Facilitating telemedicine project sustainability in medically underserved areas: a healthcare provider participant perspective

Digitally-mediated coordination in healthcare: the effects of teleconsultation on doctor-to-doctor relational coordination

BACKGROUND

Digitalization transforms the way in which interdependent work is coordinated, especially in healthcare settings. This work deepens the effect of teleconsultation use on health professionals' coordination. For this aim, we rely on Relational Coordination Theory (RCT), which explores coordination as an interactive process among group participants within the context of task interdependency.

METHODS

We collected data through an online survey administered to Italian specialist doctors between March and April 2023. 489 complete answers were gathered. Hypotheses have been tested through Structural Equation Modelling.

RESULTS

We found that teleconsultation frequency of use has a positive and significant effect on both components of relational coordination, confirming our hypotheses.

CONCLUSIONS

Theoretically, this research contributes to our understanding of the effect of digitally mediated coordination mechanisms on relational coordination. In practice, we shed light on the organizational implications of telemedicine under a novel perspective, focusing on the role of professional interactions in digitally mediated work and providing useful elements for the organizational design of telemedicine.

A cross-sector systematic review and synthesis of knowledge on telemedicine interventions in chronic wound management-Implications from a system perspective

Based on initially identified needs for further telemedicine (TM) and chronic wound management research, the objective of this article is twofold: to conduct a systematic review of existing knowledge on TM interventions in chronic wound management-including barriers and opportunities-across the specialist and primary care sectors, and to incorporate the review findings into a system framework that can be further developed and validated through empirical data. We conclude that there is a pressing need for broader and more comprehensive empirical explorations into quality improvement and integration of TM in chronic wound management, including using system frameworks that can capture cross-sector system perspectives and associated implications. Of practical consideration, we suggest that the design and execution of TM improvement interventions and associated research projects should be conducted in close cooperation with managers and practitioners knowledgeable about barriers and opportunities that can influence the implementation of important interventions within chronic wound management.

Factors Influencing Telehealth Implementation and Use in Frontier Critical Access Hospitals: Qualitative Study

Background

Telehealth has potential to help individuals in rural areas overcome geographical barriers and to improve access to care. The factors that influence the implementation and use of telehealth in critical access hospitals are in need of exploration.

Objective

The aim of this study is to understand the factors that influenced telehealth uptake and use in a set of frontier critical access hospitals in the United States.

Methods

This work was conducted as part of a larger evaluation of a Centers for Medicare & Medicaid Services–funded demonstration program to expand cost-based reimbursement for services for Medicare beneficiaries for frontier critical access hospitals. Our sample was 8 critical access hospitals in Montana, Nevada, and North Dakota that implemented the telehealth aspect of that demonstration. We reviewed applications and progress reports for the demonstration program and conducted in-person site visits. We used a semistructured discussion guide to facilitate conversations with clinical, administrative, and information technology staff. Using NVivo software (QSR International), we coded the notes from the interviews and then analyzed the themes.

Results

Several factors influenced the implementation and use of telehealth in critical access hospitals, including making changes to workflow and infrastructure as well as practitioner acceptance and availability. Participants also cited technical assistance and support for implementation as supportive factors.

Conclusions

Frontier critical access hospitals may adopt telehealth to overcome challenges such as distance from specialty practitioners and workforce challenges. Telehealth can be used for provider-to-patient and provider-to-provider interactions to improve access to care, remove barriers, and improve quality. However, the ability of telehealth to improve outcomes is limited by factors such as workflow and infrastructure changes, practitioner acceptance and availability, and financing.

Built to last? The sustainability of healthcare system improvements, programmes and interventions: a systematic integrative review

INTRODUCTION

The sustainability of healthcare delivery systems is challenged by ageing populations, complex systems, increasing rates of chronic disease, increasing costs associated with new medical technologies and growing expectations by healthcare consumers. Healthcare programmes, innovations and interventions are increasingly implemented at the front lines of care to increase effectiveness and efficiency; however, little is known about how sustainability is conceptualised and measured in programme evaluations.

OBJECTIVES

We aimed to describe theoretical frameworks, definitions and measures of sustainability, as applied in published evaluations of healthcare improvement programmes and interventions.

DESIGN

Systematic integrative review.

METHODS

We searched six academic databases, CINAHL, Embase, Ovid MEDLINE, Emerald Management, Scopus and Web of Science, for peer-reviewed English journal articles (July 2011-March 2018). Articles were included if they assessed programme sustainability or sustained outcomes of a programme at the healthcare system level. Six reviewers conducted the abstract and full-text review. Data were extracted on study characteristics, definitions, terminology, theoretical frameworks, methods and tools. Hawker's Quality Assessment Tool was applied to included studies.

RESULTS

Of the 92 included studies, 75.0% were classified as high quality. Twenty-seven (29.3%) studies provided 32 different definitions of sustainability. Terms used interchangeably for sustainability included continuation, maintenance, follow-up or long term. Eighty studies (87.0%) clearly reported the timepoints at which sustainability was evaluated: 43.0% at 1-2 years and 11.3% at <12 months. Eighteen studies (19.6%) used a theoretical framework to conceptualise or assess programme sustainability, including frameworks that were not specifically designed to assess sustainability.

CONCLUSIONS

The body of literature is limited by the use of inconsistent definitions and measures of programme sustainability. Evaluations of service improvement programmes and interventions seldom used theoretical frameworks. Embedding implementation science and healthcare service researchers into the healthcare system is a promising strategy to improve the rigour of programme sustainability evaluations.

The geographic alignment of primary care Health Professional Shortage Areas with markers for social determinants of health

Background

The Health Resources and Services Administration (HRSA), an agency within the U.S. Department of Health and Human Services (HHS), works to ensure accessible, quality, health care for the nation’s underserved populations, especially those who are medically, economically, or geographically vulnerable. HRSA-designated primary care Health Professional Shortage Areas (pcHPSAs) provide a vital measure by which to identify underserved populations and prioritize locations and populations lacking access to adequate primary and preventive health care–the foundation for advancing health equity and maintaining health and wellness for individuals and populations. However, access to care is a complex, multifactorial issue that involves more than just the number of health care providers available, and pcHPSAs alone cannot fully characterize the distribution of medically, economically, and geographically vulnerable populations.

Methods and findings

In this county-level analysis, we used descriptive statistics and multiple correspondence analysis to assess how HRSA’s pcHPSA designations align geographically with other established markers of medical, economic, and geographic vulnerability. Reflecting recognized social determinants of health (SDOH), markers included demographic characteristics, race and ethnicity, rates of low birth weight births, median household income, poverty, educational attainment, and rurality. Nationally, 96 percent of U.S. counties were either classified as whole county or partial county pcHPSAs or had one or more established markers of medical, economic, or geographic vulnerability in 2017, suggesting that at-risk populations were nearly ubiquitous throughout the nation. Primary care HPSA counties in HHS Regions 4 and 6 (largely lying within the southeastern and south central United States) had the most pervasive and complex patterns in population risk.

Conclusion

HHS Regions displayed unique signatures with respect to SDOH markers. Descriptive and analytic findings from our work may help inform health workforce and health care planning at all levels, and, by illustrating both the complexity of and differences in county-level population characteristics in pcHPSA counties, our findings may have relevance for strengthening the delivery of primary care and addressing social determinants of health in areas beset by provider shortages.

District nurses' views on and experiences with a telemedicine educational programme in palliative care

Background

Medical advancements, limited resources and shifting demographics have increased the number of patients with palliative care needs in primary care. To address educational needs, the specialised palliative care team of South Jutland, Denmark, created a telemedicine educational programme in palliative care to empower district nurses.

Aim

The study aimed to explore district nurses’ views on and experiences with a telemedicine educational programme in palliative care.

Research methods

A qualitative explorative study based on interpretive description was conducted. Data collection consisted of four focus group interviews with district nurses from three municipalities, supplemented by participant observations and a focus group interview with teachers from the specialised palliative care team. Data were analysed using predominately inductive thematic analysis.

Results

District nurses (n = 15) who participated in the programme and members of the specialised palliative care team (n = 6) who taught the programme were included. Analysis revealed the following advantages: reaffirming and updating existing knowledge, reduced professional isolation and creation of a forum to promote knowledge dissemination. A disadvantage was limited interaction between teachers and district nurses, questioning suitability for teaching complex palliative care. Initial technical problems affected motivation to participate. Organisational support differed between participating municipalities resulting in varying degrees of programme integration. Despite advantages of IT‐expert‐led sessions, key‐nurse‐led sessions in smaller groups proved more beneficial, suggesting a combination of IT support and key‐nurse management to maximise benefits.

Conclusion

The use of an inter‐professional telemedicine educational programme to teach palliative care to district nurses is beneficial. However, programmes should be designed for interactivity and address varying educational needs. Key‐nurse roles require managerial and IT support to optimise knowledge dissemination. Further research on implementation of telemedicine education in palliative care is needed.

Understanding primary care-oncology relationships within a changing healthcare environment

Background

Management of care transitions from primary care into and out of oncology is critical for optimal care of cancer patients and cancer survivors. There is limited understanding of existing primary care-oncology relationships within the context of the changing health care environment.

Methods

Through a comparative case study of 14 innovative primary care practices throughout the United States (U.S.), we examined relationships between primary care and oncology settings to identify attributes contributing to strengthened relationships in diverse settings. Field researchers observed practices for 10–12 days, recording fieldnotes and conducting interviews. We created a reduced dataset of all text related to primary care-oncology relationships, and collaboratively identified patterns to characterize these relationships through an inductive “immersion/crystallization” analysis process.

Results

Nine of the 14 practices discussed having either formal or informal primary care-oncology relationships. Nearly all formal primary care-oncology relationships were embedded within healthcare systems. The majority of private, independent practices had more informal relationships between individual primary care physicians and specific oncologists. Practices with formal relationships noted health system infrastructure that facilitates transfer of patient information and timely referrals. Practices with informal relationships described shared commitment, trust, and rapport with specific oncologists. Regardless of relationship type, challenges reported by primary care settings included lack of clarity about roles and responsibilities during cancer treatment and beyond.

Conclusions

With the rapid transformation of U.S. healthcare towards system ownership of primary care practices, efforts are needed to integrate strengths of informal primary care-oncology relationships in addition to formal system driven relationships.

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.