Presenter: Dr. Penny Jennett

1
Successes and Failures in Telehealth
FACULTY OF MEDICINE

• Organizational Readiness
• Alliance for Building Capacity Project and
  National Initiative for Telehealth Guidelines

2
Overview

• Introduction
• Definitions
• Purpose and Rationale
• Methods
• 2 studies Alliance for Building Capacity Project
  (ABC) and National Initiative for Telehealth
  Guidelines (NIFTE)
• Background
• Implementing Change Telehealth and New
  Technologies
• What is Needed for Success?
• Examples
• Why Things Fail
• Examples
• Conclusions

3
Introduction

• The process of implementing change
• Successes and failures in telehealth
  implementation
• Two studies of readiness Alliance for Building
  Capacity Project (ABC) and National Initiative
  for Telehealth Guidelines (NIFTE)
• An organizational perspective

4
Definitions

• Telehealth the use of advanced
  telecommunications technologies to exchange
  health information and provide health care
  services across geographic, time, social and
  cultural barriers (Reid, 1996)
• Readiness the degree to which an organization is
  prepared to participate and succeed in telehealth
  implementation (Harvard, 2002)

5
Purpose and Rationale

• Successful implementation of technological
  innovations in healthcare (i.e. telehealth)
  strongly depends on the organizational
  environment
• Important to assess how ready an organization
  is
• When readiness exists, an organization is
  prepared to accept change if an organization is
  not ready, the innovation may be rejected
• The purpose of this presentation is to explore
  what is needed for successful telehealth
  implementation and to explain why implementation
  efforts often fail

6
Methods

• 2 studies ABC and NIFTE
• Key-informant, semi-structured interviews within
  the organizational domain
• Data analysis focused on identifying factors of
  readiness at the organizational level and
  examples of success and failure in telehealth
  implementation
• Examples of success and failure were also found
  in the literature

7
Alliance for Building Capacity Project

• Goal to generate an understanding of the
  essence of telehealth readiness and to
  contribute to a framework that can be utilized by
  other rural and remote communities in the
  implementation of telehealth projects
• The readiness of four domains (Patients,
  Practitioners, Organizations and the Public) was
  examined in a rural Canadian community
• Core factors of telehealth readiness were
  identified
• It is important that community members understand
  factors that promote or impede telehealth
  implementation before costly investments are made

8
National Initiative for Telehealth Guidelines

• An interdisciplinary project aimed at developing
  a framework of national guidelines for telehealth
  services
• Made up of four research teams Alberta Research
  Council, Dalhousie University, Laurentian
  University and the Health Telematics Unit (HTU),
  University of Calgary
• The HTU was responsible for collecting
  accreditation relevant information concerning the
  organizational context
• This information can contribute to an
  understanding of readiness and can provide
  explanations as to why telehealth initiatives
  succeed or fail

9
BackgroundImplementing Change Telehealth and
New Technologies

• When implementing telehealth systems, attention
  should be paid to organizational issues, as well
  as technical ones, as organizational attributes
  are important predictors of success
• A telehealth may be successful in one
  environment, but not in another, due to the
  organizational context and conditions
• Without a tight organizational fit, the
  implementation of new technologies will be
  problematic

10
An IT-Organizational Fit Analytic Framework
(Southon et al., 1997)

• Emphasizes the organizational configuration in
  telehealth implementation
• Operationalized as strategic planning and
  alignment
• Strategic planning refers to processes that
  ensure IT plans are consistent with strategic
  business plans, priorities and initiatives
• Strategic alignment refers to configuring the
  organization so that IT is aligned to the
  business strategy, structure and management
  processes
• These types of strategies will assist in
  effectively adapting work practices, inventions,
  reorientations and organizational changes to new
  innovations

11
Change Agents (Armenakis et al., 1999)

• Through their actions, change agents convey a
  message to other organizational members in order
  to build a commitment to telehealth
• A change message is directed at 5 core questions
• Is change really necessary?
• Is the specific change being introduced an
  appropriate reaction to the discrepancy?
• Can I/we successfully implement the change?
• Is there organizational support for the change?
• What is in it for me?
• Adequate answers to these questions can determine
  and build the readiness of people to accept
  telehealth within an organization

12
Evaluation (Aas, 1999)

• Evaluation of telehealth innovations is also an
  important element in successful telehealth
  services
• Should address issues of quality, accessibility
  and cost
• Through evaluation, one can see success and
  failure, and potentially determine the causes of
  both

13
A General Framework for Systematic Analysis of
Changes (Aas, 1999)

• An evaluation framework will contribute to the
  knowledge and evidence surrounding the
  effectiveness of programs

• General Framework for Systematic Analysis of
  Organizational
• Changes Resulting from Telehealth Implementation
• The starting point
• Mapping of applications of telemedicine where
  organizational
• consequences are possible
• Characterizing the nature of larger
  organizational consequences
• The consequences for the health sector in the
  chosen area
• Possible consequences for the number and
  placement of geographical
• subunits of the health sector
• Possible consequences for health-sector
  organizational types
• The consequences for the tools of health policy

14
What is Needed for Success?

• Successful implementation of new technologies
  depends on
• the readiness of the environment
• a clear understanding of the existing health care
  system
• systematic needs analyses
• strategic business plans
• collaborative partnerships
• adequate equipment
• program coordination
• training of users
• ongoing technical support
• evaluation

15
What is Needed for Success?

• A first step in successful implementation of
  telehealth is planning
• Includes an assessment of readiness in the form
  of a needs analysis
• The importance of using a needs analysis as a
  guide in telehealth implementation is emphasized
  in the following example from the NIFTE project

16
Example

• One of the first activities that we did once we
  started the project was we did a needs analysis,
  and we didnt survey just the communities that
  were going to get telehealth, we surveyed all 25
  communities. We did that because if were going
  to develop a strategic document that says this is
  where we are today, this is what we will have
  done in two years when the project is over, and
  this is where wed like to be in three years
  following that, then we had to survey all our
  communities
• (continued next slide)

17
Example

• We basically asked what kinds of programs do you
  see that you need will you use telehealth and
  can you integrate it in your daily activities?
  The needs analysis has been our guide on what
  clinical programs we would need, what education
  programs we would need, and how we would equip
  our basic system based on what the community
  needs All those decisions were made at a
  community level, and I think that is a better way
  to go

18
What is Needed for Success?

• Need to have in place
• administrative standards for management
• standards for policies and procedures
• strong leadership
• a clear comprehensive strategy
• a common understanding of initiatives

19
What is Needed for Success?

• Funding was seen as a key factor in successful
  implementation of telehealth innovations (ABC,
  NIFTE)
• Necessary to support initial costs and to sustain
  the service beyond implementation
• Example from the ABC Project
• Success was possible with government funding
  when starting telehealth service in a remote area

20
Example

• Well, I think that in place it wasnt just
  their local government but is was the federal
  government as well, and having funds available
  that could be accessed because I think that we
  need to recognize that place is rather small so
  that the financial resources are very limited and
  that, you know, if there was another organization
  that provided that kind of support, that we would
  be able to the use that as any kind of start-up
  So if you can apply those dollars toward the
  start-up then that would be a benefit.
  (Organization 3, page 6-7)

21
Case Analysis (Southon et al., 1997)

• Implementation of a critical application in
  telehealth
• While the final outcome was removal of the
  service, analysis demonstrates initial success
• The problem lay in the organizational fit, rather
  than the technical issues
• Factors that led to initial success
• Identification of need and dissatisfaction with
  the existing system
• Localization process
• Teams allocated to the program
• Training of staff
• Commitment of organizational members
• The presence of some immediate results

22
What is Needed for Success? (cont.)

• The preparation of staff was also emphasized
  (ABC, NIFTE
• ABC respondents indicated that users should be
  oriented, trained and educated so that telehealth
  becomes integrated into their everyday working
  lives
• Example from the ABC Project
• Successful implementation depends on services
  becoming part of routine health care

23
Example

• Well, I think that its key that if it was
  going to be a successful telehealth service,
  that it becomes an integrated part of the health
  services delivery so that its not a separate
  program but that it is, you know, --the highly
  successful one is that they dont really see a
  differentiation any more, that telehealth is just
  a part of how you deliver the services, not
  looking at telehealth as a distinct program.
  (Organization 3, page 4)

24
What is Needed for Success? (cont.)

• Allowing the creative use of telehealth equipment
• Organizations should allow, and encourage, users
  to be creative when utilizing new services
• Example from the ABC Project
• Creative use of equipment can result in
  unexpected, successful telehealth applications

25
Example

• Theres so many different applications around
  telehealth and the use of the ICTs in the
  delivery of telehealth that my experience has
  been that its one thing to plan applications and
  successful or unsuccessful pilot projects in
  telehealth, like in certain fields, certain
  specialties, and they always say only pick three
  types of things And what I end up seeing
  happening with these tools is people are using it
  for things that we have never anticipated It
  needs to be integrated within every project so
  that the projects can accommodate what the end
  users require and see as needed, instead of us as
  planners and technicians determining what we
  think might be the most successful.
  (Organization 2, page 5-6)

26
What is Needed for Success? (cont.)

• Information technology diffusion in academic
  health sciences centres (Ash, 1997)
• The following are important for successful
  adoption of an innovation
• Controlled and careful project management
• Appropriate reward systems
• Decentralized decision-making
• Top-management commitment and support
• Strong social networks
• Communication within, and outside of, and
  organization
• The ABC and NIFTE Projects also emphasized
  inter-community cooperation, as seen in the
  following examples

27
Example

• the role that our organization plays is I would
  say its like a liaison between both the end
  users and the institution and the profession. At
  the community level, at the First Nation level in
  particular, theres a whole other world that has
  to be addressed so that the liaison role is both
  educational a lot of support systems, a lot of
  policy development, procedures, trying to
  safeguard and ensure success as much as possible,
  and a successful experience for those people that
  are going to experience that. So I see that as
  our role and hopefully, you know, establishing
  and maintaining and supporting the planning
  committees. Making it as inclusive as possible
  for all participants to be able to have their say
  and be heard. (ABC, Organization 2, page 14-15)

28
Example

• We had to enlist community involvement, so we
  had a lot of communication at the community
  level. We told them what we were doing. We
  actually went and traveled to different
  communities and did a show-and-tell of what
  telehealth was almost a year before they got it
  and weve had constant communication with them,
  so that they are never out of the loop If you
  dont have their support, youre lost. (NIFTE)

29
Why Things Fail

• While information on what is needed for
  successful implementation of telehealth exists,
  there are still a number of projects that fail
• Failure is often due to the fact that the entire
  change process is not followed through, monitored
  and managed from beginning to end
• While there are always financial risks for
  organizations implementing telehealth, many
  failures are rather due to the lack of
  recognition of the human component in
  implementation

30
Why Things Fail

• Lack of and actual needs assessment in the
  targeted community often leads to implementation
  failure
• This example from the NIFTE Project supports this
  idea

31
Why Things Fail (cont.)

• The ABC Project revealed failure of telehealth
  services resulting from equipment being dumped
• The needs of the users were ignored and they were
  unable to use the equipment correctly or
  effectively
• Important that staff are supported throughout the
  implementation process and that they are prepared
  to use the application
• The following is an example of this situation

32
Example

• The Docs knew very little about it. They hadnt
  been consulted about this Telehealth Network
  beforehand. It was dropped in. We were there to
  discuss with them what we could do to provide CME
  before we gave them the programs.
• Was that a problem that they had just been
  dropped in?
• I think it was because lots of times
  sometimes we would go there and they Docs they
  wouldnt know what room the equipment was in and
  once they found out they would say it
  shouldnt be there, what is the good of it
  there? I think under ideal circumstances it is
  only common sense that you would consult with the
  physicians and as many people as possible before
  putting equipment in. (Practitioner 2, page 3)

33
Why Things Fail (cont.)

• Change is only successful when an entire
  organization participates in the effort
• People resist change for a number of reasons,
  that can be categorized as dont need to
  change, cant change and wont change
  (Garside, 1998)
• If a lack of need exists, implementation will not
  be successful
• This is seen in the following example from the
  ABC Project

34
Example

• Yeah, within our network we have two regions.
  We have place1, which is where we started, and
  we have place2. place1 is way ahead. Its
  just basically telemedicine is part of the fabric
  of health care in some of these towns. place2,
  which is more recent, is way behind. You have to
  ask yourself, you know, why?
• Hm-mm
• And basically I think that the driver there is
  that the needs arent as great. Theyre not that
  far, okay? They dont have the same needs.
  (Organization 4, page 17)

35
Why Things Fail (cont.)

• The whole organizational culture needs to be
  receptive to the change
• The focus needs to be on managing change through
  learning, communication, training and human
  resource support
• Employees need to know that there is a
  predictable routine in place, that they will be
  treated fairly and that they can trust that those
  in charge are capable of delivering what they
  promise (Garside, 1998)

36
Why Things Fail (cont.)

• Inadequate funding can result in failure of
  telehealth service
• Example from the ABC Project
• Even if the organizational members are on
  board, without funding, the application will
  not succeed

37
Example

• The other issues are probably that we have not
  found the best champions to push this forward,
  and part of the reason for that is actually lack
  of funding. We did place on a shoestring so we
  couldnt pay medical directors, you know, more
  than a pittance and couldnt really get their
  support in the same way. Theyre all committed
  but they just dont have the time to do it.
  (Organization 4, page 17).

38
Southon et al., 1997

• This case analysis can also be used as an example
  of failure
• A critical application successfully implemented
  in the United States, was removed after
  implementation efforts in a large, divisional
  organization in New South Wales
• Some factors that led to failure in the
  Australian organization were
• Financial constraints
• Focus on a cost-benefit analysis
• Lack of involvement of organizational members
• Minimum training for staff
• System considered user unfriendly
• Dependency on technical support
• Difference between was the service provided and
  what people thought they needed

39
Conclusions
40
Summary
41
References

• Aas, I,H.M. (1999). Telemedicine and the
  organization of the health sector. Journal of
  Telemedicine and Telecare, 5(S1), S126-S128
• Aas, I.H.M. (2001). A qualitative study of the
  organizational consequences of telemedicine.
  Journal of Telemedicine and Telecare, 7(1),
  18-26.
• Alliance for Building Capacity. (2002).
  Framework for rural and remote readiness in
  Telehealth (Project Report for CANARIE).
  Calgary, Alberta, Canada University of Calgary.
• Armenakis, A.A., Harris, S.G. Feild, H.S.
  (1999). Making Change Permanent A Model for
  Institutionalizing Change Interventions. Auburn,
  Alabama Auburn University.

42
References

• Ash, J. (1997). Organizational factors that
  influence information technology diffusion in
  academic health sciences centers. Journal of the
  American Medical Informatics Association, 4 (2),
  102-111.
• Garside, P. (1998). Organizational context for
  quality lessons from the fields of organizational
  development and change management. Quality in
  Health Care, 7 (Suppl.), S8-S15.
• Information Technologies Group, Center for
  International Development at Harvard University,
  (2002). Readiness for the Networked World A
  Guide for Developing Countries. Accessed at
  http//www.readinessguide.org/ on February 26,
  2002.

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References

• NIFTE
• Southon, F.C.G., Sauer, C. Dampney, C.N.G.
  (1997). Information technology in complex health
  services Organizational impediments to
  successful technology transfer and diffusion.
  Journal of the American Medical Informatics
  Association, 4(2), 112-24.