = 4.55, p = 0.033). Group 1 patients reported greater satisfaction with their intervention. However, both groups rated telehealth delivery positively. The mean cost of each 20-minute telehealth visit was 30 dollars while the total cost of the telehealth intervention for each patient was 420 dollars. These costs included telehealth equipment, initial installation, longdistance telephone charges, nurse salary, and intervention materials. Conclusions are that telehealth interventions are a potentially cost-effective service for increasing adherence to prescribed medical treatments. Replication studies with large samples and in other clinical groups are recommended.

Outcomes associated with a home care telehealth intervention

To determine whether adding telehealth technology to traditional home care services increases health-related quality of life (HRQOL) and home care satisfaction, and decreases resource utilization among home care patients. This trial included 37 home care patients receiving services in a Veterans Affairs medical center, randomized into intervention and control groups. Outcome measures included patient satisfaction and HRQOL at baseline and 6-month follow- up, and the use of inpatient and outpatient services before and during the 6-month study period. Intervention group patients reported greater improvement in the mental health component of HRQOL, (t = 2.27; df = 15; p = 0.04). Satisfaction with the telehealth equipment was high (means exceeded 4.0 on six measures ranging from 1-5). However, no statistically significant differences were observed between intervention and control groups in terms of changes in physical health, inpatient admissions, bed days of care, emergency department visits, or general satisfaction with home care services. Intervention group members did show a trend (p = 0.10) toward fewer overall outpatient visits (mean = 29.1; standard deviation [SD] +/- 30.1) compared to those receiving traditional home care services (mean = 38.9; SD +/- 28.9) The use of telehealth services as an adjunct to traditional home care is associated with greater improvements in mental health status and a trend toward lower use of inpatient and outpatient healthcare services. Further work, utilizing larger sample sizes, is needed to investigate the relationship between telehealth services, the use of healthcare resources, and other outcomes.

Overhead Analysis in a Surgical Practice: A Brief Communication

Evaluating overhead is an essential part of any business, including that of the surgeon. By examining each component of overhead, the surgeon will have a better grasp of the profitability of his or her practice. The overhead discussed in this article includes health insurance, overtime, supply costs, rent, advertising and marketing, telephone costs, and malpractice insurance. While the importance of evaluating and controlling overhead in a business is well understood, few know that overhead increases do not always imply increased expenses. National standards have been provided by the Medical Group Management Association. One method of evaluating overhead is to calculate the amount spent in terms of percent of net revenue. Net revenue includes income from patients, from interest, and from insurers less refunds. Another way for surgeons to evaluate their practice is to calculate income and expenses for two years, then calculate the variance between the two years and the percentage of variance to see where they stand.

Moving research into practice: A decision framework for integrating home telehealth into chronic illness care

Home telehealth is an effective alternative for some aspects of traditional care in chronic illnesses such as diabetes, congestive heart failure and asthma. However, in spite of evidence to support use of home telehealth technologies, they have not been adopted as predicted. A significant challenge for decision-makers is applying results from multiple small studies to the care of large numbers of clients in a health region. Aside from the technology, this complex decision must also include expected client outcomes, variations in nursing resources and their deployment in service delivery. This paper presents research evidence supporting the effectiveness of home telehealth for diabetes care, with attention to the range of technologies and outcome measures reported. It also discusses implications of a recently released national study on "Homecare Indicators" that reported resource allocation and outcomes in home care. The burden of illness, evidence of technology effectiveness and proposed home care outcome indicators are considered together in a decision framework to demonstrate an approach for decision-makers and practitioners to transfer home telehealth research into practice. The resulting decision framework is applied to diabetes care within one large health region in Canada to illustrate its utility as a research transfer strategy.

Socioeconomic stakes in the development of telemedicine

This brief article points out that more empirical knowledge is required about the diverse factors that influence the diffusion, implementation, outcomes and behaviours associated with the spread of information and communication technologies (ICT). This includes the domain of telemedicine and ICT-based outpatient care. A detailed understanding of these processes and the participants involved offers the potential to illuminate the multiplicity of inter-related issues with which medical practitioners and health-care policy makers must contend. More important, it is only through such a detailed, user-centred understanding--as opposed to abstract assessments of technological potential--that we can formulate effective strategies that do not lose sight of the clinical and therapeutic aspects of health care in the quest to improve its delivery.

Teledermatology research review

Teledermatology consultations can be performed using either store-and-forward or real-time technology. The best-studied aspect of teledermatology is diagnostic reliability, also known as diagnostic agreement. A good level of diagnostic reliability is achieved by dermatologists using both store-and-forward and real-time modalities and is comparable to that found between clinic-based examiners. Less information is available regarding diagnostic accuracy. Current data suggest that teledermatologists reviewing store-and-forward consults achieve accuracy comparable to that of clinic-based dermatologists. When store-and-forward consult systems are used, approximately one in four in-person clinic appointments are averted. Real-time consult systems avoid the need to schedule approximately one in two clinic visits. Store-and-forward technology results in timelier interventions for patients when compared to a conventional referral process. To date, surveys of both store-and-forward and real-time teledermatology consult modalities suggest that patients, referring clinicians, and dermatologists are all highly satisfied with teledermatology consults. Very little has been published about the economic impact of store-and-forward teledermatology, whereas several studies have evaluated real-time modalities. Teledermatology has ranged from a cost-saving strategy to an intervention that incurs greater costs than conventional care, depending on the health care setting and economic perspective. Future research focusing on diagnostic accuracy, clinical outcomes using clinical course or disease status as outcome measures, development of reliable and valid teledermatology-specific survey instruments, and economic analyses that assess cost-effectiveness will help guide future teledermatology program assessments and policy.

Telemedicine in wound healing

Better care for patients and improved health care depends on the availability of good information which is accessible when and where it is needed. The development of technology, more specifically the Internet, has expanded the means whereby information can be acquired and transmitted over large distances enabling the concept of telemedicine to become a reality. Telemedicine, defined as the practise of medicine at a distance, encompasses diagnosis, education and treatment. It is a technology that many thought would expand rapidly and change the face of medicine. However, this has not happened and during the last decade although certain telemedicine applications, such as video-consulting and teleradiology, have matured to become essential health care services in some countries, others, such as telepathology, remain the subject of intensive research effort. Telemedicine can be used in almost any medical specialty although the specialties best suited are those with a high visual component. Wound healing and wound management is thus a prime candidate for telemedicine. Development of a suitable telemedical system in this field could have a significant effect on wound care in the community, tertiary referral patterns and hospital admission rates.

Making the business case for telemedicine: an interactive spreadsheet

The objective of this study was to demonstrate the business case for telemedicine in nonrural areas. We developed an interactive spreadsheet to conduct multiple financial analyses under different capital investment, revenue, and expense scenarios. We applied the spreadsheet to the specific case of poststroke rehabilitation in urban settings. The setting involved outpatient clinics associated with a freestanding rehabilitation hospital in Oklahoma. Our baseline scenario used historical financial data from face-to-face encounters as the baseline for payer and volume mix. We assumed a cost of capital of 10% to finance the project. The outcome measures were financial breakeven points and internal rate of return. A total of 340 telemedicine visits will generate a positive net cash flow each year. The project is expected to recoup the initial investment by the fourth year, produce a positive present value dollar return of more than $2,000, and earn rate of return of 20%, which exceeds the hospital's cost of capital. The business case is demonstrated for this scenario. Urban telemedicine programs can be financially self-sustaining without accounting for reductions in travel time by providers or patients. Urban telemedicine programs can be a sound business investment and not depend on grants or subsidies for start-up funding. There are several key decision points that affect breakeven points and return on investment. The best business strategy is to approach the decision as whether or not to build a new clinic.

Cost-minimization analysis of a telehomecare program for patients with chronic obstructive pulmonary disease

A cost-minimization analysis was performed on a telehomecare program for patients with a chronic obstructive pulmonary disease (COPD). The research was quasi-experimental and included a control group. We compared the effects and costs of care provided to a group of 19 patients under a telehomecare program to a comparable group of 10 patients receiving regular home care without telemonitoring. Our results clearly indicate that there were fewer home visits by nurses and hospitalizations for patients in the experimental group. However, these patients made more telephone calls than patients in the control group, although this difference was not statistically significant. Of utmost importance, the cost-minimization analysis yielded positive results. Indeed, telemonitoring over a 6-month period generated $355 in savings per patient, or a net gain of 15% compared to traditional home care. Our study confirms the findings of previous studies that analyzed the efficacy of telemonitoring for patients with COPD. Patients were found to easily accept the idea of using the technology, and the telehomecare program demonstrated significant clinical benefits. Financial advantages of the program could have been more pronounced had it not been for the cost of technology that effectively erased a good portion of the savings.

Home telehealth improves clinical outcomes at lower cost for home healthcare

Patient outcomes and cost were compared when home healthcare was delivered by telemedicine or by traditional means for patients receiving skilled nursing care at home. A randomized controlled trial was established using three groups. The first group, control group C, received traditional skilled nursing care at home. The second group, video intervention group V, received traditional skilled nursing care at home and virtual visits using videoconferencing technology. The third group, monitoring intervention group M, received traditional skilled nursing care at home, virtual visits using videoconferencing technology, and physiologic monitoring for their underlying chronic condition. Discharge to a higher level of care (hospital, nursing home) within 6 months of study participation was 42% for C subjects, 21% for V subjects, and 15% for M subjects. There was no difference in mortality between the groups. Morbidity, as evaluated by changes in the knowledge, behavior and status scales of the Omaha Assessment Tool, showed no differences between groups except for increased scores for activities of daily living at study discharge in the V and M groups. The average visit costs were $48.27 for face-to-face home visits, $22.11 for average virtual visits (video group), and $32.06 and $38.62 for average monitoring group visits for congestive heart failure and chronic obstructive pulmonary disease subjects, respectively. This study has demonstrated that virtual visits between a skilled home healthcare nurse and chronically ill patients at home can improve patient outcome at lower cost than traditional skilled face-to-face home healthcare visits.

The Arizona Telemedicine Program business model

The Arizona Telemedicine Program (ATP) was established in 1996 when state funding was provided to implement eight telemedicine sites. Since then the ATP has expanded to connect 55 health-care organizations through a membership programme formalized through legal contracts. The ATP's membership model is based on an application service provider (ASP) concept, whereby organizations can share services at lower cost; that is, the ATP acts as a broker for services. The membership fee schedule is flexible, allowing clients to purchase only those services desired. An annual membership fee is paid by every user, based on the services requested. The membership programme income has provided a steady revenue stream for the ATP. The membership-derived revenue represented 30% of the ATP's 2.6 million dollars total income during fiscal year 2003/04.

The need for cost-effectiveness studies in telemedicine

Telemedicine has the potential substantially to improve the delivery of health care. However, cost-effectiveness studies are needed to help define the appropriate scope and application of telemedicine in different settings. Reports on the evaluation of telemedicine are dominated by technical and feasibility studies. Such studies may be very helpful for initial decision making. However, any cost information at this level tends to be very preliminary and often concerned with making a case to proceed further. Decision makers will wish for further information as the telemedicine application is introduced, to consider its effectiveness - its performance under routine conditions. Without information on the costs and effectiveness of telemedicine services, decision makers run the risk of supporting telemedicine systems that are not responsive to health-care needs or which do not provide cost-effective services. The most immediate needs seem to be improvements in the conduct and reporting of studies, and additional information on the performance of telemedicine in routine practice. Investigators need to provide transparent accounts of their studies, describing in detail the approaches taken, sources of data and assumptions made, and indicating the reliability of their results. Decisions may have to be made on the basis of limited studies, but sufficient detail must be made available to decision makers.

Management of heart failure patients using telemedicine communication systems

Heart failure (HF) continues to place significant demands on health care resources because of the large number of hospital admissions for HF, the growth of the elderly population with HF, and the improved survival of patients with chronic heart disease who develop HF that requires continuous care. Because HF is best managed using a disease management approach, frequent communication is an important component of care. A variety of studies using the telephone to maintain communication have demonstrated reduced hospital admissions and improved morbidity rate. Hardware monitoring systems that can record vital signs and transmit information from the home to a data center have also demonstrated their value in HF care, but such systems become expensive when considered for large populations of HF patients. Most HF patients can transmit their vital signs, weight, and symptoms to a practice data center using the Internet with no specialized hardware other than a sphygmomanometer and a scale. We have used such a system to monitor HF patients and have provided care instructions using the same system. With use of an Internet communication system, it is possible to reduce hospitalizations and maintain a stable HF status without frequent office visits.

Conducting an economic analysis to assess the electrocardiogram's value

BACKGROUND AND PURPOSE

Health economic analyses seek to assess the relative value (cost vs health benefit trade-offs) of medical technologies. However, these methods have been underused in studies of the electrocardiogram (ECG).

METHODS

We develop a framework for the economic evaluation of the ECG as a decision support tool within broader treatment strategies. We then apply this framework to the development of an economic study protocol for the Prehospital Wireless Transmission of Electrocardiograms to a Cardiologist via a Hand-held Device Multicenter study.

RESULTS

Our framework defines key cost-effectiveness concepts and describes alternative methods for estimating medical costs and health benefits. We demonstrate how this framework has been applied to develop the Prehospital Wireless Transmission of Electrocardiograms to a Cardiologist via a Hand-held Device Multicenter economic protocol.

CONCLUSIONS

The conduct of health economic studies alongside ECG clinical studies could provide important information for those seeking to promote newer ECG applications that require significant financial investments.

Marketing the 'Sex Check': evaluating recruitment strategies for a telephone-based HIV prevention project for gay and bisexual men

Designing effective marketing and recruitment strategies for HIV prevention research requires attention to cultural relevance, logistical barriers, and perceived psychosocial barriers to accessing services. McGuire's communication/persuasion matrix (1985) guided our evaluation, with particular attention to success of each marketing "channel" (i.e., strategy) vis-à-vis the number of all callers, eligible callers, and enrolled callers, as well as reaching so-called "hard-to-serve" individuals. Nearly all channels offered success in reaching specific subgroups. Latinos responded favorably to posters, bisexuals responded favorably to paid media in an alternative (non-gay) publication, and precontemplators responded to referrals by family and friends. Although multiple recruitment strategies were used, three were crucial to the success of the project: (a) recruiters' presence in gay venues, (b) referrals by family and friends (snowball technique), and (c) paid advertisements in alternative (non-gay) local newspapers. Resource allocation and costs are also presented for each channel.

Trials and tribulations: a small pilot telehealth home care program for medicare patients

This article describes a home care agency's experience initiating the technology of a telehealth program for a selected view of its home care patients. The goal of the telehealth program was to improve patient outcomes by augmenting patients' regularly scheduled in-home skilled nursing visits with video-conferencing encounters. Patient selection, costs, projected savings, patient satisfaction, and the technical, clinical, and patient problems with the telehealth system are discussed.

Telestroke: extending stroke expertise into underserved areas

Telestroke systems offer the opportunity to extend stroke-care expertise into rural and underserved areas. These systems are being used to give alteplase to patients with stroke in previously underserved areas safely, effectively, and rapidly. Telestroke will probably play a large part in improving the quality of stroke care and in enrolling patients into clinical trials in rural and community hospitals. One such telestroke system, REACH (remote evaluation of acute ischaemic stroke), is a low-cost, web-based system that allows the consultant to access the system from work, home, or on the road. REACH is presently being used to give alteplase and guide acute stroke care in eight rural community hospitals in Georgia.