28 Challenges to Telehealth Implementation

Introduction

The use of technology in improving the delivery of health services has become fundamental to modern healthcare. Telehealth – the means of delivering medical information and health care through the use of telecommunication technologies – holds particular promise for vast portions of the Circumpolar North, due to the uneven distribution of specialized care between rural and urban population centers; the substantial distances which often must be travelled to receive health care; and challenges to recruitment and retention of health professionals in rural, remote and Indigenous communities.

Despite the promise and the need, telehealth use in most of the Circumpolar North remains in an early adoption phase rather than a normal part of health care delivery. The technology exists; but the processes and uptake are evolving slowly. This chapter will provide an introduction to telehealth, its promise to contribute to care, and the current challenges to implementation for communities in the Circumpolar North.

What is Telehealth?

Telehealth is a means of delivering medical information and health care through the use of telecommunication technologies. This may include providing clinical services to patients from a distance, monitoring a patient’s vital signs from a remote health care facility, transmitting x-rays from a patient at a northern clinic to a radiologist in an urban hospital, or broadcasting continuing education programs to physicians, Registered Nurses (RNs) and other providers.

Telehealth does not typically create new or different health care services. It simply provides a new way to deliver existing services. On the clinical side, telehealth bridges the distance between patient and health care provider by allowing patients to remain in their communities, while being seen by a health care provider at a distant site. This enables those living in northern communities or areas that are underserved to have improved access to health care. Telehealth also saves time and money by reducing the amount of travel time and expenses, as well as reducing the time patients are off work or away from family responsibilities.

With the use of videoconferencing, remote presence robotics, or other equipment, a patient can have a live, real-time interaction with a specialist as if they are in the same room. The health care provider is able to conduct a sufficient examination of their patients by asking them about their past history and current symptoms; getting information from on-site providers, such as the local RN; and using electronic diagnostic equipment and other peripheral devices to mirror that of an in-person visit. This can be done by understanding the requirements from a provider perspective and identifying what peripherals are needed to ensure the patient is cared for the same way as in-person.

Though live-interactive videoconferencing,
and increasingly remote presence robotics, are traditional forms of technology used in telehealth, there are others, such as remote monitoring equipment, used in home health and intensive care programs. In both cases, clinical data is collected from the patient and transmitted to a health care provider at an offsite location. The provider reviews the data and acts accordingly based on the findings. The clinical data may include
a patient’s weight, blood pressure, heart rate, oxygen saturation, and blood glucose, as well as other measurements, such as laboratory data, depending on the patient’s condition.

Store-and-forward imaging is another technology used in telehealth that allows x-rays, CT scans, MRI images, digital images, and other images to be transmitted from the patient site to a physician located at a distant health care facility. In the case of tele-radiology, images are sent to a radiologist to be read and the results are transmitted back to the patient site.

Telehealth also includes non-clinical services. Many telehealth sites can be connected simultaneously for collaborative purposes, such as continuing professional education, grand rounds, administrative meetings, and mentoring, amongst others. The use of telehealth for these professional development and networking functions also reduces travel time and expenses.

There is a large body of evidence confirming the central promise of telehealth: that it provides consistently high quality care at a lower cost. A few summaries of the growing body of telehealth research are available (McLean et al, 2013; American Telemedical Association, 2015). Generally, the research has demonstrated that:

• Telehealth outcomes are generally found to be equivalent or higher than in-person services (e.g. Dellifraine & Dansky, 2008).
• Patient satisfaction rates are as high or higher than in-person care (e.g. Sucher et al, 2011; Gustke et al, 2000).
• Costs can be lower than hospital based services (e.g. Holt et al, 2018; Cryer et al, 2012; Baker et al, 2011; Darkins et al 2008; Kohl et al, 2007)

There are many types of medical care that have been delivered via telehealth that achieve these kinds of positive results, including tele-stroke care, tele-pharmacy, tele-psychiatry, tele-optometry/ophthalmology, tele-dermatology, tele-rehabilitation, remote monitoring, and other uses. Given this strong track record across diverse disciplines and services, it should not be assumed that certain types of health services cannot be delivered, or are inappropriate, via telehealth.

Implementation Challenges

Introducing new systems and processes in large bureaucracies is often difficult. Northern contexts add additional layers of complexity. This section highlights some of the barriers to the implementation of telehealth.

Culture and Behaviour

It can be incredibly difficult
to change the culture and behaviours of large, complex systems, such as health care. Many of the processes are path dependent on other processes and cannot be easily changed in isolation. Interjecting telehealth processes into existing systems promises a struggle with the status quo.

It will be difficult to change behaviours without either making telehealth as easy, or easier,
than existing processes, and/or by providing performance or financial incentives to adopt new practices. Incentives can motivate and reward change and assist in more timely adoption of new processes. Implementing telehealth may require incentives at five levels:

1. The payer (i.e. government or insurance company), to save money/resources and/or improve services;
2. The client, to receive better/more convenient/more accessible services;
3. The local health care provider who is with the patient, often a nurse, who may need to provide additional or different care than they would if the patient was simply sent to see the provider/specialist in-person; and
4. The provider/specialist at the linked facility providing the expertise/diagnosis/treatment, who will need to be paid at the same rate, and not be inconvenienced by using technology over an in-person visit.
5. The administrators responsible for particular clinics or health regions need the resources to host and install telehealth equipment and connections, and the human resources to coordinate appointments.

If telehealth is conceived as a plan that provides equivalent services at the same price, but requires expensive new technology and supports; or expands services but also costs, it will be difficult to get health ministries or insurance companies to invest in them. A critical mass of usage is required to realize the cost benefits of investments in telehealth.

Fear/Distrust in Reliability and Ability of the Technology

A major concern often shared by northern health care professionals is about the reliability of telehealth, given the often inferior connectivity in their communities. This concern is certainly valid; the potential benefits of telehealth provide a solid business case for further investing in rural and remote community broadband access. However, many telehealth devices are optimized for low bandwidth, and even remote communities typically have internet access at the community health centre. A greater concern is the cost of this connectivity, which can be prohibitive. However, medical transportation also entails some connectivity issues, including loss of cellular coverage over long distances.

Payment for Services

One of the biggest current obstacles to implementing telehealth is the difficulty and confusion around payment for services. Physicians and other providers will not go out of their way to provide online and virtual services if they cannot get paid for them.

The best practice has been to seek legislation that ensures health care providers are paid the same rate for telehealth services as for in-person visits. Ideally, no distinction would be made in how services are delivered, but focus rather on what service is being delivered.

Trends in telehealth
are to move from expensive hardware-based telehealth room systems to software solutions like Skype for Business, Vidyo, etc. Legislation, privacy policies and billing codes need to be developed for these new technologies.

Jurisdictional Issues

In a similar vein, telehealth uptake can be hindered by restrictions to the ability of remote/offsite health care providers to provide care to patients who are not receiving care in the same region in which they are licensed. For example, if a patient is geographically in northern Saskatchewan, but seen by a physician in another province, the College of Physicians
and Surgeons of Saskatchewan holds that it is responsible for licensing that physician. Other Colleges have taken the geographic location
of the physician to determine which regulatory body is responsible for the licensure. For Registered Nurses in Canada, a fee is required to practice in different provinces, but licensure is not an issue.

In the United States, several states have made moves to allow providers to provide care across the country, through an inter-state compact, so long as they are licensed in the state of their physical location. Other jurisdictions may want to explore similar options to facilitate most effective telehealth use across borders.

Telehealth use raises additional issues in terms of professional conduct and privacy issues that need to be reviewed.

Privacy and Policy Implications

There are likely to be policy and liability implications associated with introducing telehealth and associated equipment. This can take time and resources to figure out. One example is the introduction of a remote presence robot into a hospital, which can create privacy issues. Who can access the robot and where can the robot travel to within a clinic?

The best practice is to maintain the same standards and practice guidelines for telehealth as for in-person visits.

Northern Clinic Capacity

In northern Canada, as elsewhere in the Circumpolar North, many community health clinics are frequently short-staffed and over-burdened. Efforts to keep clients in their home community using telehealth are likely to transfer some responsibilities for care onto local nursing and other staff.  This could be challenging without appropriate training and support.

In addition, the comprehensive adoption of telehealth processes will require Information and Communications Technology (ICT) supports and maintenance. Many communities and smaller regions may not yet have the capacity to support a minimum standard of support and service.

Resources will need to be assigned to ensure there are not strong disincentives at the local level to adopt telehealth.

Need a Critical Mass of Users and Specialists

In order to obtain the financial benefits of telehealth, a critical mass of usage will need
to be obtained. An up-front investment in technology, training, and resources is required to adopt and implement telehealth practices. If only a small number of practitioners subsequently use tele-health, the investment will not be a good one. Many telehealth suites in northern Canada, for example, are under-utilized. There needs to be enough specialists on one end, and local providers on the other, leveraging the service to make it viable. Therefore, a commitment is needed at a variety of levels.

Sustainability

There are likely to be “early adopters” who are enthusiastic about the potential of telehealth and eager to use the system. This may be a necessary condition for telehealth implementation, and for finding and supporting champions. However, for telehealth to be successful and sustainable, it will need to be adopted beyond single champions and pilot projects and become part of “normal” operations.

Post-secondary health sciences programs can be instrumental in normalizing telehealth by teaching the practice and theory to students before they are licensed practitioners, invoking an expectation of telehealth use in their clinical practice.

Standardization of technologies across jurisdictions, would improve uptake, ease of coordination, cost effectiveness and the patient experience.

Conclusion

Telehealth has the potential to transform health care in the North, by expanding access and reducing transportation needs and costs. The technologies exist; northern health care systems must find a way to implement and integrate telehealth tools in to their services.

References

Baker, Laurence C., Scott J. Johnson, Dendy Macaulay, and Howard Birnbaum Integrated Telehealth And Care Management Program For Medicare Beneficiaries With Chronic Disease Linked To Savings Health Affairs September 2011 30:91689-1697;

Cryer, Lesley, Scott B. Shannon, Melanie Van Amsterdam, and Bruce Leff (June 2012). “Costs For ‘Hospital At Home’ Patients Were 19 Percent Lower, With Equal Or Better Outcomes Compared To Similar Inpatients” in Health Affairs, 31(6) pp.1237-1243.

Darkins, Adam, Patricia Ryan, Rita Kobb, Linda Foster, Ellen Edmonson, Bonnie Wakefield, Anne E. Lancaster (December 2008). “Care Coordination/Home Telehealth: The Systematic Implementation of Health Informatics, Home Telehealth, and Disease Management to Support the Care of Veteran Patients with Chronic Conditions” in Telemedicine and e-Health, 14(10), pp. 1118-1126.

Dellifraine JL, Dansky KH (2008). “Home-based telehealth: a review and meta analysis” in J Telemed Telecare, 14(2), pp. 62-6.

Gustke, S.S., Balch, D.C., West, V.L., and Rogers, L.O. 2000. “Patient satisfaction with telemedicine” in Telemedicine Journal, Spring 6(1), pp. 5-13.

Holt, Tanya, Nazmi Sari, Gregory Hansen, Matthew Bradshaw, Michael Prodanuk, Veronica McKinney, Rachel Johnson, and Ivar Mendez (2018). “Remote Presence Robotic Technology Reduces Need for Pediatric Interfacility Transportation from an Isolated Northern Community” in Telemedicine and e-Health, 24(11), pp. 1-7.

Kohl, Benjamin A, Frank D Sites, Jacob T Gutsche, Patrick Kim (2007). “Economic Impact of eICU Implementation in an Academic Surgical ICU, Anesthesiology and Critical Care”, in Crit Care Med. University of Pennsylvania, Philadelphia, PA, 35(12), p. A26.

Sucher, Joseph F. S. Rob Todd, Stephen L. Jones, Terry Throckmorton, Krista L. Turner, Frederick A. Moore (2011). “Robotic telepresence: a helpful adjunct that is viewed favorably by critically ill surgical patients” in The American Journal of Surgery 202 (6), pp. 843-47.