Telehealth Organizational Implementation Guideline Issues: A Canadian Perspective

ABSTRACT

The current status of policies, guidelines and standards related to the organizational context of clinical telehealth practice were investigated. The directions these should take to meet the healthcare needs of Canadians also were outlined. An environmental scan approach was employed, consisting of a literature review, stakeholder survey questionnaire, and 12 key informant interviews. The literature review resulted in 260 sources related to organizational leadership issues, of which 176 were abstracted. The stakeholder survey questionnaire response rate was 64% (156/245), with 55% (84/154) completing the organizational context section. All (100%) key informants who were selected for interviews participated. Findings were categorized into four key organizational themes: organizational readiness, quality assurance, accountability, and continuity. Organizations need to review existing policies, standards, and guidelines in order to determine whether telehealth is covered and, if not, revise them or develop new telehealth-spe-cific policies. Telehealth policies and procedures should be integrated with those in existence for face-to-face services.

INTRODUCTION

In Canada, there are 14 health jurisdictions; all are engaged in deploying telehealth applications. Telehealth, as defined in this project, is “the use of information and communications technology to deliver health and healthcare services and information over large and small distances” (Picot, 1998). Clinical telehealth applications are now operational in tertiary and community healthcare settings. As the number of telehealth projects, programs, and services has increased steadily, greater attention is being focused on policy and quality issues related to the delivery of telehealth services. There is increasing interest among healthcare professionals and administrators, healthcare institutions, organizations, businesses, government agencies, and regulatory bodies to develop and adopt policies, procedures, guidelines, and standards for use within provinces across Canada.

The National Initiative for Telehealth Guidelines (NIFTE) was established in order to develop consensus on a national, interdisciplinary framework of guidelines for use by health-sector organizations (National Initiative for Telehealth Guidelines, 2003). The guidelines were designed by telehealth providers for use by health professionals in developing their specific standards and as benchmarks for standards of service and by accrediting agencies in developing accreditation criteria. A major activity of the project was an Environmental Scan designed to examine four content areas related to telehealth: Organizational Context, Technology and Equipment, Clinical Standards and Outcomes, and Human Resources (National Initiative for Telehealth Guidelines Research Consortium, 2003).

The organizational context team investigated the status of policies, guidelines, and standards as they related to the organizational or adm inistrative context of clinical telehealth practice in Canada. In addition, this component also explored the directions that telehealth administrative policies, guidelines, and standards should take in order to meet the healthcare needs of Canadians. The purpose ofthis article is to synthesize the findings of the environmental scan and to summarize the organizational issues and recommendations related to clinical telehealth implementation within organizations.

LITERATURE REVIEW

There is a recognized need for national standards for healthcare professionals and guidelines for the accreditation of healthcare organizations and facilities that provide telehealth services. This lack of standards and guidelines has been considered to be a barrier to the successful integration of telehealth into healthcare facilities. Standards are requirements that an organization must meet in order to earn accreditation and are important, because they provide a benchmark for measuring quality. At present, there are no existing Canadian telehealth accreditation standards. A variety of policies and guidelines were found in the literature review. Although many published papers, reports, and documents were reviewed, few provided insight into organizational policies, standards, or guidelines with respect to the provision of telehealth services nationally or internationally. The majority of the documents reviewed on the subject of organizational policies, guidelines, and standards for telehealth and telemedicine tended to focus on technical aspects. Standards need to be established for the administrative management of telehealth services. In addition, national standards need to be established for the management of privacy, confidentiality, and security, as well as for the documentation of policies and procedures.

The Advisory Committee on Health Infos-tructure (2001) asserted that several ingredients must be in place if the national health infos-tructure is to be implemented in an effective manner, including strong leadership; a clear and comprehensive strategy and detailed plan; and a common understanding of federal, provincial, and territorial initiatives. Jennett and Andruchuk (2001) stated that the successful implementation of telehealth services in Canada depends on several key factors: (1) the readiness of the environment; (2) systematic needs analyses, strategic business plans, and diverse, collaborative partnerships; (3) adequate equipment and IT vendors; (4) staged implementation; and (5) evaluation. Jennett and Siedlecki (2001), in a paper looking at the issue of policy development in telehealth, concluded the following:

The success of the telehealth venture is contingent on the development of policy to support and enable the use of technology in delivering quality care and equal access to stakeholders. A successful system is seamless, ubiquitous, and integrated. It supports a single point of access to stakeholders and incorporates clinical, administrative, educational, and transactional functions. The policy enabling this success ensures that privacy, confidentiality, and security are ensured; equality of appropriate access is provided; jurisdictional boundaries are not an impediment to optimal care; cultural diversity and human dignity are respected; stakeholder needs are met; and the telehealth service is timely cost-effective, and patient-centered.(Jennett & Siedlecki, 2001, p.57-58)

There is a recognized need to develop tele-health policies, guidelines, and standards, but few policies, guidelines, or standards actually were found to exist in practice within Canada. Those policies, guidelines, and standards that do exist are specific to a particular organization, program, or project and are not integrated.

RESEARCH METHODOLOGY

An environmental scan approach was used to address the following research questions: (1) What is the status of policies, guidelines, and standards as they relate to the organizational or administrative context of clinical telehealth practice in Canada? (2) What direction should telehealth administrative policies, guidelines, and standards take to meet the healthcare needs of Canadians? As illustrated in Figure 1, the organizational context environmental scan framework methods included a literature review, stakeholder survey questionnaire, and key informant interviews.

Literature Review

The purpose of the literature review was to (1) identify key issues that need to be explored in the stakeholder survey, specific to the organizational context; (2) help to formulate the survey questions. The literature search was limited to English only, with an emphasis on Canada. The search of articles explicitly dealing with the organizational context (and similar keywords) of telehealth and policy issues, such as standards, guidelines, and protocols, resulted in 260 papers and documents being obtained and reviewed. Of these, 176 references met the review criteria (dealing with organizational context of telehealth and policy issues, such as standards, guidelines, and protocols) and were abstracted. The number of articles explicitly dealing with the organizational context of telehealth and policy issues was minimal. The majority of the literature obtained was related to the topics of organizational readiness, accountability, quality assurance, and continuity within the context of telehealth and/or health technology.

Stakeholder Survey Questionnaire

A mailed survey questionnaire was used to collect the more structured and quantitative information about the organizational context from telehealth stakeholders. Questions were asked about readiness for telehealth, leadership of telehealth programs, quality assurance, policies, processes, accessibility, and coordination of services. The semi-structured questionnaire was developed specifically for the environmental scan survey, using the knowledge gained from the literature review. Face and content validity were established by pilot testing the questionnaire with a sample of nine stakeholders that were representative of telehealth practice in Canada.

A total of 245 questionnaires were mailed to all the individuals listed in the Telehealth Stakeholder Database, a mailing list of individuals and organizations compiled and maintained by a Canadian Secretariat. To facilitate a quality response rate, an e-mail reminder (two weeks after initial mailing) and a second questionnaire mailing (two weeks after the e-mail reminder) were employed. Questionnaires were coded so that the second mailing could be targeted to non-responders. Of the 156 (64%) returned questionnaires, 84 (55%) completed the organizational leadership section of the survey. These 84 were coded and analyzed. Descriptive statistics were calculated using SPSS (Statistical Program for the Social Sciences) Version 11.0. The respondents’ open-ended survey responses were transcribed and content analyzed by the research team. The largest portion (36%) of respondents completing the organizational leadership section were nurses (n=30), while administrators (n=18) accounted for 21%, physicians (n=11) accounted for 13%, allied healthcare professionals (n=6) accounted for 9%, and other professions (n=18) accounted for 21%.

Key Informant Interviews

The specific objectives of the 12 key informant interviews were to determine directions that tele-health polices, guidelines, and standards should take, and how they should evolve in order to meet the healthcare needs of Canadians. Organizational key informants were defined as individuals who frequently used telehealth (delivering or receiving telehealth services) within an organization in order to provide care or information related to care and who held management or administrative leadership positions within their organizations. The organizational key informants were selected by the researchers from individuals listed in the Telehealth Stakeholder Database to be representative of organizations offering clinical telehealth services across all Canadian provinces and territories. All (100%) key informants selected for interviews participated. Six physicians, three nurses, two administrators, and one psychologist participated in the interviews.

Semi-structured, open-ended questions were developed and asked during a telephone interview. The interviews were tape recorded with key informants’ consents. The key informants were asked to provide their thoughts and opinions about what key organizational factors should be in place for the successful implementation of clinical telehealth services. The tape-recorded interviews were transcribed. The transcriptions and handwritten notes were summarized and analyzed independently by two researchers. Analysis was a multi-step process involving each researcher independently reviewing the transcriptions; becoming familiar with the content; and extracting significant comments, themes, phrases, or ideas. The researchers then met and discussed the independently reviewed transcripts in order to reach consensus on the common themes, phrases, or ideas.

RESULTS

The following summaries synthesize and describe the four key organizational themes identified during the environmental scan: Organizational Telehealth Readiness, Accountability, Quality Assurance, and Continuity.

Organizational Telehealth Readiness

The need to systematically assess an organization’s readiness to use telehealth technology was identified. Overall, the survey findings and key informants’ responses support the literature, stressing the importance of organizational readiness in ensuring the long-term success of telehealth programs and services. Organizational readiness for telehealth is a multi-faceted concept consisting of planning, workplace environment, healthcare systems, and technical readiness.

Figure 1. Organizational context environmental scan framework

Organizational context environmental scan framework  

Planning Readiness

An important component of an organization’s telehealth readiness is planning readiness (Advisory Committee on Health Infostructure, 2001; Jennett & Andruchuk, 2001). Planning readiness involves organizations being able to demonstrate that the organizational leadership has completed required upfront work in terms of planning for the implementation and sustainability of telehealth (Alliance for Building Capacity, 2002). Planning readiness includes (1) a telehealth strategic plan, including a needs assessment and analysis, business plan, marketing plan (internal and external), communication plan, and evaluation plan; and (2) leadership, including program champions and collaborative partnerships. The dynamics of the planning process and order in which the steps in the planning process are conducted are very important. A phased approach to implementing the strategic plan was identified as important by the key informants.

A needs assessment and analysis was identified as an important factor in the successful implementation of telehealth. The majority (73%) of survey respondents reported that their healthcare organization or facility had conducted a needs assessment for its telehealth services. All 12 key informants (100%) noted that a needs analysis is a critical component of a healthcare organization’s telehealth readiness and that there are several components to a needs analysis, including an assessment of community readiness and provider readiness. The rapidly changing status of telehealth services suggests that an almost ongoing approach to needs assessment should be in place. Organizational policies and guidelines should reflect this unique aspect of telehealth. A strategic business plan is an important component of organizational telehealth readiness. Indeed, the majority (83%) of survey respondents reported that their telehealth services were part of their organizational business plan, or that the business plan was in development. These findings are an indication that telehealth services are becoming recognized as a part of routine healthcare services. A telehealth strategic business plan needs to take into account research and evaluation of telehealth as an innovation. Given the rapidly changing nature of telehealth, the needs assessment and business plan must remain open to change and revision on a regular basis. Two subthemes—cost-benefit/cost effectiveness and financial readiness for sustainability—were identified. An indicator of sustainable funding would be that new investment dollars are put forth by the organization in order to address service gaps that use telehealth.

The survey findings indicated that the marketing of telehealth services is in an evolving phase. Only three of the 84 respondents reported that their organizations had a marketing plan in place or in development. Healthcare organizations currently are marketing primarily internally among healthcare providers within their institution or region or to their partners rather than to external audiences. A need was recognized for an open communication plan and for all stakeholders to be kept informed during the planning and implementation stages. It was felt to be critical for achieving buy-in and support for the planned programs, facilitating the change process, and team building. Since telehealth involves communication between organizations, a good working relationship between them is needed, as well as a sense that the receiving organization is a trusted authority.

Leadership Readiness

One of the key informants used the term leadership readiness to refer to the need to have program champions and collaborative partnerships in place and informed prior to beginning a telehealth program (Ash, 1997). Survey respondents (36%) indicated that there is a move toward the involvement of multiple advocates in senior positions or telehealth committees. Different types and levels of program champions and/or primary advocates are needed, based on their ability to influence. Within organizations, two types are needed: a clinical or provider champion and a senior-level administrative champion. At the community level, someone from within the community is required to promote what telehealth can provide (Alliance for Building Capacity, 2002). Senior management support is critical for the success and sustainability of telehealth services in healthcare organizations. All 12 key informants (100%) indicated that collaborative partnerships are an important component of organizational readiness. These partnerships should be in place before beginning and should include a variety of partnerships with different groups. The types of partnerships developed depend on the scope and application of the telehealth services. Partnerships need to be revised over time. Collaborative partnerships demonstrate that an organization has the ability to partner.

Workplace Environment Readiness

Findings also noted that organizations need to take into account the impact that telehealth services have on the workplace environment and work routines (Aas, 1999). The workplace environment should be ready to implement telehealth services (Aas, 2001). The identified components of workplace environment readiness include awareness of legislation; professional, and regulatory requirements; structural readiness; administrative support for telehealth; along with change management, human resources, healthcare system, and technical readiness. Healthcare organizations ready to use telehealth technology are aware of all legislation and professional regulations that may impact the delivery of telehealth services (e.g., health information protection laws that mandate policies and procedures to be in place in order to protect the privacy and confidentiality of sensitive information) as well as regulatory specific policies to determine telehealth coverage.

The workplace environment must be ready for the required telehealth technology and equipment (Kaplan, 1997). An organization with structure, capacity, means, and resources to implement telehealth is required because of the large amount of coordination needed to deliver and to receive requests for services. The workplace setting should have telehealth equipment in locations where it is convenient for providers and where it can facilitate the delivery of patient care (i.e., structural readiness). Support needs to be established for clinical decision making, functioning, and the process of using the telehealth system. These administrative support policies and procedures include mechanisms for the transfer of patients; a standardized, well-defined, easy-to use referral system; a standard and consistent method of recordkeeping at both the receiving and referring sites; and definitions for who gets privileges to use telehealth both at the receiving and referring sites. The introduction of telehealth services into an organization is often disruptive to the work environment (Aas, 1999; Ash, 1997). Readiness also means that the organization’s leadership understands this impact and has a change management plan in place (Garside, 1998; Southon, Sauer & Dampney, 1997).

Human Resources Readiness

Human resources readiness involves having adequate and dedicated human resources in order to implement the strategic plan. Clarification of roles and responsibilities provides the required policies and procedures that are related to user characteristics, such as training and specialty. Six key informants (50%) stressed that an organization that is ready to use telehealth technology would have an education or learning plan in place for those individuals who provide care via telehealth.

Healthcare System Readiness

Healthcare system readiness for telehealth involves the healthcare system being ready in terms of providing strategic support and expertise and having policies, guidelines, and procedures in place at provincial/territorial and/or national ministry levels related to the required infrastructures, funding, remuneration, support for innovation, and diffusion processes (Olsson & Calltorp. 1998-1999).

Technical Readiness

Four key informants (33%) stated that the technical requirements and feasibility of providing telehealth services were essential components of organizational readiness with respect to such things as network and local site technical readiness and interoperability, technical feasibility, bandwidth, verification of fidelity of data transmission, and procedures to make sure that it is checked regularly. Technical support must be in place. Two key informants (17%) representing rural and remote telehealth services stressed that the technology support aspect of telehealth equipment requires consideration, particularly related to the maintaining of equipment in communities that do not have easy access to technology support services.

Quality Assurance

The literature review indicated a need to determine whether or not telehealth does improve the quality and accessibility of care (Jennett, Gao, Hebert & Hailey, 2000; Kangarloo, Dionisio, Sinha, Johnson, & Taira, 1999; Office of Health and the Information Highway, 2000; Yawn, 2000). All 12 key informants (100%) and survey respondents reported that telehealth quality assurance is important. Nearly all respondents (83%) indicated that their organizations were collecting some data or had such activities in development. Telehealth services evaluation is evolving; however, there is still a lack of sophistication in data collection. Evaluation of telehealth services currently focuses on the collection of system utilization, technical performance data, patient/client satisfaction, and provider satisfaction data. The more challenging areas related to the provision of telehealth services, such as access to care/services (Jennett, Person, Watson, & Watanabe, 2000), patient/client outcomes, cost-benefit/cost effectiveness, the impact on workflow, team relationships, provider roles, and responsibilities need to be evaluated more frequently. In addition, all aspects of the tele-health encounter should be evaluated, including a patient’s physical and psychological comfort, technical quality of the service, quality of communication between caregivers and patients, duration of the consultation, timeliness of the care delivery, degree of confidentiality, and the costs (Hailey & Jennett, 2004; Sisk & Sanders, 1998). Informed, evidence-based evaluation of quality of care and cost effectiveness is still mainly in an early stage. However, the need to have baseline data to show that quality of care and patient safety are at least equal to face-to-face encounters is becoming recognized. The collection of both qualitative and quantitative data to evaluate telehealth services is needed (Lee, 1997). Four key informants (33%) indicated that telehealth services should be evaluated in a continuous and ongoing process. All key informants (100%) expressed that regular review of telehealth services should be part of an organization’s overall evaluation process. It was suggested that they be done quarterly for the first year and then semi-annually.

The survey findings indicated that a wide range of organization or program-specific indicators and measures are being used to evaluate telehealth services. Standardization of data collection tools, common measures, and key indicators for tele-health applications are needed. Key performance indicators for telehealth should be defined in order to ensure consistency in how they are monitored, reported, and evaluated. Four key informants (33%) responded that standardized quality indicators, defined at both the program level and the organizational level, are needed related to system utilization, patient and provider satisfaction, and technical performance.

At the organizational level, a condition of accountability is the requirement of monitoring what is occurring through the development of an ongoing evaluation plan. Part of this accountability for quality assurance involves organizations having mechanisms in place in order to make the necessary adjustments to services, based on evaluation results.

Accountability

For each accountability issue, strengths and areas for improvement were identified. Key informants indicated that strengths can be demonstrated by the policies and procedures that organizations have in place and by the accountability mechanisms and structures present to address key requirements. Eight topics were identified: governance framework; privacy, confidentiality, security, and ethics; cultural awareness; document and storage of patient/client telehealth records; liability and risk management; licensure; cross-jurisdictional services and other liability issues; and remuneration/reimbursement.

Governance Framework

Organizations need to develop a governance framework that focuses on the roles and responsibilities of all individuals involved in telehealth activities (Industry Canada, 2001). Two issues related to the governance structure of the organization were identified:

1. Where telehealth is positioned in the organizational structure as well as the lines of accountability for telehealth services were reported to be important by both key informants and survey respondents. The person to whom telehealth is accountable should be at a high senior administrative level and positioned in the organization to make a strategic impact.

2. Administrative processes should be in place in order to support the governance structures and to help those individuals responsible for telehealth to assume accountability. Telehealth services ultimately should be accountable to a board or some other body that would provide governance with the appropriate administrative steps to support that structure: technical, personnel, supervisory, and managerial. To whom and for what telehealth is accountable needs to be defined and documented in writing. There are three levels of accountability: the health system itself, including health regions; the organization (administrative and clinical accountability); and the Privacy Commission (consent, confidentiality, and privacy).

Privacy, Confidentiality, Security, and Ethics

The literature indicated that privacy, confidentiality, and security must be considered when implementing telehealth services (Committee on Maintaining Privacy and Security in Health Care Applications of the National Information Infrastructure, 1997; Privacy Working Group, 2000). The practice of telehealth does not appear to raise any new policy issues regarding confidentiality. Traditional confidentiality policies should be applied in this new context with consideration for the specific technical issues involved in applying these polices for telehealth applications. In 2001, COACH, Canada’s Health Informatics Association, published Guidelines for the Protection of Health Information (Canada’s Health Informatics Association, 1997) as a framework to assist health organizations in the development and implementation of comprehensive privacy and security programs.

Protection of privacy requires organizational-level policies (Committee on Maintaining Privacy and Security in Health Care Applications of the National Information Infrastructure, 1997; Privacy Working Group, 2000). Most organizations have corporate privacy policies, and thus, 70% of questionnaire respondents and all key informants (100%) felt that a separate privacy policy specific to telehealth was not needed. However, existing privacy policies will have to accommodate the crossing of organizational and facility boundaries and the sharing of highly personal information. Organizational policies are required to govern who can be present during a videoconferencing session and who must declare themselves.

Confidentiality is an important issue that requires organizational-level policies around the protection of health information and the consenting process (American Medical Association, 1996; Privacy Working Group, 2000). Confidentiality is protected under the Health Information Act or similar provincial legislation, and the principles must be reflected in writing in the organization’s policies (Canada’s Health Informatics Association, 1997). The policies must reflect the impact of the human, organizational, and technical aspects of telehealth.

All key informants (100%) identified security as an important organizational policy issue, an area in which additional policies and standards related to telehealth were needed. Telehealth has some unique aspects that require special mention in the organization’s security policies, guidelines, and procedures (Canada’s Health Informatics Association, 1997). These policy and procedures issues are similar to those around electronic health records, and key informants believed that in the near future, these would be integrated. In addition, two informants (17%) stated that there should be an educational component in order to deal with the security issues related to human behavior. This was felt to be of particular importance in the remote regions of Canada due to the use of lay healthcare providers and lay telehealth coordinators.

The majority of survey respondents (65%) stated that their organizations did not have tele-health-specific codes of ethics and appeared to rely on their organizations’ existing codes of ethics and/or legal guidelines. However, there are several ethical aspects related to telehealth concerning informed consent, protection of confidentiality, privacy and security, handling of confidential electronic information, and so forth that are unique to this method of delivering health services (Iserson, 2000). Respondents’ suggestions on what should be included in a telehealth code of ethics support the need to review existing codes of ethics to determine if they include telehealth-specific ethical considerations. All 12 key informants and 13% of questionnaire respondents believed that the same ethical principles that apply in face-to-face care should be applied to telehealth encounters. Existing provincial/territorial policies, standards, guidelines, and procedures should be used. The issue of consent for healthcare via telehealth is one area that was identified as needing special consideration (Joint Interdisciplinary Telehealth Standards Working Group. 1998; Stanberry, 1998). Organizations should have procedures in place to have patients/clients give informed consent before they agree to the telehealth consultation. In addition, policies need to be in place that outline what information needs to be given to patients/clients for informed consent. Two key informants (17%) reported that special ethical needs must be taken into consideration in policies, standards, guidelines, and procedures when providing telehealth services to First Nations and Inuit communities in the more isolated and remote areas of Canada.

Documentation and Storage of Patient/ Client Telehealth Record

Although 56% of survey respondents reported that there was a protocol in place in their organizations or facilities for the documenting and storing of patient information for telehealth, the wide range of survey responses to the location of the patients’ medical records (18% referring site; 18% consulting site; 24% copies at both sites; 12% other) indicated that there were no uniform standards that everyone could follow. Record-keeping and documentation for telehealth care was identified as another accountability issue that requires organizational policies to be in place so that what is going on can be tracked and so that two institutions can generate a record for the same patient and same encounter (Huston, 1999). With the coming age of the electronic health record, three key informants (25%) felt that standards should be developed in keeping with the total electronic communication environment.

Liability and Risk Management

The literature review indicated that there are several types of liability relating to the health professionals involved, the technology, the organization or institution, the human resources and training, and the telehealth application (Canadian Nurses Association, 2000; Saltzman, 1998). Organizations should have a written policy statement regarding whether healthcare providers need to be certified or not in order to potentially cover liability issues related to credentialing and privileging. It is recommended that established risk management policies be followed and that new telehealth-specific policies be created for anything not covered under existing policies (Switzer, 2001).

Licensure, Cross-Jurisdictional Services, and Other Liability Issues

Licensure was felt to be an important policy issue (Blum, 2000; Jacobson & Selvin, 2000). However, there was lack of agreement among the survey respondents and key informants as to whether or not it was necessary to require health professionals to be licensed in order to practice telehealth.

A number of policy issues need to be resolved with respect to the provision of cross-jurisdictional telehealth services (Pendrak & Ericson, 1996). Four key informants (33%) and 39% of survey respondents indicated that a common Canada-wide level of agreement should be in place with respect to cross-jurisdictional services. Also, policies regarding other cross-border liability issues need to be established at the national level by professional associations or regulatory bodies before healthcare organizations can put in place their organizational policies and procedures. Until national policies are developed, interim policies and agreements are required in order to address these issues.

Remuneration/Reimbursement

The issue of reimbursement, as it relates to physicians and other healthcare professionals in private practice, is unique to telehealth due to its borderless and cross-jurisdictional nature (Hogenbirk, Pong & Liboiron, 2001; Pong & Hogenbirk, 2000). All key informants (100%) felt that the development of policies in order to address reimbursement for health professionals paid on a fee-for-service basis is not an organizational-level issue and would have to be handled at the provincial level.

Continuity

Overall, the findings indicated that organizational leaders are just beginning to integrate telehealth into healthcare organizations and facilities as a service.

Integrated Telehealth Delivery Model

Organizations have to ensure that they do not develop policies and procedures that are different from existing policies and procedures for a regular visit. An integrated telehealth delivery model should be developed that positions telehealth as a strategic resource, which makes it possible to continuously improve the organization’s capacity to deliver services and information across distances. One key informant indicated that a high accreditation rating should be given to an organization in which healthcare providers, during the course of the day, move easily from one medium to another as seamlessly as talking on the phone, going to a meeting, or sending an e-mail.

Administrative Interoperability

Telehealth services should be integrated into existing administrative policies, guidelines, and procedures. There are clearly the following well defined policies and guidelines that need to be in place for telehealth: technical interoperability; clinical practice, including liability; protection of privacy; freedom of information; and financial issues (Jennett & Siedlecki, 2001; Lemaire, 19982000). An integrated system of information and communication technologies rather than a focus on just videoconferencing is required in order to enable continuity of care, particularly in the remote areas of Canada. Scheduling of telehealth services is a unique administrative interoperability issue that requires standardization. Two key informants indicated that administrative policies should be put in place that allow all providers access to information about teleconsultations. As telehealth applications become more complex (e.g., homecare, preoperative care at a distance, regionalization of health facilities), some central coordination of telehealth communications will be required. A standard for coordination and linkages should be developed along with administrative structures to facilitate these standards. How do we make it work in a practical sense? How much is centralized? How much is a function of existing administrative structures, and how much needs to be new? Telehealth can provide coordination and linkages to facilitate the continuity of care without physically having to move patients. Tele-health can facilitate a different way of linking together virtually rather than physically, but the coordination has to come from the providers or organizations.

Coordination of Multiple Telehealth Services

Key informants suggested that organizations should look at how they currently deliver several services and deliver multiple telehealth services in the same manner and try as much as possible to integrate into routines that are already in place. The organization of outpatient services was proposed by one key informant as a useful model. A small-core telehealth group is needed to look after and manage the equipment and physical space. Macro-level organizational policies should be in place that are relevant to all telehealth applications (e.g., what has to happen in the event of a failure; maintenance standards; how booking is done; considerations of privacy, ethics, and informed consent). Coordination of multiple telehealth services should be the responsibility of a telehealth management committee, with site coordinators or network coordinators responsible for day-to-day operations. Setting priority criteria and guidelines for use of the services would be an administrative responsibility. The site coordinators would be coordinating the clinical services, using the developed criteria and guidelines.

Strategies and Policies to Ensure Sustainability

Business plans, regular reviews, and reliable, long-term funding strategies were identified as mechanisms around which policies and guidelines should be developed in order to ensure accountability and sustainability of telehealth services within organizations. One key informant stated that the extent to which an organization has demonstrated continuity would be evident by how much telehealth is in place. The majority of survey respondents (83%) and all 12 key informants (100%) recognized the importance of long-range business plans in terms of sustainability of tele-health services within an organization. However, they tended to believe that five years was too long of a period for a telehealth business plan to be in place, as it is difficult to do a long-range business plan with such a vibrant, growing technology. Program-related infrastructure supports need to be developed in order to ensure sustainability (e.g., bridging, scheduling, information repositories, telehealth information repositories, and directories). The budget for telehealth should be an integrated part of the complete budget, not an add-on. Long-term funding was identified by all key informants (100%) as being critical to the sustainability of telehealth services. A sustain-ability policy with funding to sustain it needs to be in place across Canada.

DISCUSSION AND CONCLUSION

This organizational environmental scan established that there are a number of organizational-level items that require consideration when developing policies, standards, and guidelines for telehealth services (see Table 1). These include the human, physical, and environmental infrastructures required for telehealth; organizational telehealth readiness; the business case specific to telehealth services; the governance framework for telehealth; provincial, territorial, national, and international policy-related activities; different policies, guidelines, and procedures for different types of telehealth activities; quality assurance, including safety and required processes and indicators; and the integration of telehealth services with existing non-telehealth services. In addition, telehealth quality assurance, accountability, and continuity policies, standards, guidelines, and procedures should be integrated as much as possible with those in existence for face-to-face services.

Table 1. Summary of clinical telehealth organizational implementation guideline issues


Key Themes

Issues

General Organizational Issues

Concept of a Virtual Organization Integration of Telehealth Policies Telehealth-Specific Policy Issues

Flexibility and Sensitivity to Innovation

Multiple Types of Clinical Telehealth Applications and

Technologies

Organizational Telehe/lth Readinerr

Planning Readiness

• Telehe/lth Strategic Plan

• Needs Assessment and Analysis

• Strategic Business Plan

• Leadership Readiness

• Evaluation Plan

• Dynamics of Planning Workplace Environment Readiness

• Aw/tonorr of Legislation, Professional and Regulatory Requirements

• Structural Readiness

• Administrative Support for Telehealth

• Communication Plan

• Change Management Readiness

• Human Resources Readiness HealthCare System Readiness Technical Readiness

Quality Assurance

Ongoing Evaluation for Quality Assurance Key Performance Indicators

Assfentafility

Governance Framework

Privacy, Confidentiality, Security, and Ethics

Documentation and Storage of Patient/ Client Telehealth Records

Liability and Risk Management

Licensure

Cross-Jurisdictional Services Remuneration/Reimbursement

Continuity

Integrated Telehealth Delivery Model Administrative Interoperability Coordination of Multiple Telehealth Services Strategies and Policies to Ensure Sustainability

These findings are a demonstration of the current status of telehealth in Canada and are reflective of the organizational implementation issues related to clinical applications in 2003.

The pan-Canadian funding andjurisdictional priorities and envelopes at the time of this work focused considerable attention on telehealth readiness and evaluation. Thus, it is not surprising that the majority of the findings relate to the areas of organizational readiness and accountability. Attention had not yet been directed to telehealth clinical outcomes, quality of care, or patient safety at the time of this study. This may be why less input was provided in these areas.

Telehealth is an innovation with rapidly changing characteristics and is a new alternative way of providing services. Therefore, organizations must move beyond site-specific focus to network considerations. The recommendations arising from these findings provided the groundwork for the development of the Organizational Context sections of the NIFTE framework of guidelines (National Initiative for Telehealth Guidelines, 2003). These sections are Organizational Readiness, Overarching Organizational Leadership Issues, Accountability, Quality Assurance, and Continuity. These are now being operationalized and considered in the organizational hospital accreditation processes.

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