Restraining and facilitating factors in the diffusion of telemedicine
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Restraining and facilitating factors in the diffusion of telemedicine - An interview studyBy Deede GammonBackgroundThere appears to be every indication that telemedicine will spread rapidly within the Norwegian health care sector. A wide range of telemedicine applications has already been established as permanent services in several health care institutions, and more hospitals are anxious to establish their own services. The Norwegian Ministry of Health and Social Affairs has accredited telemedicine as a specialist field, and has appointed the University Hospital of Tromsø as a national competence centre devoted to furthering developments in telemedicine. If today's wide and positive (both popular and professional) press coverage continues, telemedicine will soon become a term both understood and anticipated by the general public.In spite of these positive developments, however, there is every reason to ask: How will telemedicine fare within the Norwegian health care sector? What factors will influence the diffusion process - that is the rate and pattern of dispersion. While both technical and user group experiences are well documented, social, economic and organisational issues now come to the foreground as essential in assessing the potential diffusion of this technology. These issues now come to the foreground in our efforts to anticipate and influence the future of telemedicine within the Norwegian health care sector. The interview material reported in this paper was our first effort in gaining a better idea of the factors which can influence the process of diffusion within the Norwegian health care sector. Subjects who have participated in, or been affected by Norwegian Telecom's telemedicine R&D activities were interviewed based on the following general question: What factors can be expected to have restraining and facilitating effects on the diffusion of telemedicine within the health care sector? They were asked to formulate "educated guesses" about the future of this technology as they saw it from each of their varying experiences and positions: local and central hospitals, municipality administrations, the Ministry of Health and Social Affairs, Norwegian Telecom, and the Norwegian Telecom's primary collaborators. The goal of the study was to
What can be gained by the diffusion of telemedicine?Ideally, the primary factor facilitating the diffusion of telemedicine is its ability to achieve important health care goals, in addition to the goals of telemedicine-related industry. Indeed, the majority of interview subjects emphasised all that telemedicine can help us to achieve as the major factor which would facilitate the diffusion of telemedicine. We will not discuss the validity of this assumption (that "do-good" technologies diffuse quickly, while others do not). Here we will merely provide a summary of the reasons why Norwegian Telecom as well as the health care sector are concerned with the issue of diffusion.The Norwegian Telecom has fairly straight forward motives for its efforts in developing and spreading telemedicine; increase the use of telecommunications and thus increase the profits. Furthermore, the health care sector provides challenges which are important to tackle in order to maintain dominance in other areas of the public and private sector. The health care sector on its part is obligated to provide satisfactory health care to all members of society within the economic framework provided by the government. Here, the legitimacy of telemedicine will be assessed according to its ability to contribute in achieving important goals within the health care sector. The following list shows the types of goals or potential benefits which both health care personnel in the telemedicine pilot projects and interview subjects have formulated:
Interview studyTwenty-nine interview subjects were selected according to two criteria: a) acquaintance with the developments of telemedicine, either directly through participation in pilot projects, or indirectly through contact and co-operation with the Telemedicine project, and b) representation of areas of interest and influence as shown in table 1.It is worth noting that several of the interview subjects are pioneers who have invested a fair amount of energy and prestige in developing and implementing telemedicine applications. Furthermore, the study was conducted by a Norwegian Telecom research scientist also involved in this field. The questions and opinions of potential users and institutions who have not been involved in these developments will be important in gaining a more complete and reliable idea of the types of factors that will influence diffusion. At this stage, however, few apart from those directly involved with telemedicine have enough knowledge and experience to have developed opinions on these issues. The subjects were asked the following open question: What factors can be expected to have restraining and facilitating effects on the diffusion of telemedicine within the health care sector? While no specific subset of questions was formulated, we prompted the subjects to comment on the following types of issues; personnel, economics, organisation and technology. Within this framework the subjects were free to follow the lines of thought they found most relevant based on their varying experiences and positions. Facilitating and restraining factorsThe interview material is summarised into nine groups of factors which emerged as central throughout the interviews. For each group, the material is organised into facilitating and restraining factors as indicated in the shadowed boxes. Since most of these factors are self-explanatory, we have limited our comments to a) supplementing general impressions, b) areas subject to misinterpretation, and c) issues where the subjects had seriously divergent views. It should be kept in mind that several of the factors may be both facilitating and restraining, depending upon the context at hand. Furthermore, some of the factors presented are descriptive (based on the subject's own experience), while others are normative (based on the subject's opinion of how it should be).General social and political factorsThe ongoing public concern and debate about the "crisis" in the health sector creates a readiness to assess newer and more radical measures in helping solve some of the structural and economic problems in the health care sector. The majority of subjects in our study reflected this attitude towards telemedicine. Further, if broad and positive media coverage is any indication, telemedicine appears easy to understand and to "sell" to the public. As one subject put it, "This is a type of technology that the politicians will fall for." A simple, practical demonstration of telemedicine is often enough to give lay persons perspectives of how this technology can help attain important values and goals in society; equal access to generalist and specialist health care, more quality health care per krone.The restraining factors most frequently mentioned were related to mechanisms regulating the roles and responsibilities between the different levels of public health administration. These mechanisms, often described as rigid and complex, are constantly under public assessment and debate. In most cases, telemedicine is used between institutions administered at different levels or between, for example, municipalities in different regions. Among the problems which arise in this interaction is the issue of economic compensation tied to the health care services themselves (travel, consultation fees, etc.) as well as the issue of dividing the burden of investments in telemedicine systems - an issue which is complicated by a strong trend towards decentralised goal management. Restraining- Rigidity and complexity of mechanisms regulating national, municipal and local activities- Decentralised goal management of investments and measures which are in the interest of all parties - Exaggerated focus on technology rather than goals Facilitating+ Social/political values and demands for:
+ Trends towards cross-sector collaboration + Public debate on changes in traditional hospital structure Restraining Characteristics of telemedicine system solutionsThe only characteristic listed under facilitating factors which was descriptive of today's telemedicine applications was that they had potential for achieving the goals referred to under section 2. Most subjects described today's telemedicine applications in terms of restraining factors. Telemedicine's overall success to date, which was acknowledged by the majority of interview subjects, is clearly in spite of its present characteristics.It is therefore important to emphasise the fact that telemedicine has to date been driven by enthusiastic pioneers within a research and development (R&D) context. The technical and organisational problems experienced, both within the health care field sites and within Norwegian Telecom's own organisation, have been perceived as challenges to be tackled within this context. This will not be the case for future users who pay for the systems, and who will lack the support of enthusiastic R&D personnel. Future user groups can be expected to be more apprehensive and critical towards the changes imposed by this type of technology. Few problems need arise before telemedicine would be rejected as unsuitable. All of the subjects who expressed opinions on this issue emphasised the characteristics listed to the right as critical before broad diffusion of telemedicine could be expected. Several expressed high expectations towards Integrated Service Digital Network (ISDN) which will support text, data pictures and speech through a single plug in the wall. If ISDN achieves projected functionality, it can be expected to accelerate diffusion of both existing and new telemedicine applications. Flexible, cheaper, office based solutions will lower the threshold for a wide range of user groups. In addition to necessary technical improvements, several underlined the importance of well organised routines for preparation and booking of the studios. Procedures for ensuring the presence of trained personnel in both the sender and receiver studios before and during the consultation must be established. This means new responsibilities for technical and administrative personnel, and must be figured into implementation costs and plans. Restraining- Expensive equipment for limited applications- Users (of VC studio) are dependent on organising their time around other user groups - Causes annoying and time demanding break with existing routines (new and confusing booking procedures, running to and from VC studio) - Vendor dependency, lack of standardisation - Technical instability (periodically poor sound quality, break in communications lines) Facilitating+ Potential for achieving important goals (see "What can be gained ...")+ Packaged telemedicine products (including technology, service, training, consultation services tied to implementation and organisation) + Modularity, mobility, decentralised (desktop) + Standardisation + Faster and cheaper + Simple additions to existing medical technology (microscope, endoscope, etc.) + Easy to learn and use Restraining Norwegian Telecom (NT) as vendorWe received two types of general comments from health care representatives concerning NT as a vendor; confidence and satisfaction with collaboration at the local and regional levels, along with a somewhat sceptical, wait-and-see attitude towards NT's policy making at the central level. The latter had primarily to do with the tempo at which policies for pricing and organisation of the product and service apparatus were clarified.NT's marketing and service departments have traditionally been organised around telecommunication products. In later years, these departments began organising their services around customer categories or branches. While the health care sector has been categorised as a branch during the last 2 - 3 years, it presents unique challenges which NT has only recently begun to work on in a systematic way. NT's lack of an overall strategy for the health care sector was a major concern for the majority of subjects both inside and outside NT. This is reflected in the interview material in that the restraining factors listed on the left are predominantly descriptive of today's situation. The short term consequence of this is the time lag expected before telemedicine is available as a commercial product. The health care sector needs guidelines for both short term and long term planning and investments in telecommunications. Due to lack of workable market and service organisation, research scientists are often tied up in operative tasks for user institutions. Active measures are being taken to correct these problems. NT is implementing an encompassing reorganisation which will have implications for NT as a competitive organisation in general, as well as its operations within the health care sector in particular. NT's marketing strategy for the health care sector will be completed medio 1993. Mechanisms for ensuring rapid transfer of R&D products to the market organisation are also being implemented. Restraining- Lack of strategy towards the health care sector- Premature release of new products, promising more than can be delivered - Pricing policy
- Lack of knowledge about the health care sector - "Paranoid" of being accused of cross-subsidising - Poor contact and utilisation of NT's own R&D department Facilitating+ Health care customers should have few (preferably one) point of access to NT+ Overall positive contact/co-operation with NT at the local level + Large and dependable organisation + Greater freedom/flexibility in commercialising telemedical products + Competition + Knowledge of and strategy towards health care sector + Active use of introduction prices Economic and legal issuesThe difficulties imposed by today's system of transferring funds between national insurance authorities, county municipalities and local authorities, was mentioned by a majority of the subjects.For example, the national insurance authorities cover travel expenses (including transportation, diet and hotel) for ambulating specialists, as well as travel expenses for patients. Thus, they save money by replacing ambulatory services and/or patient travel with distant consultations. It is the county municipalities and local authorities, however, who bear the burden of investing in telemedicine. Further, the central hospitals (who supply specialists for distant consultation) find their incomes dwindle due to the reduced number of guest patients from neighbouring municipalities. Today's regulations state that specialist fees are contingent upon the physical presence of the specialist. In many cases, the local physician is together with the patient while the specialist performs a diagnostic examination via the telenet. According to the regulations, this is not a specialist consultation, and is thus ineligible for coverage of specialist fees. Several legal issues must also be resolved. For example, who is legally responsible for the patient - the distant specialist, or the local physician who is together with the patient? Those who expressed opinions on this issue were unanimous in support of today's regulation which places full legal responsibility with the specialist. Nevertheless, situations may arise where the issue is not definite. The Ministry of Health and Social Affairs is collaborating with the University Hospital of Tromsø in order to clarify legal and economic guidelines for distant consultations. Restraining- Complicated and rigid system of transferring funds between parties- The benefits of telemedicine are not enjoyed by those who bear the costs - Unclarified legal questions Facilitating+ Settlement based on actual cost/benefits for each party+ Each party benefits while increasing the amount of health per krone (which some believe possible) Trends in health careA series of factors - here called trends in health care - were expected to influence the diffusion of telemedicine.Several expressed a belief that the strong and inevitable trend towards sub-specialisation in the health care sector would be among the most pervasive facilitative factors in diffusion. (An example of sub-specialisation is an ear-nose-throat specialist who specialises in ears.) Sub-specialisation implies fewer specialists per subgroup - the number of which - is growing. This, in addition to the expense of highly specialised personnel and the accompanying medical technology, compounds the trend towards centralisation of care delivery, and thus also adds to the challenges of attaining the goal of equal access to quality health care. It is argued that this is among the major reasons why the effects of hard handed cost containing measures are "eaten up" by higher quality standards. Theoretically, the quality services is heightened, but it is increasingly difficult to attain the goal of equal access to quality health care. This, combined with an increase in expense and quality standards caused by rapid diffusion of high-tech medical technology will - according to some - necessitate telemedicine. Field trials involving a distant specialist who examines the patient together with the patient's general practitioner indicate that the GP - after a series of these specialist consultations - is able to diagnose and treat a greater number of patients (some estimate up to 50 %) before referring them to the specialist. The endoscopic trials will investigate this question more systematically over a period of a year. This type of knowledge transfer to rural physicians is important in achieving the LEON-principle which states that treatment should be provided at the lowest possible level of the medical professional "hierarchy", and as close as possible to the patient's local environment. The ideals of continuity in the treatment program and consideration of the patient's total life situation - both previous to and following hospital admittance - was also mentioned as a factor expected to facilitate diffusion of telemedicine. Restraining- The filling of available positions for physicians- "Protectionism" between health care professions - Shutting down of rural hospitals Facilitating+ Increased sub-specialisation+ "High-tech" medical equipment which heightens quality norms for - and expenses of - health care services + Ideals of a "wholeness" approach to patient treatment + Upgrading of general practitioner's position as the patient's primary advocate + Network concepts in organising health professionals + Increasing need for extended education and training + Increasing need and demand for more flexible collaboration between hospitals and the general practitioner (e.g. before hospital admittance, and under rehabilitation) Centralisation and decentralisationThe Norwegian society in general - the health care sector included - highly values the maintenance of decentralised public services. Thus, measures which facilitate decentralisation are viewed as positive while those involving centralisation of services are considered necessary evils forced upon health care by lack of resources and demands for rationalisation.Several subjects were concerned that telemedicine would reduce pressure for recruiting physicians in rural areas, while others were convinced that telemedicine would increase the attraction of rural positions and thus support recruitment. Telemedicine confuses some of the traditional ways of defining centralisation/decentralisation. Future considerations of this issue should build upon a renewed assessment of the advantages and disadvantages of each. It is important to keep in mind that it is policy and practical use which will determine the consequences of telemedicine along this dimension, not the technology itself. Restraining- Telemedicine has centralising effectsFacilitating+ Telemedicine has decentralising effectsPhysiciansSeveral subjects expressed the opinion that doctors - particularly specialists - would be the single most influential group effecting the diffusion process. As one put it, telemedicine won't have a chance if doctors don't like it - regardless of how supportive hospital management or politicians might be. Likewise, if doctors respond to telemedicine in a positive way, its success is assured.Although none of the doctors interviewed acknowledged the factors on the left as their personal attitudes or interests, they were confident that these factors would play an important role in acceptance and diffusion. In discussing this issue, it is useful to distinguish between two groups:
The specialists interviewed were asked why they were positive towards distant consultations. These expressed an interest in new and exciting technology, as well as emphasising the advantages for the patient and the health care system in general. Again, these specialists are among the pioneers in telemedicine developments in Norway, and it is doubtful that their attitudes and motives are representative of their colleagues as a whole. The second group - expertise receiving physicians - has to date consisted of physicians at rural hospitals and institutions in the primary health care. Through distant consultations with specialists, these physicians have built up a new degree of competence and thus an increased ability to screen, diagnose and treat patients locally. Our subjects assumed that this would promote acceptance and diffusion of telemedicine. Rural physician access to a wider professional network, as well as accreditation of specialist consultations as part of the continuing education curriculum, was also emphasised as an important incentive. Among the potentially restraining factors for this group's acceptance of telemedicine was the fear of surveillance or control from central experts, as well as concern for diluting their role as general practitioners. The effects of telemedicine on the physician's work environment was underlined as a factor influencing acceptance and diffusion. Some were concerned with the consequences of working long periods with video or screen based consultations. The importance of organising the number and type of consultations in order to allow a varied work schedule was emphasised. The effects of telemedicine on the physician's work environment will also interplay with other environmental factors. Physicians working in environments characterised by overload and stress will most likely perceive implementation of telemedicine as an additional burden. This, coupled with telemedicine's replacement of ambulatory services (i.e. "fleeing the drudge of the hospital ward") as well as a possible fall in income, will doubtlessly muster resistance - if not outright sabotage - towards implementation of telemedicine. Development of reasonable incentives as well as measures for integrating telemedicine into the work environment will be important concerns. Restraining- Preference for travel due to
- "Surgeon syndrome" - conservatism towards all other technologies than one's own - Unsatisfactory work environment - Unsatisfactory telemedicine ergonomics - Fear of "surveillance" Facilitating+ Tired of - or outright refusal - to perform ambulatory services+ Prefer using travel time for productive or rewarding work + Place importance on family and leisure time + Increase in number of female physicians + Idealists - seek the well being of patients and the health care sector Organisational cultureOrganisational culture reflects a given organisational entity's values and norms and thus also its ability to accept and grasp change. It affects the way implementation processes are dealt with, and thus also the rate at which the organisation is able to enjoy the benefits of innovations such as telemedicine.The factors grouped and listed below are limited to user organisations - in our case hospitals, hospital wards, primary health institutions, etc. Cultural issues related to other relevant organisational entities (e.g. the health care sector as a whole, vendor organisations such as Norwegian Telecom) are scattered throughout the interview material under other factor group headings. Both the facilitative and restraining factors listed above can be recognised as having general relevance for any encompassing technical innovation and implementation process. Diffusion of telemedicine implies far more than purchase and installation of telemedicine equipment and communication services. It implies new roles and ways of interacting between professional personnel, as well as new tasks for technical and administrative personnel. The decisive role physicians are expected to play in the diffusion of telemedicine (see previous section) is in part due to the powerful effect they can have as opinion leaders - and thus also the organisational culture - within health care institutions. Restraining- Job insecurity due to hard-handed rationalisation policies- Poor experiences with similar technology implementation ("more technology dumped over our heads") - Exaggerated focus upon short-term savings - Personnel generally worn out - Implementation designed solely by individual enthusiasts, thus making the organisation vulnerable to turnover - Lack of supportive management - Lack of incentives for change Facilitating+ Management support and view that technical implementation implies organisational development+ Oriented towards goals and common vision + Open information flow and personnel participation in implementation process + Tolerance for enthusiasts/those who take risks + Value status of modernised operations + Hope for "saving angel" (e.g. small rural hospitals threatened with closing down) Cost/benefit assessmentsSeveral subjects expressed the view that the time is right for initiating cost/benefit assessments. It is assumed that this type of documentation is necessary in order to obtain "diffusion facilitative decisions" from both health care authorities and telemedicine related industry. Few, however, offered specific views as to how such studies should be performed, or if and how the results would be used.Some were concerned that cost/benefit studies could do more harm than good if the studies weren't conducted properly. There was an awareness that it is methodologically difficult - as well as touchy - to find meaningful measurements (i.e. "price tags") for the wide range of elements involved in providing health care services (e.g. to rural areas) - with and without telemedicine. Restraining- Assessment made too early or too late- Assessment based upon one party's point of view - Tendency to focus upon short timespan - Tendency to ignore qualitative factors which are difficult to measure Facilitating+ Used to demonstrate need for restructuring reimbursement system+ Used as basis for tailoring distant consultation fees Summary discussionThe interview material gives an idea of what persons with telemedicine experience believe will be important restraining and facilitating factors in the diffusion of telemedicine. The following factors which emerged have been discussed:
The most obvious facilitative factor which emerged from the interviews is the belief that telemedicine will benefit both patients and the health care sector. The majority of subjects - many of which are decision makers - repeatedly emphasised the potential benefits of telemedicine as the major facilitative factors for the diffusion of telemedicine (see "What can be gained ..."). Although we cannot assume that "do-good" technologies diffuse more effectively than other technologies, we can assume that the opinions of those interviewed will play an important role in the diffusion process in Norway. The subjects belong to a network of health care, administrative and political professions which - compared to many countries - are relatively personalised and transparent in Norway. Those who saw potentially negative consequences of telemedicine, suggested ways to avoid these consequences. These suggestions included technical, organisational, economic and legal measures, each of which were believed feasible. The major overall restraining factor which emerged throughout the interviews is the complexity of the two parties playing decisive roles in diffusion: Norwegian health care sector, and the Norwegian Telecom. The health care sector - as the recipient and user of telemedicine - must implement a series of economic and organisational measures in order to achieve the projected benefits of telemedicine. Telemedicine - the use of which often breaches traditional organisational boundaries - will be hampered by the rigid roles and division of responsibility between national, county and local authorities. Characteristic of large, intricately rule-governed systems is a built-in sluggishness in the types of decision making processes necessary in designing and implementing new policies conducive to utilisation of innovations like telemedicine. Similarly, the process of developing and implementing medical and technical standards into an integrated "health network" (emphasised as decisive for telemedicine's success) can be characterised by tug of war between a wide range of interest groups within the health care system. These characteristics of the health care sector are particularly challenging for vendors of information and communication technology. As opposed to many other business customers, there is no co-ordinating IT-strategy to which vendors can tailor their product and marketing strategy. Norwegian Telecom (NT) is the major locomotive for telemedicine related industry in Norway. NT itself is undergoing encompassing changes as it moves from a monopoly to a competitive role. The splitting of products and services into ONP and competitive groups, and the emergence of a series of small companies as part of the liberalisation process, makes NT appear like "a troll with many heads" as one subject described it. Few have a clear idea as to how these different entities will collaborate in marketing telemedicine within the health care sector. Customer demand for packaged solutions (including all necessary equipment, communication, training, installation, service) and fewest possible (preferably one) vendor relationship, is a formidable challenge for telemedicine related industry. Another important challenge is development of the type of competence needed within the marketing organisation in order to anticipate and meet the diverse needs within the health care sector. We contend that a great number of the restraining factors which emerged during this study can be understood in light of the complex nature of the health care sector's and NT's organisation - and their consequent ability to grasp the acknowledged potentials provided by telemedicine. The technical problems described by our subjects as restraining would appear to be the least concern. These types of problems receive continuous attention and are being solved at a rapid rate. As we try to anticipate the diffusion of telemedicine, it is important to keep in mind that telemedicine is not a single product (e.g. PC, telephone, or new type of medicine) to a single customer category (e.g. Norwegian households where one or two persons decide purchase and routines for use). Realisation of telemedicine's potential benefits demands fundamental change within both receiver and vendor organisations. Background referencesAndersen, K A. 1992. Videokonferanser i helsevesenet: erfaringer fra to års bruk i Troms og Finnmark. Kjeller, Norwegian Telecom Research. (TF paper N3/92.)Foss, G, Jøsendal, O. 1991. Fjernkonsultasjoner. Kjeller, Norwegian Telecom Research. (TF report R9/91.) Gammon, D. 1991. Evaluering av teleradiologiforsøket v/RST - TMS; aksept, bruk og diffusjon. Kjeller, Norwegian Telecom Research. (TF report R67/91.) Valvåg, H et al. 1992. Applied Telemedicine. Tromsø, Tromsø teleområde. Kjeller, Norwegian Telecom Research.Table 1 |
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Sist oppdatert 03-09-99.