Two Leading Edge Telemedicine Projects: Lessons Learnt

John Mitchell Managing Director John Mitchell & Associates

A paper presented at the Australasian Teleconferencing Association ATA Telecon'95 Conference 30-31 October 1995 The Landmark Hotel, Potts Point

The Two Projects

John Mitchell & Associates (JMA) has a close involvement with two of the major telemedicine projects in Australia, the South Australian Telepsychiatry Project and The Queen Elizabeth Hospital's (TQEH) Renal Dialysis Telemedicine Project.

Firstly, JMA was the evaluator of the South Australian Mental Health Services (SAMHS) Telepsychiatry Project in 1994, focusing on user rates and types, cost effectiveness, training, implementation, management and cost effectiveness issues. Our final report "The Challenge to Embed Telepsychiatry" emphasised the early successes but fragile nature of the project. The report was favourably received and further funds were injected into the network in 1995, enabling its expansion from three to six sites.

Secondly, JMA has managed TQEH's four-site Renal Telemedicine Project since June 1994 and now has been re-engaged until July 1996. In September 1995 we produced a comprehensive evaluation of the first twelve months of the project, entitled "Establishing Renal Clinical Telemedicine." This paper draws considerably on material contained in our two reports.

Within the Context of Telemedicine in Australia

While telemedicine is very topical at the moment , the two South Australian projects are among a handful of telemedicine projects that have survived into their second year. Other telemedicine activities of some note are the telepsychiatry initiatives of Professor Peter Yellowlees from Queensland University and the long-standing achievements of the Tanami network in the Northern Territory.

Overview of Telepsychiatry Project

The evaluation study of the telepsychiatry project identified a crucial challenge for the SAMHS and the South Australian Health Commission (SAHC): how to ensure that the significant successes of the 1994 Telemedicine Pilot Project between Adelaide and Whyalla would lead to the embedding of telepsychiatry in the SAMHS and the SAHC.

Telemedicine involves the use of telecommunications technology for the delivery of health care to remote locations and for other purposes such as clinical assessment, patient management, staff training and administration. The particular telecommunications technology used in this project provided for the transmission of live, two way videoconferencing, using digital compression. Telepsychiatry is defined as the application of telemedicine in the mental health field.

The videoconferencing equipment linked clinicians and other health workers at Glenside Hospital in Adelaide, Riverland Regional Hospital (255km from Adelaide) and Mt Gambier Hospital (400km). Although Whyalla Hospital (400km) was not formally part of this Project, some evaluation of their use of the facilities is recorded in the report.

The evaluation focused on the 'non-clinical' aspects of the pilot such as the types of uses, rate of use, user acceptance, user friendliness, cost effectiveness, productivity gains, technology reliability and effectiveness and the use of the facilities for service delivery and education and training.

The SAMHS received a grant from the Health Commonwealth Network in 1993 to enable it evaluate the use of telecommunications equipment for a number of applications including telepsychiatry, that is, professional psychiatric support for clinical services delivered over a videoconferencing link, mental health team training and development and case management reviews.

The objectives of the telepsychiatry project included:

  • to design an evaluation process to assess the impact of the telemedicine health system on performance indicators set out below
  • to implement and co-ordinate the evaluation process for clinical applications and administration and education
  • and to analyse the following performance indicators: technical, economic, usage and acceptance of the system, productivity gains, service delivery and education and training.

Telepsychiatry Project: Lessons Learnt

The major theme of the report "The Challenge to Embed Telepsychiatry" was that the SAMHS Pilot Telemedicine Project had achieved much in 1994 but the project was in a fragile state after its first six months of operation. The following achievements were recorded:

  • the Log of Uses demonstrated that the facilities were used by a wide range of health care related bodies for numerous applications, including clinical consultations, staff training and community health activities
  • a User Survey completed by 77 users gave resounding support for the medium
  • interviews with stakeholders at Glenside, Berri and Mt Gambier revealed strong support among a range of personnel and staff were convinced that the medium was effective for a range of clinical, training and administrative purposes
  • the literature review indicated that there were aspects of this pilot, such as the breadth and quality of mental health applications, that are of international significance
  • the willingness of the emergency section at Glenside Hospital to use videoconferencing for urgent consultations with the country mental health teams was a significant breakthrough
  • a number of patients were able to stay in their country town rather than be transferred to Glenside for an assessment, because of the use of the telemedicine facilities.

Problems and issues

Compared to similar telepsychiatry projects undertaken overseas, the SAMHS project produced outstanding results in its first year. However, as could be expected in any pilot project, problems and issues arose that needed addressing in the second stage of the project:

  • while many organisations had used the facilities either once or twice, very few had become regular users
  • only four psychiatrists used the facilities more than five times, and one more than ten, between May and October 1994 and only two general practitioners have been involved
  • it is unclear to the outsider as to how much the SAMHS telemedicine equipment is meant to be used by psychiatrists, how much it is to be used by other practitioners in the mental health field and how much it is to be used by other medical fields
  • most users have declined the offer of training
  • the videoconferencing equipment at Berri and Mt Gambier was unreliable and prone to breakdown (this was later replaced)
  • legal and ethical problems regarding telepsychiatry needed further investigation
  • if the handful of significant advocates or users of the telemedicine facilities at each of the three sites was to withdraw from active participation in the project, the project would flounder .

Cost Effectiveness

Cost effectiveness issues were discussed in some depth in the report and the following are summary points:

  • use of telepsychiatry will require additional funding, to account not only for the equipment and transmission costs and the necessary administration, but also to account for new services that could be offered to the many people in country areas presently denied access to mental health care
  • whilst on the basis of current client demand, some savings could be made by the SAMHS in terms of the reduction in the number of hospital beds that could be required each year and a reduction in the number of patients transported by ambulance or the police (which could be as high as 50% of annual figures), as a result of assessments conducted using telepsychiatry, telepsychiatry may also uncover presently unmet needs.

Early adopters

In terms of the stages that any innovative technology-based project moves through, after six months the telemedicine project was still dominated by "early adopters" who will always support a new approach if they can predict benefits will arise. For the project to survive, it needed to move to the next stage where more conservative "early majority" users, who like to know that the risks in using the equipment have been removed and who can see concrete benefits arising, become involved.

"Early majority" users will only join in if the project is robust, well resourced and likely to succeed. For the "early majority" to provide active support, telepsychiatry needed to be embedded as a normal way of providing mental health care in the SAMHS.

It needs to be stressed that most projects involving videoconferencing take at least 2-3 years before usage reaches an optimal level, and the SAMHS equipment had only been operating for six months when our evaluation concluded in November 1994.

In summary, the telepsychiatry network was in a vulnerable stage after its first six months of operation: it needed ongoing funding support, a clear policy framework, improved equipment and maintenance arrangements, vigorous promotion and continued strong management if it was to prosper in its second and subsequent years. We are pleased to report that our challenging report was well received and that the telepsychiatry network has prospered in 1995. A Telemedicine Unit has now been formed within the SAHC for Telepsychiatry: a first in Australia.

Overview of TQEH Renal Telemedicine Project

TQEH's Renal Dialysis Telemedicine Project was undertaken by TQEH Renal Dialysis Unit from May 1994 to June 1995 and included the installation of telemedicine facilities at its four renal dialysis centres at Woodville, Wayville (10 km from Woodville), North Adelaide (8 km) and Port Augusta (300 km). The Unit dialyses a total of 145 patients at these four centres, with each patient normally dialysing three times per week and attending an outpatients clinic once every two months. The Unit also cares for 29 patients who dialyse at home.

Funding for the project was provided by the SAHC in November 1993, a brave initiative given the embryonic state of telemedicine at that time. TQEH's Senior Staff Nephrologist, Dr. Alex Disney, was appointed Project Director and John Mitchell, Managing Director of John Mitchell & Associates, was appointed Project Manager and Researcher, in June 1994. Registered Nurse Julie Meyer was appointed Project Officer in October 1994. Dr. Disney, John Mitchell and Julie Meyer formed the project management team. Psychology graduate Benjamin Mitchell, also from John Mitchell & Associates, provided research and training assistance.

Telemedicine and dialysis services

Dialysis supports the majority of patients with chronic renal failure. The number of patients treated is growing at a rate of 10% per year. 75% of patients are supported on haemodialysis and in South Australia the majority of these are located in satellite centres. The trend here and overseas is increasing in this direction.

Problems which arise in delivering dialysis in these satellite units are numerous and include: maintenance of standards of care, initial training of staff, continuing education of staff and updating of procedural skills, managing acute problems in patients such as incidental illness, collapse, fistula problems and maintenance of professional relationships and discipline in a chronic care situation remote from senior management and assistance.

These problems are currently managed by high cost options which involve either staff spending more time gaining a high initial skill level with regular updating at the parent institution or skilled personnel travelling to the site (e.g. management, paramedical support, medical staff). Even with this level of support, compromise is frequent and in the case of country patients, referral of the patient back to Adelaide is often necessary.

The project was undertaken as it was considered that telemedicine has the potential to address a number of the problems listed above.

Aims

The original aims of the project were to assess the feasibility and cost effectiveness of telemedicine as a means of improving the quality of patient care. The project also aimed to determine the need for the further education of dialysis staff and to monitor dialysis processes and equipment at sites remote from the main dialysis institution.

These aims were later expanded, based on experience, to include the development of strategies to accelerate user adoption and to maximise both the number of users within the Unit and the breadth of telemedicine applications. A further aim was to assess the value of desktop videoconferencing for clinical consultations.

The term telemedicine implies the use of telecommunications to provide health care. The aspect of telemedicine trailed in the project was the use of videoconferencing. The definition of telemedicine is discussed in some depth in the final report "Establishing Renal Clinical Telemedicine".

Critical factors for success

The final report provides insights into the factors critical for the successful implementation of telemedicine in its first year. The report indicates that much planning, effort, co-operation and an appropriate culture within the Renal Unit were needed to achieve a high level of acceptance of telemedicine.

International Breakthroughs

The project made a number of international breakthroughs for the cause of telemedicine and for the SAHC: notably,

the ability to conduct clinical consultations at low bandwidths (128kbps);

the effective use of state-of-the-art desktop videoconferencing for clinical consultations;

the use of telemedicine by the full gamut of staff and patients in a workplace;

and the collection of considerable data related to user adoption of telemedicine.

Renal Telemedicine: Lessons Learnt

The report "Establishing Renal Clinical Telemedicine" demonstrates that telemedicine is a human activity, not a technological event, and that the technology is merely the vehicle for enabling the delivery of health care services. Hence, much of the focus during the project was on cultural issues such as staff and patients' perceptions and expectations, beliefs and motivation.

Importantly, the project management centred on responding to users' needs; providing a constant flow of information, support and training; adapting the technology to the workplace; and giving staff and patients sufficient time to see the benefits of telemedicine to themselves.

Cultural Change

This story of negotiation and cultural change is uncomfortable news for those vendors who expect telemedicine equipment sales to boom merely because the equipment works. It also signals caution to those consultants who develop cost benefit analyses for telemedicine based on fanciful assumptions and projections about adoption rates and patterns as well as to health care administrators who might hope that telemedicine is easy to implement.

No Transplanting

The report also shows that TQEH's successes with telemedicine cannot simply be transplanted to every other health care unit either in TQEH or any other hospital. While TQEH project can provide invaluable information about critical success factors and about how to introduce innovative technology, telemedicine projects in other organisations will need to address challenges similar to those that arose in this project, but specific to their own organisational context. There are telemedicine facilities in Australia and overseas that failed to address these general and specific issues, and now lie idle.

The report locates the TQEH Renal Dialysis Telemedicine Project within the context of the international evolution of telemedicine, and more recently, the explosion of activity in this field. The study demonstrates that the challenges and unresolved issues faced in the project are similar to those faced elsewhere. The project demonstrates the need for the SAHC to investigate generic issues such as legal liability, payment for telemedicine clinical services and confidentiality of clinical sessions.

Change management strategies

The report describes the particular culture of the Renal Unit of TQEH and the management strategies used to implement telemedicine. Much effort was required to continually modify what was essentially boardroom videoconferencing equipment to suit the busy and sometimes frantic, high pressure context of a dialysis ward.

Key strategies used to introduce telemedicine included:

  • addressing staff and patients' concerns, particularly about confidentiality, privacy and the mobility of the equipment;
  • conducting awareness raising and induction activities as well as basic and advanced training;
  • consulting users and providing them with adequate information about the aims of the project;
  • developing adequate operational documentation;
  • continually modifying the technology;
  • promoting the concept;
  • and providing feedback from evaluation surveys and research.

Evaluation Strategies

The main evaluation instruments used were six surveys, including one longitudinal study, and numerous interviews, observations, small group discussion and collection of data regarding actual usage. A case study was also conducted of the use of the desktop videoconferencing unit by a physician. As a result, the project has gathered one of the most comprehensive sets of data in the world on user acceptance and adoption issues within telemedicine.

The main form of evaluation used during the project was participant evaluation, conducted by the project managers and designed to provide up-to-date information for the project management team, for immediate response.

The formative evaluation reveals the hopes, concerns, impressions, surprises, disappointments and, ultimately, the acceptance of telemedicine by the staff and patients. The data emphasise the need for

  • a continual dialogue with the users about the project's goals;
  • extensive training and practice in how to use the technology;
  • and for modification of the equipment so that it is easy to move and use, reliable and able to provide quality images in a private setting.

The staff interviews illustrate the range of telemedicine users, from the clinician, registrar, clinical nurse consultant and registered nurse to the pharmacist, dietitian, social worker, nurse educator, technician and ward clerk. This range was much broader than originally anticipated and adds considerably to the cost effectiveness of the facilities.

The case study in the report on the use of the desktop videoconferencing unit is of international significance, as this technology has only recently become available and there are few precedents for its use in the clinical setting.

Cost Effectiveness

It was not possible to examine, in any detail, cost effectiveness issues during the project due to the delayed start of the project at the final two sites, especially Port Augusta. It was also considered premature to evaluate the project until it had a minimum consistent level of use had been achieved, otherwise we would just be evaluating the early installation issues.

However, the report demonstrates that the facilities are saving time and expenses for TQEH and patients and it clearly illustrates the role telemedicine can play in ensuring the quality and effectiveness of satellite centres not staffed by doctors.

In the long term, the major savings from telemedicine may come from less obvious benefits such as improving the provision of services to patients, including dietitian and pharmacist services, so that the health of dialysis patients does not deteriorate to the point of requiring hospitalisation. The report also demonstrates that the cost effectiveness of telemedicine is enhanced by many intangible benefits such as improved staff development, staff cohesion, faster decision making and instant diagnosis.

Summary Lessons

Added to the many lessons already noted above are the following points.

Modifying Boardroom Technology

Videoconferencing technology is still mostly designed for static boardrooms, where dark glass cabinets are appropriate. The two projects discussed above have shown that:

  • mobility of the units is a serious issue. The units are often too heavy and cumbersome to move from room to room, despite manufacturers' use of the term "rollabout".
  • confidentiality of the patient interview is also a significant issue. The addition of headsets with headphones and microphones overcomes most of these issues.
  • miniature probe cameras are available and, when placed on a stand, are a valuable clinical aid
  • newer model videoconferencing equipment with cordless keypads are an asset in the clinical arena. PictureTel, who supplied TQEH's equipment and the second set of equipment for the telepsychiatry project, have met this requirement.
  • a technology integration firm, such as Network Nomis who were involved with the two projects discussed, is essential for any substantial installation beyond one or two sites
  • project management requirements for telemedicine implementation are substantial. We are occasionally surprised by health organisations who think that the hardest decision in telemedicine is selecting between different brands of videoconferencing equipment. Others think that if they ask the technology providers to show staff how to press the buttons, the equipment will be magically integrated into the daily operational fabric of the hospital. It isn't that easy!

Effective Change Management Techniques

JMA has considerable experience with managing the implementation of videoconferencing in organisations, based on our educational, psychological and management expertise. Factors we consider influence the adoption of telemedicine into an organisation, such as TQEH and the telepsychiatry network, include the following:

  • unless the technology is perceived as being easy to use, reliable and effective, the system will not be used
  • unless users are properly inducted and given support and understanding over their concerns with the equipment, they will not progress past novice level of use
  • unless users are provided with higher order training, adequate documentation and structures (such as timetables and local support), they will not progress to become regular users
  • unless users can see specific applications that can make their job easier or enable them to provide improved quality of care and service to the client, they will not progress to become regular users
  • users will use the system to the extent that it provides positive advantages for them in a personal and organisational context
  • users are more likely to develop into frequent users if they have specific goals regarding their use of the system.

These beliefs were tested in surveys and interviews during the TQEH project and the results are discussed in the final report. In the TQEH project the following strategies were used to manage the concerns of the patients and staff, and to gradually win their support:

  • activities to raise awareness were undertaken, acknowledging the concerns of the users
  • the process was promoted through regular memos, newsletters, one-to-one and small group discussions
  • information about project developments, such as the timing of installations and the provision of training and support, was regularly made available to the staff and patients
  • the results of surveys were provided directly to the staff
  • the staff were consulted when decisions were needed on issues that would affect them, such as the siting of the equipment and the modification of the rooms
  • a structured staff development program was developed, progressing from awareness raising activities, to induction, basic and advanced training
  • accurate lists were kept of staff and patients who had been inducted and trained
  • a series of demonstrations and special events were arranged
  • equipment designed for ease of use was selected.

Matching organisational goals and individual users' goals

Our research for the TQEH project showed that some of the initial fears of staff about using the system were due to the mismatch between the project or organisation's goals and the individual user's goals. For example, at different stages of the twelve month project, some staff were not sure what the aim of the project was, what staff were expected to use it for and how often staff were expected to use it. In TQEH's Renal Unit, this lack of congruence was aggravated by the staff being dispersed over four locations, the shift work nature of the Unit, and the fact that a number of staff are temporary.

Many of the change management strategies listed above enabled us to address this mismatch in goals. Most importantly, we developed feedback loops between the Project Management Team and the staff, so that staff knew we were taking into account their views. In the second year of the project, we are negotiating performance agreements with staff on how, why and how often staff will use the facilities.

Techniques for fast-tracking user adoption

Some readers of this section may have hoped that "fast-tracking" would mean quick short cuts. From our work with the two telemedicine projects and other related projects, we know that there are necessary processes that, once followed, enable the project to be fast-tracked, as follows:

  • conducting of needs analysis
  • clearly defining aims and objectives
  • developing a project plan, a project team and clear roles and responsibilities
  • managing the technology installation and modifications
  • regularly consulting with key stakeholders and users to match project and individuals' goals
  • developing an operational management system
  • conducting structured methodology training
  • evaluating the project.

In addition to these generic steps, we know that each project involves a unique organisational culture and different levels of experience and acceptance of innovations, so the above processes need to be tailored to suit the specific context.

The role of formative evaluation

In the two telemedicine projects we have discussed above, formative evaluation consisted of surveys, structured interviews, observations, and regular reports. This formative evaluation was crucial for:

  • providing feedback for everyone involved with the project
  • enabling the Project Management Team to measure the achievement of objectives
  • providing formal data on usage patterns and behaviour
  • providing objective data to complement subjective data
  • highlighting problem areas and evaluating the effectiveness of interventions designed to overcome them.

Final Comment

As mentioned earlier, telemedicine is essentially a human activity not a technological event, where users' attitudes, beliefs, skills and knowledge are more important than the technology used. There is a need to rigorously manage the processes of project planning, implementation, management and training, but every project involves a unique organisational culture and special challenges.

Profile of John Mitchell

John Mitchell is Managing Director of John Mitchell & Associates, a company providing consulting services in telemedicine, videoconferencing and open learning to health care, educational, corporate and government clients. The company specialises in planning, implementing, project managing, evaluating and researching. It also provides information services on telemedicine, including bi-monthly reports, marketing editorial, briefing papers, speech notes and customised reports.

The company is at the forefront of videoconferencing and telemedicine in Australia. In 1994 the company produced the report "The Challenge to Embed Telepsychiatry. An evaluation of the non-clinical aspects of the South Australian Mental Health Services Telemedicine Pilot Project, June-October 1994." John Mitchell is the main author of the 1994 DEET publication "An Evaluation of Videoconferencing in Higher Education." In 1994 the company evaluated New Zealand Telecom's eleven site videoconferencing network and produced the report, "Videoconferencing as a Business Tool."

The company provides services to 13 Australian universities, the Securities Institute of Australia, leading private companies such as F.H. Faulding and Co. Limited, health care organisations and technology companies.