THE THREE COMPONENT CONCEPT
Why is the healthcare market, so advanced in many ways, slow to adapt to technology changes when it comes to data and communications?
The reasons behind the mainstream healthcare innovation inertia can probably be divided into a number of different dimensions covering a wide spectrum of societal institutes. The healthcare market is still troubled by skepticism toward new digital and data technology implementations, both on a regional and international scale. The feeling is that “what has always worked will continue to work in the future” and the wards are filled with conservatism while outside the hospital walls society is moving forward toward ever-increasing connections and innovation.
A case for telehealth
The World Health Organization (WHO) has published a number of pilot studies showing the benefits of telehealth applications. These studies imply that telehealth applications can improve care by minimizing office visits, thus reducing costs and patient discomfort, and at the same time reducing time consumption for the healthcare professionals, which can support the possibility of greater care quality.
What these studies do not consequently show is how the telehealth application would financially benefit or inhibit the investor. Out of 65 studies regarding telehealth applications linked to monitoring chronic conditions in a home environment, only 28 percent contained some form of cost analysis, according to the WHO report “How can telehealth help in the provision of integrated care?”
Generally, an evidence-based approach is constructed of assessments resulting from studies in relevant areas. These assessments further produce support for a decision, for which a process could be initiated. Evidence-based care delivery is an alternative path for a healthcare professional to treat his or her patient. That is, gathering data from relevant and up-to-date studies and assess it to acquire support in treatment decisions adapted to the needs of the patient (according to a definition made by Ferguson in 2011).
Three factors to consider
As such, using an evidence-based approach for assessing whether or not to adopt innovative healthcare technology is a valid approach not only for clinical practice but also for technology processes. From the WHO report, we can identify three different components related to healthcare innovation: the economic component, the organizational component and the legal/ethical component.
1. THE ECONOMIC COMPONENT
One must carefully evaluate the economic component of an implementation project to further strengthen an initiative of investment. This includes factors related to quantitative estimates of costs and carefully evaluated prognoses of financial benefits in implementation outcomes. On this level of economic analysis it is important to look at the whole picture. How is the economic healthcare model in the current society constructed and in what way could the service or application benefit?
In many European countries there is a separate funding model for healthcare and social care where, for example, the healthcare sector invests in a new technology for which the outcome can benefit the social care sector, as is the case with many telehealth solutions. That’s why it becomes important to identify the financial impacts of the innovation as both costs and benefits. Furthermore, it must be considered on a larger scope, with an international perspective, on both a long short- and long-term basis. On a long-term basis it is important to identify factors that possibly could affect the impact of the innovation in the future. These factors could transcend into barriers of desired impact because of delayed reactions in other parts of the healthcare system as whole.
The economic analysis can have other attributes as well. If a specified application appears to be both less costly and offer a higher efficiency than a regular current application, it is easier to invest. However, if a specified application appears to be more effective but also more costly, the decision is presumably harder and requires further evidence. Here, a cost-benefit assessment is crucial.
Again, socioeconomic factors, such as resources and local infrastructure, must be included in the evaluation. On an international level, the differences between such factors could shift radically. A telehealth solution that creates a benefit in one country might form a large cost in another country, which of course affects the decision makers differently.
The cost-benefit relationship for telehealth applications is therefore highly related to its context. Thus, when it comes to investments in new healthcare solutions, it may be better to focus on the effective increase in care quality, for example from a telehealth solution, and the overall improvement of the healthcare delivery system that comes with it, rather than only identifying the value each set of stakeholders. For example, with a telehealth solution were a home environment focused care delivery system is integrated, the carer, often a close relative, can gain in workable hours by not having to be always present. Thus, funding the investment takes on a socioeconomic impact.
2. THE ORGANIZATIONAL COMPONENT
Apart from the economic component assessed through the evidence-based approach, the leap is not too large from a more organizational component. That is, what constitutes the governance and the institutional structures of the system evaluated for implementation of a telehealth solution?
Governance is defined by the rules and processes through which power is exercised in society, and is an important aspect when it comes to potential benefits of an integrated telehealth solution, according to the definition made in the WHO report. One of the key factors for success is to include a wide organizational analysis on both local and regional levels to identify good governance appropriate to the implementation strategy at hand.
Within the healthcare sector the organizational structure could often be complex or non-consistent. Processes of care delivery are not particularly integrated, thus separating stakeholders from each other and reducing the continuity of implementation. The issue of variance could be a limiting factor for a telehealth solution and exists in both a vertical and horizontal manner. That is, primary, secondary and long-term care systems could all have their own informational flows and administrational variations. It is important to map out the local and regional administrative channels and organizational structures to acquire an applicable strategy of implementation matching the variants of disciplines.
With the organizational structure mapped out, one could more effectively identify and compare factors of potential barriers to an implementation of a mainstream telehealth solution. These factors can be defined as processes of reimbursements, systems of innovation incentives and specific regulations related to care discipline.
Here, the connection to economic aspects is close. Reimbursement processes are closely related to the financial flows within the healthcare systems and may affect the various stakeholders depending on the structure of organization. It is important in the evidence-based approach to identify these financial flows in the structure in order to acquire information regarding specific factors that may pose barriers to a mainstream implementation.
When looking at the aspects of reimbursement in a healthcare organization, key attributes are input and process relative to outcome, and a quality-based approach. In the WHO report, three different models of reimbursements are pointed out: capitation, fee-for-service and salary.
So which system is best for a implementing a telehealth solution? A well-designed system with capitation or salary, where there is room for built-in initiatives to optimize a process, would be the main promoter for an effective telehealth solution. In another aspect, fee-for-service, though a costly model when the telehealth solution is requiring additional payment and there is not any compensation by other fees, could be a recommended choice in the initial phase of effectively diffusing the innovation into the organization.
Three models of reimbursement
Capitation: The healthcare professional receives an arranged payment based on a length of a time period caring for a patient. The services provided, or lack of, are irrelevant for the capitation agreement.
Salary: The healthcare professional is compensated by an agreed payment and, in addition to that, could have the right to be compensated based on performance.
Fee-by-service: The healthcare professional is compensated for each unit of service performed.
3. THE LEGAL AND ETHICAL COMPONENT
The third component is the legal and regulatory aspects connected to the healthcare sector. These aspects are well linked together within the organizational structure and pose equally as large barriers to an effective implementation of a telehealth solution. The legal contributions are not yet fully established regarding telehealth technology, nor are the practices because it is a relatively new area of healthcare technology. Usage of telehealth applications in today’s clinical evaluations is often regulated by specific legislation. Presumably, over a longer time period, more applicable regulations for telehealth technology will be more widely discussed and implemented through new policies.
As mentioned, close to the legal and regulatory aspects lie the ethics issue. Ethical questions regarding implementation of new telehealth technology are widely discussed and an area of careful evaluation. With future telehealth applications, when healthcare and care delivery systems have to reach higher levels of efficiency, the system will radically change. It is easy to focus on the technology itself and the promise of new cost-effective and time-reducing methods — a brand new healthcare world. But merely focusing on the technology and not ethical issues and legal implications, may reduce the overall chances for success (Kluge in 2011).
As an example, consider the electronic health record (EHR). Through EHRs, patients can access information about their health digitally, which requires consideration of software and communication protocols and outsourcing services to adapt to emerging patient rights and information requirements. Apart from the access to patient information, there is the fact that, in the case of the home based telehealth applications, the patient becomes engaged in the delivery of healthcare. Questions arise regarding data safety and the misreporting from patients, especially if the medications are based on data accuracy. The potential for human error could increase, affecting both the treatment and the workload of the healthcare professional. Above all, this could affect the life of the patient and involve the healthcare professional in legal consequences, according to Kluge.
Kluge further refers to telehealth applications as innovations created not to push aside the traditional processes of healthcare but rather extend care delivery systems. Any implementation of a telehealth application is a systematic process that has to blend in perfectly into the current healthcare delivery. Another factor to have in mind is that telehealth is a technology driven by rapid evolution. A telehealth application has to be evaluated to include the highest and latest standards. Accuracy compromises are not acceptable, because quality failures regarding hardware or software can jeopardize both patient safety and rights.
Different countries have wide variations in regulatory policies regarding monitoring and electronic consultation, not specifically in regard to modern telehealth applications, but similar to the medical-legal base that will form a telehealth framework in the future, according to the WHO report.
One example of a European Union founded cross-border project focusing on these questions is epSOS. The project is evaluating the issue of legal and ethical questions in information and communications technology (ICT) processes for electronic patient records and making these internationally accessible. The project is in an operational phase and a good example of showing a large collaboration in changing, or modernizing, the healthcare delivery system.
What do you think?
What are your concerns and opinions about the use of telehealth technology in modern medicine?
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epSOS (2014). “The European Health Project”, Available from http://www.epsos.eu/, [Accessed on 24th Mars 2014]
Ferguson, MK (2011) “Difficult decisions in thoratic surgery: An evidence-based approach”, London, Springer. 2nd ed., ISBN: 978-1-84996-364-0.
Kluge, E-H W (2011) “Ethical and legal challenges for health telematics in a global world: Telehealth and the technological imperative”, International journal of medical informatics 80, pp. e1–e5
Stroetmann, KA et. al., (2010) “How can telehealth help in the provision of integrated care?” World Health Organization.