TeleMed Asia '97, 17 September 1997

A Business Approach to Telemedicine

John Mitchell

The main theme of this paper is that telemedicine is becoming more complex and therefore requires rigorous planning and management, if we are to realise its full potential.

My first involvement in telemedicine was in early 1994. I had just finished an evaluation of videoconferencing in higher education in Australia when I was engaged to manage a renal dialysis telemedicine project and to evaluate a telepsychiatry network. At that stage, telemedicine was so new in Australia, my primary focus was on change management strategies - anticipating resistance and avoiding sabotage. Telemedicine has exploded since then and while change management strategies are still required, many other techniques are required to ensure that telemedicine becomes properly embedded in the health care arena.

In 1994 we needed clinical champions and while we still need them, we also need business managers, such are the increasing complexities of many telemedicine networks. Telemedicine now needs both inspiration and perspiration, both vision and practical skills.

Technology, concepts and definitions changing

We need more rigorous planning and management, not least because telemedicine is changing. In 1994 telemedicine meant, to most people, either videoconferencing consultations or teleradiology. In other words, the definition was based on the predominant technology used. In 1997, the emphasis is on telemedicine being part of a paradigm shift towards a preventative, managed care, self-care, client-focused approach to the delivery of health care.

While this shift in definition and the development of more conceptual depth are due in part to the powerful functionality of technologies now available, telemedicine is both being pulled by and helping to drive a new agenda about how health care can be provided. Concepts and available technology are impacting on each other.

The Government of Malaysia's document, 'Malaysia's Telemedicine Blueprint: Leading Healthcare into the Information Age', is an outstanding expression of this new paradigm. It is a truly 'conceptual model and implementation road map for the roll-out of telemedicine across the country'.

Such visionary statements are also a signal that we will need to develop more sophisticated techniques for transforming the vision into reality. In my work as a consultant in telemedicine, my life would be easy if I quit projects at the point of recruiting the initial clinician champions and other eager users. I believe that the main challenge with telemedicine is to manage the innovation past the early adopter phase, so that it becomes part of the daily fabric of the organisation.

The need for a business approach

What I mean by a business approach includes a comprehensive, professional approach to the multitude of issues that telemedicine raises. For me, a business approach immediately means adopting a strategic planning framework, so that every telemedicine initiative is planned in terms of needs analyses, environmental trends, resource analyses, target setting, external opportunities and threats, internal strengths and weaknesses, development of strategies and implementation steps. Again, if I wanted an easy life as a consultant, I would step aside at this point, because the harder stage is yet to come: that is, carrying out the plan.

Once a telemedicine project commences, it requires high order strategic management skills and knowledge to succeed. This is because telemedicine requires substantial changes to work practices, it requires people to collaborate in ways they may never have been asked to in the past, it upsets previous power balances, it may be for the benefit of the patient and not the clinician, and it opens up a whole new world of what can be provided for staff and patients in the areas of education and information services.

Telemedicine also requires robust strategic management, because it raises people's expectations. Telemedicine managers need to not only manage the resisters, they also need to manage those whose imagination run too far ahead of what most people are able or want to achieve.

Telemedicine also needs thorough management because, as an industry, it is not only still in its childhood, or at best adolescence, it is in flux, and may continue to be in flux for some time, if not forever! Telemedicine is an adolescent industry, in that there is a lack of cohesion between the many and different players in the field, which I will discuss below, regarding a national scoping study I am undertaking for the Australian Government. Telemedicine is in flux because its borders keep being moved. For instance, just as we became comfortable with telemedicine in the hospital ward, there is an exciting new push for telemedicine to the home.

Just as we thought telemedicine would settle down into the two main camps of videoconferencing and teleradiology, other technologies are opening up new doors of opportunities, such as the Internet, call centres and electronic patient record systems. We now have 'battlefield telemedicine', 'correctional services telemedicine', 'mental health telemedicine', 'elderly care telemedicine', 'disaster telemedicine' as well as all the specialties we can attach the prefix tele- to, such as tele-psychiatry, tele-cardiology, tele-paediatrics, tele-neurology and many others.

While we have this exciting explosion of applications, we still have significant barriers. In every telemedicine initiative I am aware of, there are significant legal, regulatory, financial, cultural and skill barriers that still need to be addressed.

Business approaches at four levels

I would now like to use my own country as the reference point for the following discussion. We need business approaches in telemedicine at the four levels at which telemedicine generally occurs: at the national, State/regional, hospital/district and speciality levels.

National level

At the national level, the Australian Government has recently undertaken extensive consultation with key industry players and has concluded that what is needed is a concise scoping study to identify and bring together information on the increasing number of organisations interested in developing the telemedicine industry. It is also necessary to assess the scale and extent of the existing and emerging opportunity, to serve as a basis for a future industry development strategy.

The study has been designed by the Department of Industry, Science and Tourism and my company has been commissioned to undertake the exercise in the coming months. The study is an indication that telemedicine is no longer just about enthusiastic clinicians experimenting with new technologies. A whole new industry is developing, with many different players, such as transmission providers, software developers, technology integrators, manufacturers, researchers and, bless them, consultants. The 'industry development' and market components of the study are a surprise to many telemedicine practitioners who had come to see telemedicine as centering around the early adopters of telemedicine, clinicians in hospitals. Increasingly, telemedicine is being used by allied health professionals, nurses, health educators and a variety of patient groups who were not a significant part of the telemedicine wave several years ago.

The study will requires the consultant to:

  • identify the present and potential size of the market for telemedicine products and services.
  • assess the scale and extent of the existing and emerging opportunity and serve as a basis for a future strategy.
  • identify key issues facing Australian industry in using telemedicine and potential for its use.
  • identify and where possible quantify both the costs and benefits to Australia in terms of economic activity and social impacts.
  • address the extent to which telemedicine operations from Australia would be commercially viable.
  • describe the Australian potential to create a new medical information technology industry in Australia.
  • discuss opportunities to foster industry collaboration with public/private hospitals and Australian companies with appropriate expertise for the development and export of new medical products and services.
  • provide a brief summary of how Telemedicine provides a vehicle to improve the excellence and cost effectiveness of medical education and training, and health services in urban, rural and remote communities.
  • comment on how industry development and investment focus can be designed to encourage multinational medical equipment and IT vendors to collaborate with Australian industry.
  • identify measures to encourage multinationals to consider manufacturing telemedicine equipment in Australia.

This list of tasks represents a sophisticated grasp of the emerging complexities of telemedicine and signals a determination to properly scope and positively stimulate further development. I expect to put a discussion paper on the DIST project web site in about a month's time.

Ideally, the benefits of this business approach to telemedicine are that it will encourage the market segments, it will lead to improvements in products and services and it will lead to more frequent benchmarking and pursuit of quality.

State/Regional Telemedicine

My company is currently advising a State Government on a plan to introduce telemedicine over the next three years. This an excellent opportunity for that particular Government to learn from the findings of the early adopters and to use best practice in business approaches to telemedicine.

State Governments are able to influence many facets of health care delivery. The business planning process in the State we are advising already has taken many, many months and has involved a very wide gamut of stakeholders. The planning documents are very extensive, and cover areas ranging from needs analyses, information technology, resources and sub-projects. The planning discussion has also covered designing an evaluation framework and developing risk management strategies.

Hospital/District Telemedicine

An example of how telemedicine is encouraging new business planning between hospitals and in districts is provided by two major South Australian hospitals, The Queen Elizabeth Hospital (TQEH) (North Western Adelaide Health Service) and the Women's and Children's Hospital (WCH). Each of the hospitals has a significant strength in telemedicine: TQEH in teleconsulting, and WCH in the use of the Internet for health purposes.

The WCH web site has attracted wide acclaim and can be viewed at http://www.wch.sa.gov.au The web site also includes information about their whole of hospital approach to telemedicine (telehealth is their preferred term, as it is more inclusive than the word telemedicine). The WCH is using telemedicine in the highly conceptual manner discussed earlier: to change the way they provide services. It is aiming to be a 'hospital without walls', to provide services for women and children throughout South Australia, and telemedicine is one way it will achieve this goal.

The two South Australian hospitals have sensibly formed a collaborative arrangement and registered the business name Telehealth Partners. Their web site www.telehealth.sa.gov.au provides a demonstration of the business thinking behind their initiative, providing information on the venture's objectives, benefits, strengths, services and strategies.

Specialty Telemedicine

Individual medical specialties have shown outstanding leadership in telemedicine in Australia. Professor Peter Yellowlees, who is also presenting at this Conference, has been the leading practitioner of tele-psychiatry in Australia, and has had a major impact nationally.

We have managed The Queen Elizabeth Hospital's Renal Telemedicine Network since its inception and have pursued best practice in taking a business approach to both planning and managing the network. Details of the project are available on our web site at http://www.jma.com.au This project, at the micro level, is an indication of all the issues and challenges discussed earlier in this paper. The project has become more and more sophisticated as technology has changed, as the number of users and the types of users has increased, and as the planning has constantly raised the high jump bar about what could be achieved.

The videotape made on the project - 'Clinical Telemedicine' - is an insight into the complexities of telemedicine, as it becomes a tool for the full range of staff within the renal setting, from surgeons, to nephrologists, registrars, nurses, pharmacists, dietitians and social workers. The videotape also shows how telemedicine can empower patients to seek out their specialists in the metropolitan area.

The videotape demonstrates the innovative uses of telemedicine by the Renal Unit at TQEH, focusing on clinical applications, with some reference to the administrative, staff development and educational applications of telemedicine.

Some of the clinical applications depicted in the video include:

  • renal specialists providing routine and emergency patient diagnoses for dialysis patients with arterio venous access use and complications; for transplant patients with skin lesions; and for diabetic patients with renal failure;
  • surgeons deciding to amputate an ulcerated toe during a telemedicine diagnosis session;
  • the renal pharmacist educating a patient about new drugs;
  • a very ill Aboriginal patient relocated to the capital city, linking to her family in the country, for emotional support.

The videotape demonstrates that:

  • telemedicine enables the Renal Unit to improve the quality of service;
  • the entire Renal Unit team uses telemedicine;
  • telemedicine facilitates the teamwork required for dialysis and transplantation services;
  • nursing staff in satellite centres regularly use telemedicine to link to doctors and other team members;
  • patients are keen to use it, particularly for emergencies;
  • communication with patients and other staff is markedly enhanced by the visual contact and non-verbal language;
  • telemedicine reduces patients' anxieties by providing visual access to medical staff;
  • telemedicine enables remote and rural patients (especially Aboriginal patients) relocated to hospitals in Adelaide to maintain contact with home, and to return home more quickly;
  • telemedicine provides general practitioners in remote areas with access to specialists and opportunities for continuing education;
  • telemedicine enables hospitals in country towns to provide a better service for small, remote centres;
  • telemedicine saves time and costs for doctors and patients.

The video also shows the value of integrating various technologies such as videoconferencing, computerised patient databases and scheduling programs. This integrated approach enables a clinician simultaneously to see the patient live on-screen, to search a medical database and to examine a repository of still images.

Summary

I would like to use the microcosm of the Renal Telemedicine Project to return to the main themes of this presentation. The achievements of the project were no fluke. The achievements were the result of inspiration and perspiration; of rigorous planning and exhaustive management; of consultation, collaboration and persuasion. The achievements were not made overnight: some staff resisted until they were very sure that the technology. The video 'Clinical Telemedicine' is a tribute to the staff and patients of the Unit who have made a conscious decision to change their paradigm about what can be achieved, using telemedicine.

The Renal Unit at TQEH are a microcosm of what can be achieved with telemedicine, if the appropriate planning and management practices are put in place.

Telemedicine is now a sophisticated undertaking, requiring extensive business planning and management practices, if we are to realise our dreams of what telemedicine can deliver.

Speaker's Details: John Mitchell

John Mitchell is the Managing Director of John Mitchell & Associates (JMA), a consultancy company specialising in the areas of telemedicine, open learning and videoconferencing. Services include feasibility studies, business cases, market analyses, planning reports, project management, methodology training, evaluation, research and information services.

John Mitchell is recognised as one of Australia's leading private consultants in telemedicine. Currently he is conducting a study for the Commonwealth Department of Industry, Science and Technology (DIST), the 'National Scoping Study for the Telemedicine Industry.'

JMA's reports 'The Challenge to Embed Telepsychiatry', 'Establishing Renal Clinical Telemedicine' and 'Best Practice in Telemedicine' have drawn accolades from around the world and their web site www.jma.com.au has won considerable international attention.

Presently John Mitchell is telemedicine consultant to The Queen Elizabeth Hospital's Renal Telemedicine network, telehealth consultant to the Women's and Children's Hospital in South Australia and a member of the Telehealth Partners core management group.

Recently John Mitchell completed a report for five South Australian Government agencies on 'Opportunities in Telehealth and Information Technology'.

Previous assignments have included aged care telemedicine, nurse tele-education, infectious diseases telemedicine and Aboriginal telemedicine.