Vision, Structure and Leadership of a Sustainable Telehealth Program

Executive Summary As accountable care and bundled payments are already on our way, all healthcare providers are expected to provide the best care while containing the cost. Telehealth had been acknowledged and proved in many cases that, it not only improves the patient care, but also reduces the cost. Even though many health care organizations would like to start a telehealth program, they are not sure of how to organize a sustainable program. Vision, program structure and leadership are keys to sustainability. Finding

the best vision, structure and leadership that meets every organizations needs is impossible. But while analyzing some of the successful telehealth programs, there are some common themes shared among them. A physician led, centrally administered telehealth program with the goal of patient access improvement seem to have greater success and sustainability. These common themes could be considered while designing a Telehealth program.

Vision, Structure and Leadership of a Sustainable Telehealth Program

Introduction
Recently, Telehealth is a major focus of the healthcare industry. In a 2011 market research report, Technavio predicted that Telehealth market is expected to grow at a compound annual growth rate of 19 percent [1]. Frost and Sullivans recent market research also concluded that telehealth has upswing demand and has taken huge strides forward [2]. This year, American Telemedicine Associations ( ATA) annual conference attracted close to 5000 attendees in Florida, making it one of top 10 well attended healthcare conferences [3]. In a 2010 Intel sponsored survey 89% (i.e. 9 in 10) of healthcare decision makers believed, telehealth will transform healthcare in next 10 years [4]. Based on Manhattan Researchs recent study, 7% of U.S Physicians are using video conferencing to communicate with their patients, 42% of Physicians used online to communicate with patients, more than 9 million consumers had email communication with their patients, and additional 80 million consumers are interested in online visit [5, 6]. From regulatory perspective also, FDA recently proposed regulations for mobile medical applications [7]. Center for Medicare and Medicaid Services (CMS) showed its support to telehealth by recently relaxing it rules on physician credentialing to engage in consultations across the country [8]. CMS had been expanding the CPT procedures covered under telehealth services [9]. Healthcare reform recommends ACO to use

telehealth and remote patient monitoring to improve the quality of care [10]. HITECH Act also included $2 billion to expand the broadband infrastructure to support telehealth [11].

Due to these favorable conditions, today every healthcare organization is thinking of having their own telehealth program. But many of them are not sure how to organize their program. In order to have sustainable Telehealth program, a well planned vision, organization structure and leadership are important [12-14]. This paper analyses some of the successful telehealth programs and tries to extract the common themes among them. See appendix 1.

Vision of a telehealth program

Organizations would like to develop the Telehealth program for different strategic reasons. It could be either to improve access to care or cost savings or access to market [14]. But when analyzing some of the programs, it is clear that those programs with the vision of improving access to care and addressing patient needs seem to have higher success rates than others. Dr. Darkins with VA telehealth program affirms that the main reason behind the success of their program is their vision [15]. VA telehealth program was developed to expand access and provide care as close as possible to the patients community [16]. Ontario Telemedicine network (OTN) is one of the world largest tele network, and their vision is Its about having the right provider in the right place at the right time [17]. But both these programs have realized cost savings and access to market as indirect benefits. Between 2003 and 2007, using telehealth VA showed benefits of a 25% reduction in no. of bed days of care and 19% reduction in no. of hospital admissions which is a huge cost savings for them [18]. If the program is

beginning for cost savings or market expansion, it may be hard to show the success during the early stages [19, 20]. The main reason is because cost effectiveness of telehealth depends on three factors: cost sharing by adequate patient volume and sharing of infrastructure, effectiveness of telehealth in terms of utility and satisfaction, and finally the cost savings accrued by the decreasing the patient loss of productivity [21]. Tracking and measuring these factors are difficult. When the underlying vision is cost savings or expansion of market, and the program expects the providers/patients to change the way they deliver/receive the healthcare, the program suffers with lot of resistance [22]. So focusing the vision on long term sustainability than short term revenues will help to realize the success of the program. Dr. Whittens 2010 study shows that 63.8% of telehealth programs believed Access to Care as their main organizational goal [12]. Another reason behind the emergence of telehealth program could be technology, that is organizations with rich technology and tech savvy resources would like to use those technologies to improve the patient care. If this is the case, you may need to step back and think again. Dr. Darkins, VA says that If somebody comes along and says, I have a technology which I believe is really going to make this difference, then that is usually a recipe for failure. But if someone comes along and says, I have this particular issue, challenge, problem with delivery of care, and I think that we could use technology to support care to manage those people, then that is a clear vision allied to the delivery of care. [15]. Technology should be considered as a facilitator of the relationship between the patient and the physician not as a driver behind the program. In 1990s, Dr. Whitten et al mentioned that telehealth needs to be developed as a program under medicine, rather as technology [13]. One of the thinking points out of FSMB symposium is adding

tele to any form of medicine delivered across the distance is it own barrier to progress forward [19]. So, it is recommended not to include tele in program name. Recently Massachusetts based Partners healthcare changed it s name from Partners Telemedicine into Partners Connected Health to emphasize on healthcare [23]. UPMC also call its telehealth program as a center for Connected Medicine [24].

Structure of Telehealth Program

In an article Dr. Whitten et al quoted Paul Maakestad, then Project Director at MRTC saying that, "Dont underestimate the amount of administrative support needed to make a program function smoothly. Think out structures completely, before beginning the program. [13]. So it very important to find the best structure that would suffice the need of the organization. Today there are various forms of telehealth program adopted throughout the country. Some of the programs are part of the individual medical department like Mayo Telestroke department, some of them are under Information Technology department ( IT) like Cleveland Clinic and some other are centralized stand alone departments like VA, partners healthcare etc. So which one would be best for the organization? If we analyze in depth, telehealth doesnt belong to any individual clinical department as it could serve almost all clinical services in an organization. See appendix 2. Apart from clinical services, it could also be used for medical education/training and conferencing among healthcare workers. If telehealth is a small, orphaned program, then its only hope is to develop as a kind of new silo [15]. So developing it as a centralized, free standing department, helps the program to stand aloof from infighting of the various departments.

In a 2010 research study of 92 telehealth programs, 72.3 percent of them had their telehealth program defined as a distinct entity [12]. Centralization helps to implement universal standards across the organization. It leverage economies of scale in contracting and purchasing, eliminates redundant functions and utilizes successful information delivery models, systems, and devices across projects [11, 25]. Centralized management is essential to control and secure the fast paced telehealth technology. The main disadvantage of centralization is lack of partnership between the central team and the individual departments [25]. When the program is very hierarchical and completely centralized, Individual service lines (ex. Psychiatry, radiology, dermatology etc) wont take ownerships and may lack the commitment to make the program successful. Only when the power is distributed across the organization, employees feel empowered and take pride in ownership. When front end employees are included in the decision making process, it helps to improve their commitment and encourage them to use their first hand knowledge and experience to improve the overall program. Other issues with centralization are bureaucracy and lack of responsiveness. There is no perfect answer to how a telehealth program should be structured. Since telehealth requires both centralized oversight and decentralized ownership it is highly recommended to get the best of both worlds by decentralized centralization. This can be done by deciding on who gets to make what decisions. Common rule of thumb is individual departments decide on what services could be delivered, and the central team decided on how those services could be delivered [26]. Organizations executive governance committee could finalize the roles and responsibilities of the central team and individual departments.

Common roles of central team

Develop clinical, technical and business process standards

For telehealth services, today there are no technical standards (speed, redundancy, connectivity) developed by any state or national level organization [19]. Until such standards are developed central team would have to be responsible for developing such standards. But unless otherwise the clinical and business standards are clear, technology will fail [19]. So focusing on clinical and business standardization is very important. Irrespective where the patients are, they should feel the same standard of care [27]. Clinical protocols help to reduce practice variation and clinical risks, formalize training, enhance billing and reimbursement and help educate patients [22]. Long range strategic planning Strategic planning for the telehealth program is the most important role of the central team. Central team needs to work with their executive committee on an ongoing basis and figure out the path for their program in the near future [28]. This planning process should include goal setting and periodic updating of vision and mission statements. Programs strategy should strongly in alignment with the organizations strategy. It is central teams responsibility to make sure that individual telehealth services are developed to meet the programs strategic vision. It is also important for the central team to market these strategic goals to the patients, providers and the community in order to achieve the program growth. Act as a knowledge expert and provide consulting Even though telehealth is in the industry for more than decades, it is not easy to find the experts and knowledge resources on this field. Currently American Telemedicine Association (ATA) is a good resource base. In order to develop a sustainable program, it is very important to grow an internal knowledge base [22]. Central team has the high stake in developing and fostering such a knowledgebase. Instead of reinventing the

wheel, the central team could learn from the external organizations like ATA, OTN, and VA and adopt best policies. Another service from central team could be project management. Applying project management for implementation of teleservices has been proved successful. Many of teleservices would require same set to implementation steps [14, 22]. Repetition helps to master the skill. So it makes sense to employ the project managers centrally and use them to implement multiple telehealth services simultaneously. Monitor and evaluate individual services and the overall program Telehealth programs should evaluate their performances ranging from quality of services to financial ability on an ongoing basis. Financial assessments need to include evaluations of costs and benefits, coding issues, reimbursement, account receivables, bad debt and network utilization [28]. Before assessments, it is very important to develop the performance monitoring plan with the help of individual teleservice lines. Performance assessment initiatives can help support the cost effectiveness of telehealth program [29]. Only by gathering, analyzing and communicating the performance scores, the presence of telehealth program could be justified. Train and educate Training is a critical element of the telehealth program. One of the important lessons from VA telehealth program are normal methods of clinical consultation do not automatically transpose into teleconsultations; Clinicians need training and education in teleconsultation irrespective their experience in normal setting [22]. Training needs to well thought out and developed before implementing any individual service. To sustain and grow the program, required skills and competencies should be provided to the

staffs. In order to maintain the standards across the organization, central team needs to develop and manage the training programs. Contract and procure resources Apart from human resources, Telehealth involves lot of hardware and software resources. In order to benefit from economy of scale it makes lot of sense for the central team to assume contracting and procurement roles. While choosing technologies, there are some basic rules to be considered. For example, goal of setting up telehealth applications is to deliver healthcare differently. So organizations need to go as simple as they can because the more complicated it gets, the more in the way it gets, and the acceptance level drops [30]. Following bleeding technologies is a high risk, because practitioners need to focus on the patient care rather than the technical issues. So it is recommended to use the simple, tried and used technologies. It is also recommended not to focus on the Emergency services during the initial stages as the current technology is not yet robust enough to support those acute interventions [15]. For organizations who are novice and do not have access to high tech resources, it may be wise to lease the devices and solutions, at least until the knowledge is gained. Maintaining the system at the central level helps to leverage economy of scale. Integrate Information and clinical services between departments While individual teleservices focusing on their individual units performance and management, it is the central teams responsibility to make sure, the information is Integrated with existing EMR and other IT systems to achieve best returns. Integration between the clinical services is also important. Lot of time telehealth services would require other clinical services intervention to complete their clinical care path. For example in order to do a teledermatology service, it might require the internal medicine

or family practice physicians help to get the biopsies. In such cases, central team needs to intervene and make sure there is a solution without compromising their existing policies and procedures. Manage Risks Since there are lot of state, federal and industrial regulatory requirements associated with telehealth, there is a need for central oversight and guidance, to run the program successful.

Common roles of individual Service lines

Determine the teleservice need and develop business case Individual clinical team needs to be responsible for determining the need for telehealth services in their department and develop the business case for it. As part of the business case, individual team would come up with their functional and resource needs. This helps the individual team to accept the ownership for the success of the program. But the business case needs to be reviewed and approved by the central team to make sure there is a strategic alignment. Develop clinical care pathway Delivering care with telehealth should be the same as delivering care without telehealth [14, 15]. It is about integrating current resources to manage and expand the program, rather than creating a whole new clinical silo. Providers and patients should not feel major changes between the face to face consultation and tele consultation. Fewer the changes, greater the success of the program. For example, if patients are asked to call a different phone number for a tele visit than a face to face visit, it may be a barrier to use the program. So individual teams, providing this care would need to adopt the appropriate clinical care pathway for their telehealth.

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Fund the teleservice. From the funding perspective, it is recommended that individual departments provide and manage the funding for the individual telehealth services under their own department. This way individual clinical services would make sure, they are investing on a service, where they would see positive outcomes. This will also help to discourage the individual departments from asking for shooting stars and moon from technical and manual resources perspective. Overhead costs incurred by the central team needs to be shared among the individual services, based on their usage. Manage Staffs Management of telehealth service providers need to be under the individual departments, to reinforce the fact that telehealth is just another way of delivering their service, not a new clinical silo. Individual departments need to finalize the scheduling, compensation/ benefits for the services providers including physicians, nurses and etc.

Leader of Telehealth Program

Many struggling programs seem to under estimate the personal requirements to implement a successful telehealth program [12]. Leadership is key to getting buy-in and enthusiasm further down the organization for successful, systematic telehealth program implementation. Unpopularity of telehealth for a long time is due to lack of commitment and the absence of necessary organization structure and people to make it happen [15] Many researches and surveys have found that Physicians resistance had always been the no.1 barrier to the promotion of telehealth [15, 19, 22] and todays physician education and practice does not embrace use of technology. According to Dr. Darkins, Telehealth Projects Success = Quality of Service and access to health care services /

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cost of services and professional objection [22]. VA also found that one of the biggest challenges of implementing a telehealth program was persuading doctors to use it [30]. Telehealth program leaders main responsibility is cultivating a can-do attitude among the providers. This person needs lot of enthusiasm about improving patient access and quality of care using technology, and create a free environment where everyone is able to share aspirations and interests with each other. So the best choice to lead the telehealth program would be a senior level, technology loving physician. This is mainly because, physicians listen to another physician. If no physician in the organization believes that Telehealth would address the patient needs in the organization, then it is not yet time to start the telehealth program. According to VA, emphasizing the potential for doctors to treat more patients in a way that added minimal strain to their schedules was the most persuasive case [27].

Physician leader might be able to drive the clinical and business processes well. Since telehealth involves equal amount of technology, he needs strong support from the technology officer. This technology officer need not to be same as the CIO ( Chief Information Officer). Since telehealth has strong connection with IT, having dotted report line with the CIO helps to connect the dots. Today telehealth technologies are grouped into 3 categories; 1. Store and Forward technology 2. Video Conferencing technology 3.Telehomecare technology. Technology officer would be responsible for finalizing technical infrastructure, developing technical process standards, supporting day to day technical issues and managing telehealth applications. Apart from managing the hardware and software systems, this individual would also be responsible for seamless

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integration of the telehealth systems with the hospitals EMR system and other IT systems. See appendix 3 for sample telehealth program structure.

Conclusion:
Even though there are still some barriers like lack of reimbursement, complex licensing and credentialing requirements, lack of standards and regulatory requirements there are growing evidences that telehealth will be major game changer in healthcare services. Today technology is not a huge barrier. We already have much of the technologies needed to support telehealth program. The key issue is increasing the adoption and usage of technologies [15].With a proper vision, strong leadership and well planned organization structure, adoption of telehealth today will set the stage for smart growth tomorrow.

References

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1. Berkesova, Ludmila. "OpenPR.com - Press Release - Technavio - Telemedicine Market Witnessing Significant Growth in Europe." OpenPR.com - Worldwide Open Public Relations - Publish Press Releases Free of Charge. Technavio, 30 Aug. 2011. Web. 21 Sept. 2011. <http://www.openpr.com/news/189651/Telemedicine-Market-WitnessingSignificant-Growth-in-Europe.html>. 2. Monegain, Bernie. "Global Market for Telehealth Tech on Upswing." Healthcare IT News. Healthcare IT News, 4 Mar. 2011. Web. 21 Sept. 2011. <http://www.healthcareitnews.com/news/global-market-telehealth-tech-upswing>. 3. Wicklund, Eric. "Telehealth Heads toward the Mainstream (July/August 2011)." Government Health IT. Government Health IT, 6 Sept. 2011. Web. 21 Sept. 2011. http:/www.govhealthit.com/news/telehealth-heads-toward-mainstream-julyaugust2011>. 4. Intel. "Intel Study Reveals Telehealth Will Dramatically Transform Health Care." Laptop, Desktop, Server and Embedded Processor Technology - Intel. Intel News Release, 18 May 2010. Web. 21 Sept. 2011. http:/www.intel.com/pressroom/archive/releases/2010/20100518corp.htm>. 5. Manhattan Research. "Seven Percent of U.S. Physicians Use Video Chat to Communicate with Patients - Manhattan Research." Vital Physician and Consumer Insights and Analytics - Manhattan Research. Manhattan Research, 16 May 2011. Web. 21 Sept. 2011. <http://manhattanresearch.com/News-and-Events/Press-Releases/physicianpatient-online-video-conferencing> 6. Zamosky, Lisa. "The Doctor's In-box - Manhattan Research in the Los Angeles Times Manhattan Research." Vital Physician and Consumer Insights and Analytics - Manhattan Research. Manhattan Research, 7 June 2010. Web. 21 Sept. 2011. <http://manhattanresearch.com/News-and-Events/In-The-News/33> 7. FDA. "FDA Proposes Health 'App' Guidelines." U S Food and Drug Administration Home Page. FDA, 19 July 2011. Web. 21 Sept. 2011. http:/www.fda.gov/ForConsumers/ConsumerUpdates/ucm263332.htm 8. John Pulley. "CMS Eases 'Burdensome' IT Rules." Health IT Update. Health IT Update, 4 May 2011. Web. 21 Sept. 2011. http:/healthitupdate.nextgov.com/2011/05/cms_eases_burdensome_health_it_regs.ph p 9. ATA. "Public Policy - American Telemedicine Association." American Telemedicine Association - American Telemedicine Association. American Telemedicine Association, 1 July 2011. Web. 21 Sept. 2011. http:/www.americantelemed.org/i4a/pages/index.cfm?pageID=3286 10. CSC. "Telemedicine: An Essential Technology for Reformed Healthcare." CSC Insights (2011): 3. Print.

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11. Kilbridge, Peter. "Telemedicine in the News, Part II: The Future of Telemedicine Under Accountable Care" The Advisory Board Company * Information Technology Strategy Council (2011). Print 12. Whitten, Pamela, Bree Holtz, and Lianh Nguyen. "Keys to a Successful and Sustainable Telemedicine Program." International Journal of Technology Assessment in Health Care 26.02 (2010): 211-16. Print. 13. Whitten, Pamela S., and Ace Allen. "Analysis of Telemedicine from an Organizational Perspective." Telemedicine Journal 1.3 (2009): 203-13. Print. 14. Vanderwerf, Mark. "Ten Critical Steps for a Successful Telemedicine Program." Stud Health Technol Inform 104 (2004): 60-68. Print. 15. Lindeman, David. "Interview: Lessons from a Leader in Telehealth Diffusion: A Conversation with Adam Darkins of the Veterans Health Administration." Ageing International 36.1 (2011): 146-54. Print. 16. VHA Office of Telehealth Services Home. Web. 21 Sept. 2011. http:/www.telehealth.va.gov/ 17. OTN | Ontario Telemedicine Network (OTN). Web. 21 Sept. 2011. http:/otn.ca/en/ 18. Darkins, Adam, Patricia Ryan, Rita Kobb, Linda Foster, Ellen Edmonson, Bonnie Wakefield, and Anne E. Lancaster. "Care Coordination/Home Telehealth:The Systematic Implementation of Health Informatics, Home Telehealth, and Disease Management to Support the Care of Veteran Patients with Chronic Conditions." Telemedicine and Ehealth 10 (2008): 1118-126. Print. 19. Orlando, Vanessa, and Jennifer Witten. "Ideas for Leaders Developing the Maryland Telemedicine Network." Rural Maryland Council. Rural Maryland Council Publications & Statements, 16 May 2011. Web. 21 Sept. 2011. <http://www.rural.state.md.us/Publications/FSMB_Thinking_Points.pdf>. 20. Gryfakis, Nicholas. "Telestroke Advances and Roadblocks." SG2 Health Care Community (2009). Print. 21. Agha, Zia, Ralph M. Schapira, and Azmaira H. Maker. "Cost Effectiveness of Telemedicine for the Delivery of Outpatient Pulmonary Care to a Rural Population." Telemedicine Journal and E-Health 6.3 (2002): 281-91. Print. 22. Darkins, Adam William., and Margaret Ann. Cary. Telemedicine and Telehealth: Principles, Policies, Performance, and Pitfalls. New York: Springer Pub., 2000. Print. 23. Center for Connected Health. Web. 21 Sept. 2011. http:/www.connected-health.org/ 24. Center for Connected Medicine. Web. 21 Sept. 2011. http:/connectedmed.com/ 25. Padilla, Ramon. "Is the Best IT Model the Centralized or Decentralized Approach? | TechRepublic." TechRepublic - A Resource for IT Professionals. TechRepublic, 2 Sept. 2005. Web. 21 Sept. 2011. http:/www.techrepublic.com/blog/tech-manager/is-thebest-it-model-the-centralized-or-decentralized-approach/15>.

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26. Cramm, Susan. "IT Centralization or Decentralization?" HBR Blog Network - Harvard Business Review. 22 July 2008. Web. 21 Sept. 2011. <http://blogs.hbr.org/hbr/cramm/2008/07/it-centralization-or-decentral.html>. 27. Lipowicz, Alice. "VA Sets the Telehealth Table." Federal Computer Week. Federal Computer Week, 24 May 2010. Web. 21 Sept. 2011. <http://fcw.com/articles/2010/05/24/feat-telehealth.aspx>. 28. Weinstein, RS, AM Lopez, EA Krupinski, SJ Beinar, M. Holcomb, RA McNeely, R. Latifi, and G. Barker. "Integrating Telemedicine and Telehealth: Putting It All Together." Studies in Health Technology and Informatics 131 (2008): 23-38. Print 29. Eliasson, AH, and RK Poropatich. "Performance Improvement in Telemedicine: the Essential Elements." Military Medicine 163.8 (1998): 530-35. Print. 30. Opshal, Andy. "The VA's Take on Telemedicine." GOVERNING: State Government News on Politics, Management & Finance. Governing, 3 Aug. 2010. Web. 21 Sept. 2011. <http://www.governing.com/topics/technology/VA-Telemedicine.html>.

Appendices

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Appendix 1: Program Cleaveland Clinic Goal Leader CIO Structure Centralized Source SG2 http://www.may oclinic.org/stroke telemedicine/abo ut.html

Mayo Telestroke

Improve access to care Its about having the right provider in the right place at the right time.

Physician

Part of existing ( Neurology)

OTN Partners Healthcare/ Center for Connected Health

Physician

Centralized

http://otn.ca/en/

Changing Healthcare Delivery transform healthcare into a system that facilitates communication, collaboration and coordination among all stakeholders along the care continuum Apply communication and health information technologies to provide specialty care, services and education to veterans at VA clinics closest to their homes

Physician

Centralized

http://www.conn ected-health.org/

UPMC/ Center for Connected Medicine

Physician

Centralized

http://connected med.com/

Veterans Affiars

Physician

Centralized

http://www.teleh ealth.va.gov/

Appendix 2:

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Ontario Telemedicine Network Services

OTN

Video Conferencing

Telehomecare

Webcasting

Emergency Services

Store & Forward

Clinical Telemedicine

Distance Education

Meetings

Data Source: http://otn.ca/en/

VA Telehealth Services

VA

Clinical Video Telehealth

Home Telehealth

Store & Forward Telehealth

Polytrauma

Telemental Health

Telerehabilitation

Telesurgery

Teledermatology

Teleretinal Imaging

Teleradiology

Data Source: http://www.telehealth.va.gov/

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Center for Connected Health Services

CCH Activity & Wellness Cardiac Care Dermatology Diabetes Medication Adherence Wireless Medication Adherence mHealth Remote Consultations Partners Online Specialty Consultations Operation Village Health

Virtual Coach

Connected Cardiac Care

E-Visits

Diabetes Monitoring

Prenatal Care

Kids Activity Program

Blood Pressure Connect

Nantucket Dermatology Clinic Psoriasis eCommunities

Battling Addiction

Aid in Atopic Dermatitis

DermaShare

Children Diabetes - Survey

Digital Imaging

Sunscreen Adherence

Data Source: http://www.connected-health.org/

Appendix: 3

Sample structure of the Telehealth Program

Tele Psychiatry

Psychiatry
Business Lead
Tele Dermatology

Tele Health Officer

CIO
Technical Lead

Clinical Lead

Dermatology

Strategic Planning

Quality

Store & Forward

Video Conferencing

Tele home monitoring

Tele Tele Radiology Radiology

Contract & Procurement

Clinical Protocols

Tele consultation

Radiology

Project Management

Risk Management

Tele Emergency services

Training & Education

Care Coordination

R&D and Knowledgebase

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