Sustainable rural telehealth innovation: a public health case study

The Role of Telehealth in Ultrasound Training for Remote Learners: A Systematic Review

Introduction: Remote learners and educators face geographic, professional, and personal barriers that affect their access to quality ultrasound education. The integration of telehealth in ultrasound education enables learners performing ultrasound to receive real-time instruction from an educator at a distant or remote site. However, to date, there has been poor understanding of the efficacy, benefits, shortcomings, and economic impact of telehealth education in comparison to in-person ultrasound training. The aim of this research was to assess current literature on telehealth in ultrasound education and hands-on training, its outcomes and impact, and requirements for future development. Methods: This review examined international literature on telehealth in ultrasound training. The primary author and second investigator were involved in the research and reached consensus on the eligibility criteria, search strategy, included articles, data extraction, and quality assessment. Results: A total of 23 studies were obtained from Medline, Emcare and Scopus. Key themes identified: Most studies saw an equivalent improvement in knowledge and skills through pre and postassessments in both in-person and telehealth sessions. Generally, learners felt comfortable performing ultrasound guided by a remote educator and felt their skills had been advanced across all studies. Educators reported positive feedback, however compared with learners, educators expressed less satisfaction with the telehealth session. Conclusions: This study demonstrated the feasibility of telehealth in ultrasound training for remote learners with little to no experience. Quality studies with comparable outcomes are needed to ascertain the safe and effective application of telehealth in ultrasound training.

Novel Coronavirus (COVID-19): telemedicine and remote care delivery in a time of medical crisis, implementation, and challenges

The novel Coronavirus (COVID-19) caused by the SARS-CoV-2 virus has led to many challenges throughout the world, one of which is the delivery of health care to patients while they remain home. Telemedicine, or the use of electronic information and telecommunication technologies to support and promote long-distance clinical health care, has been utilized by health care providers for many years, but its widespread implementation did not occur until the onset of the COVID-19 pandemic. Currently, it has become the primary mechanism of care delivery for patients during the COVID-19 pandemic. While obstacles are present for hospitals and providers to establish these services, most barriers exist with patient access. Patients require advanced technical support, translator services, and other measures to become comfortable engaging in a telemedicine encounter. In addition, appropriate follow-up must be provided for chronic medical illnesses and malignancies, helping to prevent the evolution of these conditions during the COVID-19 crisis. Finally, we must ensure equity for all patients seeking to access health services, including those of lower socioeconomic status. Many of these patients rely on public hotspots or library computers for their internet connectivity, but this is likely not conducive to a clinical encounter. These barriers must be addressed to ensure health equity for all patients seeking care. Telemedicine can connect patients and providers during this time of crisis and hopefully will serve as a model for continued use after the pandemic has abated.

Digital Entrepreneurship for the “Decade of Action”

In 2020, the UN launched the “Decade of Action” to achieve the Sustainable Development Goals (SDGs) by the year 2030. As the SDGs are interdependent, intersectional and interdisciplinary, so must be their solutions. This chapter argues that the best way to identify, develop, and scale solutions of such quality is (digital) entrepreneurship, building on the principles of open innovation, cutting-edge technologies, and social business. The COVID-19 pandemic in early 2020 in particular serves as a stark reminder of the interconnected nature of the SDGs and the challenges we face in achieving them. In this article, we explore the third SDG (SDG-3), “Good health and well-being”. We show the potential for digital entrepreneurship to foster the rise of new forms of digital health care and to accelerate the digitalization of the healthcare sector. Due to both perceived and real issues of regulatory compliance, user experience, and long investment/equipment use cycles, SDG-3 has been one of the slowest to adopt innovative solutions by far. We discuss specific areas, such as blended reality or quantum computing, for emerging and future digital health applications. In this chapter, we provide: the “memoreBox” of social start-up RetroBrain R&D, a special edition of gamelab.berlin’s app “Singleton”, and D-Wave’s free access to its cloud quantum computing services. All these examples of digital entrepreneurship utilize in whole or in part a combination of open innovation, future and emerging technologies, and social business, thus supporting our rationale. The article closes with recommendations for different stakeholders of entrepreneurial ecosystems, demonstrating both the necessity and the potential of digital entrepreneurship for the SDGs and the “Decade of Action”.

A systematic scoping review of change management practices used for telemedicine service implementations

BACKGROUND

Telemedicine improves access to health care services enabling remote care diagnosis and treatment of patients at a distance. However, the implementation of telemedicine services often pose challenges stemming from the lack of attention to change management (CM). Health care practitioners and researchers agree that successful telemedicine services require significant organizational and practice change. Despite recognizing the importance of the "people-side" of implementation, research on what constitutes best practice CM strategies for telemedicine implementations remains fragmented, offering little cohesive insight into the specific practices involved in the change process. We conducted a systematic scoping review of the literature to examine what and how CM practices have been applied to telemedicine service implementation, spanning a variety of health care areas and countries.

METHODS

Three bibliographic databases (CINAHL, PubMed, and ISI Web of Science) and four specialist telehealth journals were searched. To keep the review manageable and relevant to contemporary telemedicine technologies and contexts, the search was limited to articles published from 2008 to 2019. Forty-eight articles were selected for inclusion.

RESULTS

From the 48 articles, 16 CM practices were identified relating to either strategic or operational aspects of telemedicine implementations. We identify the key CM practices that are recognized in the broader CM literature as essential for successful and sustained change but are not commonly reported in telemedicine implementation studies. We draw on the CM literature to provide a comprehensive process-based, researched-informed, organizing framework to guide future telemedicine service implementations and research.

CONCLUSIONS

Our findings suggest that the slow rate of adoption of telemedicine may be due to a piecemeal approach to the change process, and a lack of understanding of how to plan, manage and reinforce change when implementing telemedicine services.

A telehealth system for automated diagnosis of asthma and chronical obstructive pulmonary disease

This paper presents the development and real-time testing of an automated expert diagnostic telehealth system for the diagnosis of 2 respiratory diseases, asthma and Chronic Obstructive Pulmonary Disease (COPD). The system utilizes Android, Java, MATLAB, and PHP technologies and consists of a spirometer, mobile application, and expert diagnostic system. To evaluate the effectiveness of the system, a prospective study was carried out in 3 remote primary healthcare institutions, and one hospital in Bosnia and Herzegovina healthcare system. During 6 months, 780 patients were assessed and diagnosed with an accuracy of 97.32%. The presented approach is simple to use and offers specialized consultations for patients in remote, rural, and isolated communities, as well as old and less physically mobile patients. While improving the quality of care delivered to patients, it was also found to be very beneficial in terms of healthcare.

Factors influencing high respiratory mortality in coal-mining counties: a repeated cross-sectional study

BACKGROUND

Previous studies have associated elevated mortality risk in central Appalachia with coal-mining activities, but few have explored how different non-coal factors influence the association within each county. Consequently, there is a knowledge gap in identifying effective ways to address health disparities in coal-mining counties. To specifically address this knowledge gap, this study estimated the effect of living in a coal-mining county on non-malignant respiratory diseases (NMRD) mortality, and defined this as "coal-county effect." We also investigated what factors may accentuate or attenuate the coal-county effect.

METHODS

An ecological epidemiology protocol was designed to observe the characteristics of three populations and to identify the effects of coal-mining on community health. Records for seven coal-mining counties (n = 19,692) were obtained with approvals from the Virginia Department of Health Office of Vital Statistics for the years 2005 to 2012. Also requested were records from three adjacent coal counties (n = 10,425) to provide a geographic comparison. For a baseline comparison, records were requested for eleven tobacco-producing counties (n = 27,800). We analyzed the association of 57,917 individual mortality records in Virginia with coal-mining county residency, county-level socioeconomic status, health access, behavioral risk factors, and coal production. The development of a two-level hierarchical model allowed the coal-county effect to vary by county-level characteristics. Wald tests detected sets of significant factors explaining the variation of impacts across counties. Furthermore, to illustrate how the model estimations help explain health disparities, two coal-mining county case studies were presented.

RESULTS

The main result revealed that coal-mining county residency increased the probability of dying from NMRD. The coal-county effect was accentuated by surface coal mining, high smoking rates, decreasing health insurance coverage, and a shortage of doctors. In Virginia coal-mining regions, the average coal-county effect increased by 147% (p-value< 0.01) when one doctor per 1000 left, and the effect increased by 68% (p-value< 0.01) with a 1% reduction of health insurance rates, holding other factors fixed.

CONCLUSIONS

This study showed a high mortality risk of NMRD associated with residents living in Virginia coal-mining counties. Our results also revealed the critical role of health access in reducing health disparities related to coal exposure.

Sustainable implementation of innovative, technology-based health care practices: A qualitative case study from stroke telemedicine

INTRODUCTION

Technology-based innovation requires long-term changes to workforce routines, otherwise practices will not be sustained. The aim of this study was to identify influential factors in the ongoing use of an acute stroke telemedicine programme.

METHODS

A new acute stroke telemedicine programme in a regional hospital receiving 375 patients with stroke or transient ischaemic attack per year was used as an exploratory case study. Semi-structured interviews with acute care and emergency department clinicians (n = 25) were conducted at two time-points: after a six-month pilot and then after a further 12-month implementation phase. Interviews (between 12-60 min) were recorded, transcribed and analysed inductively using descriptive thematic analysis. Reported barriers and facilitators were compared with those previously reported pre-implementation (deductive analysis) to identify changes over time. Using an implementation framework and a behaviour change taxonomy, strategies were developed to address influential factors on sustainability.

RESULTS

New facilitators were identified including hospital system changes, benefits to clinicians and telemedicine becoming standard practice. New and ongoing barriers included infrequent use, competing demands and the continued resistance to a specific treatment.

DISCUSSION

Understanding the factors supporting a health service in successfully implementing change can accelerate population benefits. The innovation itself may include barriers to be addressed, and barriers and facilitators can change over time. Individual attitudes remain critical to initial and ongoing success. Strategies proposed included promoting benefits across the organisation and allaying uncertainties with site-specific evidence. The effectiveness of these strategies, however, needs to be evaluated. Strategies sustaining change post-implementation should be considered.

Transitioning from a single-site pilot project to a state-wide regional telehealth service: The experience from the Victorian Stroke Telemedicine programme

Scaling of projects from inception to establishment within the healthcare system is rarely formally reported. The Victorian Stroke Telemedicine (VST) programme provided a very useful opportunity to describe how rural hospitals in Victoria were able to access a network of Melbourne-based neurologists via telemedicine. The VST programme was initially piloted at one site in 2010 and has gradually expanded as a state-wide regional service operating with 16 hospitals in 2017. The aim of this paper is to summarise the factors that facilitated the state-wide transition of the VST programme. A naturalistic case-study was used and data were obtained from programme documents, e.g. minutes of governance committees, including the steering committee, the management committee and six working groups; operational and evaluation documentation, interviews and research field-notes taken by project staff. Thematic analysis was undertaken, with results presented in narrative form to provide a summary of the lived experience of developing and scaling the VST programme. The main success factors were attaining funding from various sources, identifying a clinical need and evidence-based solution, engaging stakeholders and facilitating co-design, including embedding the programme within policy, iterative evaluation including performing financial sustainability modelling, and conducting dissemination activities of the interim results, including promotion of early successes.

Factors Determining the Success and Failure of eHealth Interventions: Systematic Review of the Literature

Background

eHealth has an enormous potential to improve healthcare cost, effectiveness, and quality of care. However, there seems to be a gap between the foreseen benefits of research and clinical reality.

Objective

Our objective was to systematically review the factors influencing the outcome of eHealth interventions in terms of success and failure.

Methods

We searched the PubMed database for original peer-reviewed studies on implemented eHealth tools that reported on the factors for the success or failure, or both, of the intervention. We conducted the systematic review by following the patient, intervention, comparison, and outcome framework, with 2 of the authors independently reviewing the abstract and full text of the articles. We collected data using standardized forms that reflected the categorization model used in the qualitative analysis of the outcomes reported in the included articles.

Results

Among the 903 identified articles, a total of 221 studies complied with the inclusion criteria. The studies were heterogeneous by country, type of eHealth intervention, method of implementation, and reporting perspectives. The article frequency analysis did not show a significant discrepancy between the number of reports on failure (392/844, 46.5%) and on success (452/844, 53.6%). The qualitative analysis identified 27 categories that represented the factors for success or failure of eHealth interventions. A quantitative analysis of the results revealed the category quality of healthcare (n=55) as the most mentioned as contributing to the success of eHealth interventions, and the category costs (n=42) as the most mentioned as contributing to failure. For the category with the highest unique article frequency, workflow (n=51), we conducted a full-text review. The analysis of the 23 articles that met the inclusion criteria identified 6 barriers related to workflow: workload (n=12), role definition (n=7), undermining of face-to-face communication (n=6), workflow disruption (n=6), alignment with clinical processes (n=2), and staff turnover (n=1).

Conclusions

The reviewed literature suggested that, to increase the likelihood of success of eHealth interventions, future research must ensure a positive impact in the quality of care, with particular attention given to improved diagnosis, clinical management, and patient-centered care. There is a critical need to perform in-depth studies of the workflow(s) that the intervention will support and to perceive the clinical processes involved.

Integrating Telehealth Emergency Department Follow-up Visits into Residency Training

Introduction Given the rapid expansion of telehealth (TH), there is an emerging need for trained professionals who can effectively deliver TH services. As there is no formal TH training program for residents, the Department of Emergency Medicine (DEM) at Thomas Jefferson University (TJU) developed a pilot training program for senior post-graduate-year three (PGY-3) residents that exposed them to TH practices. The objective of the study was to determine the feasibility of developing a resident-led, post-Emergency-Department (ED) visit TH follow-up program as an educational opportunity to 1) address patient satisfaction; and 2) expose senior residents to TH delivery. Methods During a one-month block in their third-year of training, EM residents were exposed to and educated on TH delivery and utility through on-the-job, just-in-time training. Residents spent four hours per week evaluating patients previously seen in the ED within the last 5-7 days in the form of TH follow-up visits. ED patients were screened to identify which patient chief complaints and presentations were appropriate for a follow-up visit, given a specific day and time for their TH encounter, facilitated by a resident, and supervised by a faculty member trained in TH. Demographic patient and visit data were collected. Residents then completed a brief survey at the end of the rotation to capture their educational experiences and recommendations for subsequent training improvement. Results Over 12 months, 197 TH follow-up visits were performed by 12 residents. One hundred twenty-six patients (64%) were female. Top chief complaints included extremity pain (11.2%); abdominal pain (8.1%); upper respiratory infections (8.1%); lacerations (7.6%), and motor vehicle accidents (7.6%). The average number of days between the ED visit and the TH follow-up call was 5.1 days (IQR 3-6). 44.7% of patients were compliant with their discharge instructions and medications. On a Likert scale low (1) to high (10)], average patient helpfulness rating was 8.2 (IQR 7.8-10) and the average patient likelihood to recommend a TH follow-up visit was 8.5 (IQR 8-10). Ten residents completed the follow-up survey on the educational experience of the rotation (response rate 83%), of which seven described there is value to have a TH rotation in the curriculum. Thematic analysis of open-ended responses yielded constructive feedback for programmatic improvement. Conclusion The authors propose a feasible TH training opportunity integrated into EM residency training to assist them with meeting a rapidly-growing demand for TH and prepare them for diverse job opportunities.

Clinical Update: Telepsychiatry With Children and Adolescents

This Clinical Update reviews the use of telepsychiatry to deliver psychiatric, mental health, and care coordination services to children and adolescents across settings as direct service and in collaboration with primary care providers or other clinicians. The update defines terms and presents the current status of telepsychiatry as a mode of health service delivery. The update presents procedures for conducting telepsychiatry services and optimizing the clinical experience.

Examination of Coaching Behaviors Used by Providers When Delivering Early Intervention via Telehealth to Families of Children Who Are Deaf or Hard of Hearing

The Individuals with Disabilities Education Act (IDEA, 2004) states that infants and toddlers with disabilities, and their family members, are to receive family-centered early intervention (FCEI). This study investigated providers' use of FCEI strategies when intervention was delivered to young children who were deaf or hard of hearing via telehealth. Telehealth is the use of telecommunication technologies to provide health services to people who are located at some distance from a provider. Telehealth also offers access to specialists and eliminates barriers of geography and weather. This study examined the frequency of occurrence of desired FCEI provider behaviors during telehealth sessions and contrasted them with the same behaviors used during in-person therapy. The use of FCEI provider behaviors was measured by observing and coding digitally recorded intervention sessions. Results demonstrated that selected FCEI provider behaviors occur in the telehealth condition more frequently than in the in-person condition reported in the literature. Three of the provider behaviors studied (i.e., observation, parent practice with feedback, and child behavior with provider feedback) were used more frequently in the telehealth condition. Direct instruction was used in similar amounts in both treatment conditions. This study affirms that the use of FCEI strategies may be enhanced through telehealth.

Does Telecare Improve Interorganisational Collaboration?

INTRODUCTION

Previous studies have suggested that telecare can improve interorganisational collaboration within fragmented health care systems, yet this outcome has not been examined in a large-scale setting. This study explores the effects of a large-scale interorganisational telecare programme in Denmark based on home-monitoring on collaboration in a telecare network between municipalities, hospitals, and general practitioners.

METHODOLOGY

Semi-structured interviews and observations of collaborating health professionals from the municipalities, hospitals, and general practitioners were undertaken and then repeated a year later. Collaboration was analysed both at the interorganisational network level and within each part of the network, including its interrelations.

RESULTS

Collaboration between municipalities and general practitioners was initially intensified as a result of implementing telecare, though this changed over time as the first start-up obstacles were overcome and the patients became more active in their treatment. Conversely, collaboration between hospitals and municipalities and hospitals and general practitioners was unaffected by telecare.

DISCUSSION

Changes in collaboration among municipal nurses, general practitioners, and hospital staff were related to dependency structures and municipalities' newly gained central role in a telecare network. While the telecare network was initially characterised by asymmetrical dependency structures, these were partially equalised over time because of the municipalities' new position in the network.

Mixed methods for telehealth research

Mixed methods research is important to health services research because the integrated qualitative and quantitative investigation can give a more comprehensive understanding of complex interventions such as telehealth than can a single-method study. Further, mixed methods research is applicable to translational research and program evaluation. Study designs relevant to telehealth research are described and supported by examples. Quality assessment tools, frameworks to assist in the reporting and review of mixed methods research, and related methodologies are also discussed.

Investigating the preferences of older people for telehealth as a new model of health care service delivery: A discrete choice experiment

Introduction Telehealth approaches to health care delivery can potentially improve quality of care and clinical outcomes, reduce mortality and hospital utilisation, and complement conventional treatments. However, substantial research into the potential for integrating telehealth within health care in Australia, particularly in the provision of services relevant to older people, including palliative care, aged care and rehabilitation, is lacking. Furthermore, to date, no discrete choice experiment (DCE) studies internationally have sought the views and preferences of older people about the basic features that should make up a telehealth approach to these services. Methods Using a DCE, we investigated the relative importance of six salient features of telehealth (what aspects of care are to be pursued during telehealth sessions, distance to the nearest hospital or clinic, clinicians' attitude to telehealth, patients' experience of using technology, what types of assessments should be conducted face-to-face versus via telehealth sessions and the costs associated with receiving telehealth). Data were obtained from an online panel of older people aged 65 years and above, drawn from the Australian general population. Results The mean age for 330 study participants was 69 years. In general, individuals expressed strong preferences for telehealth services that offered all aspects of care, were relatively inexpensive and targeted specifically at individuals living in remote regions without easy access to a hospital or clinic. Participants also preferred telehealth services to be offered to individuals with some prior experience of using technology, provided by clinicians who were positive about telehealth but wanted all or some pre-telehealth health assessments to take place in a hospital or clinic. Preferences only differed by gender. Additionally, respondents did not feel that telehealth led to loss of privacy and confidentiality. Discussion Our findings indicate a preference amongst respondents for face-to-face pre-telehealth health assessments and, thereafter, a comprehensive telehealth model (in terms of services offered) targeted at those with some technological know-how as a substitute for attendance at hospitals and clinics, especially where these health facilities were far away from older people's homes. The findings may be usefully incorporated into the design of future telehealth models of service delivery for older people.

Expanding stroke telerehabilitation services to rural veterans: a qualitative study on patient experiences using the robotic stroke therapy delivery and monitoring system program

PURPOSE

The present study reports on a robotic stroke therapy delivery and monitoring system intervention. The aims of this pilot implementation project were to determine participants' general impressions about the benefits and barriers of using robotic therapy devices for in-home rehabilitation.

METHODS

We used a qualitative study design employing ethnographic-based anthropological methods including direct observation of the in-home environment and in-depth semi-structured interviews with 10 users of the hand or foot robotic devices. Thematic analysis was conducted using an inductive approach.

RESULTS

Participants reported positive experiences with the robotic stroke therapy delivery and monitoring system. Benefits included convenience, self-reported increased mobility, improved mood and an outlet for physical and mental tension and anxiety. Barriers to use were few and included difficulties with placing the device on the body, bulkiness of the monitor and modem connection problems.

CONCLUSIONS

Telerehabilitation robotic devices can be used as a tool to extend effective, evidence-based and specialized rehabilitation services for upper and lower limb rehabilitation to rural Veterans with poor access to care. Implications for Rehabilitation Participants whose formal therapy services had ended either because they had exhausted their benefits or because traveling to outpatient therapy was too cumbersome due to distance were able to perform therapeutic activities in the home daily (or at least multiple times per week). Participants who were still receiving formal therapy services either in-home or in the clinic were able to perform therapeutic activities in the home on the days they were not attending/receiving formal therapy. Based on the feedback from these veterans and their caregivers, the manufacturing company is working on modifying the devices to be less cumbersome and more user-friendly (lighter-weight, more mobile, changing software, etc.), as well as more adaptable to participants' homes. Removing these specific barriers will potentially allow participants to utilize the device more easily and more frequently. Since participants expressed that they wished they could have the device in their homes longer than the 3-month usage period required for this pilot project, the project team is working on a proposal to extend this project to a wider area and the new paradigm would extend the usage period until the patient reaches a plateau in progress or no longer wants to use the device.

Exposing some important barriers to health care access in the rural USA

OBJECTIVES

To review research published before and after the passage of the Patient Protection and Affordable Care Act (2010) examining barriers in seeking or accessing health care in rural populations in the USA.

STUDY DESIGN

This literature review was based on a comprehensive search for all literature researching rural health care provision and access in the USA.

METHODS

Pubmed, Proquest Allied Nursing and Health Literature, National Rural Health Association (NRHA) Resource Center and Google Scholar databases were searched using the Medical Subject Headings (MeSH) 'Rural Health Services' and 'Rural Health.' MeSH subtitle headings used were 'USA,' 'utilization,' 'trends' and 'supply and distribution.' Keywords added to the search parameters were 'access,' 'rural' and 'health care.' Searches in Google Scholar employed the phrases 'health care disparities in the USA,' inequalities in 'health care in the USA,' 'health care in rural USA' and 'access to health care in rural USA.' After eliminating non-relevant articles, 34 articles were included.

RESULTS

Significant differences in health care access between rural and urban areas exist. Reluctance to seek health care in rural areas was based on cultural and financial constraints, often compounded by a scarcity of services, a lack of trained physicians, insufficient public transport, and poor availability of broadband internet services. Rural residents were found to have poorer health, with rural areas having difficulty in attracting and retaining physicians, and maintaining health services on a par with their urban counterparts.

CONCLUSIONS

Rural and urban health care disparities require an ongoing program of reform with the aim to improve the provision of services, promote recruitment, training and career development of rural health care professionals, increase comprehensive health insurance coverage and engage rural residents and healthcare providers in health promotion.

Generating new telehealth services using a whole of community approach: experience in regional Queensland

We implemented a community telehealth project in the three towns in the Darling Downs area of Queensland over a 2-year period starting in July 2012. The purpose of the project was to generate telehealth activity in hospitals, general practice and selected residential aged care facilities. Telehealth education and training was provided to clinicians in the three towns and a community awareness campaign was delivered using advertisements in newspapers, messages in social media and presentations at community events. A total of 55 stakeholders were engaged with during 61 site visits to health care facilities during the first two years of the project. During the study period, telehealth activity in Queensland increased in the hospital sector by 39% and in the non-hospital sector by 99%. In the Darling Downs region, telehealth activity in the hospital sector increased by 104%, compared to 28% in the rest of Queensland. However, in the non-hospital sector, the increase in telehealth activity in the Darling Downs region was similar to the rest of Queensland. Telehealth services established and/or facilitated by the project included specialist geriatric ward rounds in Dalby, Chinchilla and Miles for patients in the local hospitals and nursing homes; and ad-hoc teleconsultations for children and adults living in these communities, with specialists at Toowoomba and hospitals in Brisbane. An increase in telehealth implies better access to a range of clinical services, which may result in improved clinical outcomes for patients.

Examining the potential of information technology to improve public insurance application processes: enrollee assessments from a concurrent mixed method analysis

OBJECTIVE

To assess the perceived readiness of Medicaid and Children's Health Insurance Program (CHIP) enrollees to use information technologies (IT) in order to facilitate improvements in the application processes for these public insurance programs.

METHODS

We conducted a concurrent mixed method study of Medicaid and CHIP enrollees in a southern state. We conducted focus groups to identify enrollee concerns regarding the current application process and their IT proficiency. Additionally, we surveyed beneficiaries via telephone about their access to and use of the Internet, and willingness to adopt IT-enabled processes. 2013 households completed the survey. We used χ(2) analysis for comparisons across different groups of respondents.

RESULTS

A majority of enrollees will embrace IT-enabled enrollment, but a small yet significant group continues to lack access to facilitating technologies. Moreover, a segment of beneficiaries in the two programs continues to place a high value on personal interactions with program caseworkers.

DISCUSSION

IT holds the promise of improving efficiency and reducing barriers for enrollees, but state and federal agencies managing public insurance programs need to ensure access to traditional processes and make caseworkers available to those who require and value such assistance, even after implementing IT-enabled processes.

CONCLUSIONS

The use of IT-enabled processes is essential for effectively managing eligibility and enrollment determinations for public programs and private plans offered through state or federally operated exchanges. However, state and federal officials should be cognizant of the technological readiness of recipients and provide offline help to ensure broad participation in the insurance market.

Communicable disease control programmes and health systems: an analytical approach to sustainability

There is renewed concern over the sustainability of disease control programmes, and re-emergence of policy recommendations to integrate programmes with general health systems. However, the conceptualization of this issue has remarkably received little critical attention. Additionally, the study of programmatic sustainability presents methodological challenges. In this article, we propose a conceptual framework to support analyses of sustainability of communicable disease programmes. Through this work, we also aim to clarify a link between notions of integration and sustainability. As a part of development of the conceptual framework, we conducted a systematic literature review of peer-reviewed literature on concepts, definitions, analytical approaches and empirical studies on sustainability in health systems. Identified conceptual proposals for analysis of sustainability in health systems lack an explicit conceptualization of what a health system is. Drawing upon theoretical concepts originating in sustainability sciences and our review here, we conceptualize a communicable disease programme as a component of a health system which is viewed as a complex adaptive system. We propose five programmatic characteristics that may explain a potential for sustainability: leadership, capacity, interactions (notions of integration), flexibility/adaptability and performance. Though integration of elements of a programme with other system components is important, its role in sustainability is context specific and difficult to predict. The proposed framework might serve as a basis for further empirical evaluations in understanding complex interplay between programmes and broader health systems in the development of sustainable responses to communicable diseases.

Interpretive flexibility in mobile health: lessons from a government-sponsored home care program

Background

Mobile technologies have emerged as important tools that health care personnel can use to gain easy access to client data anywhere. This is particularly useful for nurses and care workers in home health care as they provide services to clients in many different settings. Although a growing body of evidence supports the use of mobile technologies, the diverse implications of mobile health have yet to be fully documented.

Objective

Our objective was to examine a large-scale government-sponsored mobile health implementation program in the Danish home care sector and to understand how the technology was used differently across home care agencies.

Methods

We chose to perform a longitudinal case study with embedded units of analysis. We included multiple data sources, such as written materials, a survey to managers across all 98 Danish municipalities, and semistructured interviews with managers, care workers, and nurses in three selected home care agencies. We used process models of change to help analyze the overall implementation process from a longitudinal perspective and to identify antecedent conditions, key events, and practical outcomes.

Results

Strong collaboration between major stakeholders in the Danish home care sector (government bodies, vendors, consultants, interest organizations, and managers) helped initiate and energize the change process, and government funding supported quick and widespread technology adoption. However, although supported by the same government-sponsored program, mobile technology proved to have considerable interpretive flexibility with variation in perceived nature of technology, technology strategy, and technology use between agencies. What was first seen as a very promising innovation across the Danish home care sector subsequently became the topic of debate as technology use arrangements ran counter to existing norms and values in individual agencies.

Conclusions

Government-sponsored programs can have both positive and negative results, and managers need to be aware of this and the interpretive flexibility of mobile technology. Mobile technology implementation is a complex process that is best studied by combining organization-level analysis with features of the wider sociopolitical and interorganizational environment.

The Alabama Coalition for a Healthier Black belt: a proof of concept project

The Alabama Coalition for a Healthier Black was a demonstration of concept project. This paper is a descriptive and qualitative overview of this 2.5 year project. Limited key project results are reported here. Located in the rural Black Belt region of Alabama this coalition had several key aims: to develop a collaboration between primary care and mental health care through co-location of services; use of video-conferencing capability to provide mental health services more efficiently; enhanced training in rural healthcare; and development of stigma reduction campaigns along with other coalition partner specific initiatives. Co-location and telepsychiatry implementation produced the major challenges and resulting adaptations to original aims. Despite many challenges these new service patterns were put into place and appear to be sustainable.

A mixed methods descriptive investigation of readiness to change in rural hospitals participating in a tele-critical care intervention

BACKGROUND

Telemedicine technology can improve care to patients in rural and medically underserved communities yet adoption has been slow. The objective of this study was to study organizational readiness to participate in an academic-community hospital partnership including clinician education and telemedicine outreach focused on sepsis and trauma care in underserved, rural hospitals.

METHODS

This is a multi-method, observational case study. Participants included staff from 4 participating rural South Carolina hospitals. Using a readiness-for-change model, we evaluated 5 general domains and the related factors or topics of organizational context via key informant interviews (n=23) with hospital leadership and staff, compared these to data from hospital staff surveys (n=86) and triangulated data with investigators' observational reports. Survey items were grouped into 4 categories (based on content and fit with conceptual model) and scored, allowing regression analyses for inferential comparisons to assess factors related to receptivity toward the telemedicine innovation.

RESULTS

General agreement existed on the need for the intervention and feasibility of implementation. Previous experience with a telemedicine program appeared pivotal to enthusiasm. Perception of need, task demands and resource need explained nearly 50% of variation in receptivity. Little correlation emerged with hospital or ED leadership culture and support. However qualitative data and investigator observations about communication and differing support among disciplines and between staff and leadership could be important to actual implementation.

CONCLUSIONS

A mixed methods approach proved useful in assessing organizational readiness for change in small organizations. Further research on variable operational definitions, potential influential factors, appropriate and feasible methods and valid instruments for such research are needed.

Implementation factors and their effect on e-Health service adoption in rural communities: a systematic literature review

Background

An ageing population is seen as a threat to the quality of life and health in rural communities, and it is often assumed that e-Health services can address this issue. As successful e-Health implementation in organizations has proven difficult, this systematic literature review considers whether this is so for rural communities. This review identifies the critical implementation factors and, following the change model of Pettigrew and Whipp, classifies them in terms of “context”, “process”, and “content”. Through this lens, we analyze the empirical findings found in the literature to address the question: How do context, process, and content factors of e-Health implementation influence its adoption in rural communities?

Methods

We conducted a systematic literature review. This review included papers that met six inclusion and exclusion criteria and had sufficient methodological quality. Findings were categorized in a classification matrix to identify promoting and restraining implementation factors and to explore whether any interactions between context, process, and content affect adoption.

Results

Of the 5,896 abstracts initially identified, only 51 papers met all our criteria and were included in the review. We distinguished five different perspectives on rural e-Health implementation in these papers. Further, we list the context, process, and content implementation factors found to either promote or restrain rural e-Health adoption. Many implementation factors appear repeatedly, but there are also some contradictory results. Based on a further analysis of the papers’ findings, we argue that interaction effects between context, process, and content elements of change may explain these contradictory results. More specifically, three themes that appear crucial in e-Health implementation in rural communities surfaced: the dual effects of geographical isolation, the targeting of underprivileged groups, and the changes in ownership required for sustainable e-Health adoption.

Conclusions

Rural e-Health implementation is an emerging, rapidly developing, field. Too often, e-Health adoption fails due to underestimating implementation factors and their interactions. We argue that rural e-Health implementation only leads to sustainable adoption (i.e. it “sticks”) when the implementation carefully considers and aligns the e-Health content (the “clicks”), the pre-existing structures in the context (the “bricks”), and the interventions in the implementation process (the “tricks”).

The role of the champion in telehealth service development: a qualitative analysis

Telehealth 'champions' are enthusiastic individuals who initiate and promote the uptake of telehealth services. Their role and impact was investigated as part of a qualitative study into the uptake and sustainability of telehealth services in Australia. Semi-structured interviews were conducted with 39 individuals who had been involved in the establishment and operations of 37 diverse telehealth services throughout Australia. A grounded theory analysis was carried out. The results indicated that most services were initiated by champions (25 of the 37). The champions appeared to have three main roles: enthusiastic promotion of telehealth, acting as legitimators, and relationship building. Champions were capable of keeping small scale services operating, but the services were vulnerable to cessation when they lost interest or moved on. As long as participation in telehealth remains optional, the role of the champion will be an important factor in continued operations.

State primary stroke center policies in the United States: rural health issues

OBJECTIVE

To explore the relationship between state primary stroke center (PSC) designation policy implementation and access to optimal stroke care for residents of rural areas.

MATERIALS AND METHODS

Primary data were collected during the period September 2008-August 2009. Following content analysis of state PSC policies, four case study states were selected for fieldwork, in part for state rural healthcare access challenges. Variables included the barriers and facilitators to PSC designation policy implementation. More than 100 semistructured stakeholder interviews were conducted by teams of researchers. Large-group meetings were also observed. Interview summaries were reviewed by stakeholders for accuracy and completeness.

RESULTS

The consistent finding in all study states was that PSC designation and state policy implementation in rural areas are unlikely for a variety of reasons, including lack of financial resources for telemedicine, difficulty maintaining neurology coverage, and emergency departments unable to administer thrombolytics. Findings indicate recognition by states about the need for stroke-care public policy specific to telemedicine in rural areas.

CONCLUSIONS

Although state PSC designation policies raise awareness of rural issues, designation policy alone cannot overcome the obstacle of rural access to optimal stroke care. States must be technology-ready, and providers need to embrace e-health and telemedicine to ensure coordination of care for stroke victims in rural areas. More important is that state policy makers should provide rules and regulations to encourage PSC hospitals to use telemedicine and "proxy credentialing" to support their affiliated rural facilities.

Review of American Indian veteran telemental health

Rural American Indian veterans have unique healthcare needs and face numerous barriers to accessing healthcare services. Over the past decade, the Department of Veterans Affairs in conjunction with the University of Colorado Denver has turned to the promising field of telemental health to develop a series of videoconferencing-based clinics to reach this vulnerable population and improve mental healthcare services. The ongoing development, implementation, and expansion of these clinics have been assessed as part of a program improvement. The outcomes of these assessments have been documented in a series of published articles, controlled studies, program and case reports, and model descriptions. This article summarizes a decade of experience with the American Indian Telemental Health Clinics, the clinic model, and the literature arising from these clinics and presents lessons learned while establishing, maintaining, and evaluating these clinics. The ability to tailor the clinics to individual sites and cultures and to provide various services has been critical to the operation of the clinics. Culturally specific care through culturally knowledgeable providers, onsite tribal outreach workers, and collaboration with community services has proven essential in operating the clinics, as well as building rapport, trust, and engagement with the target patient population. It is hoped that the lessons learned and practices presented here can not only assist others working to improve the care for rural Native veterans but also serve as a model in the use of telemental health services for improving care and access to rural veteran and non-veteran populations.

Telemedicine in an international context: definition, use, and future

PURPOSE

Use of telemedicine is increasingly prevalent in order to provide better access to expert care, and we examine telemedicine use internationally.

DESIGN/METHODOLOGY

Using Donabedian's structure, process outcome framework, we conduct an analysis of published studies in the United States, Europe, and Asia to examine the uses, conditions treated, barriers, and future of telemedicine.

FINDINGS

We identify several similarities and challenges to telemedicine use in each region. We find use of videoconferencing between providers or providers and patients for the treatment of acute and chronic conditions. Studies in the United States are more likely to identify applications for the use of chronic conditions, whereas studies in Europe or Asia are more likely to use them for acute access to expertise. Each region reported comparable challenges in reimbursement, liability, technology, and provider licensing.

RESEARCH LIMITATIONS

We compare available research articles from three diverse regions, and many of the articles were merely descriptive in nature. Furthermore, the number of articles per region varied.

PRACTICAL IMPLICATIONS

Barriers to telemedicine use include a lack of reimbursement, language commonality, technological availability, physician licensure or credentialing, trained support staff and patient privacy, and security assurances. Practitioners and policy makers should work to address these barriers.

ORIGINALITY/VALUE

Through this work, a summary of the research to date describes telemedicine use in the United States, Asia, and Europe. Identification of use and barriers may provide impetus for improving access to care by finding ways to increase telemedicine use through standardization.

The diagnosis and treatment decisions of cancer patients in rural Western Australia

BACKGROUND

People living in rural areas who have a diagnosis of cancer have poorer outcomes than people living in urban centers. The reasons for this are unclear. Little is known about the impact that living in a rural area has on the diagnosis and treatment decisions of these people and how these may in turn impact on care outcomes.

OBJECTIVES

This study explored the reasons why people living in rural areas may delay diagnosis and what issues affected the decisions they made regarding their cancer treatment.

METHODS

In depth, semistructured interviews were conducted with 18 participants from 3 rural Western Australian health regions. Content analysis was used to develop themes.

RESULTS

Four themes were identified to describe the rural cancer experience. The first 3 themes, Experiences of Diagnosis and Referral, The Treatment Journey, and Managing your own Care, relate to the experiences of rural cancer patients during their journey through the health care system. The final overarching theme, Implicit Faith, described the level of confidence that rural cancer patients had in the health system, often despite delays and inconveniences.

CONCLUSIONS

There is a need to improve primary health care and care coordination for rural cancer patients living in Australia and to promote self-advocacy and consumer empowerment for rural cancer patients.

IMPLICATIONS FOR PRACTICE

Rural patients need help and support throughout their cancer journey, including through the process of diagnosis.