How does Telehealth
change health care delivery?
- a qualitative study
Victoria Wade
Discipline of Public Health
The University of Adelaide
Prof Janet Hiller, Dr Jaklin Eliott
Prof Jon Karnon, Dr Adam Elshaug
Telehealth is the delivery of health care
at a distance, using information and
communications technology
electronic
decision
support
telehealth
e-health: all the uses of digital data in
health care: transmission, storage, retrieval
secure
messaging
sharable electronic
health records
Telehealth examples:
• Real-time video: mental health
assessment and treatment advice
• Store-and-forward: sending
photographs of burns, wounds or skin
conditions to specialists for review
• Tele-homecare: direct delivery of
services to people at home: for example,
those with cognitive impairment who live alone
If telehealth is so terrific, why
isn’t it everywhere?
The reality of uptake is:
• Slow and fragmented
• Many pilot studies, feasibility tests and
research trials: few ongoing services
• Difficulty in integrating telehealth into routine
care
What is going on?
Central Research Question:
What are the barriers and enablers to telehealth
delivering value to the routine operation of
healthcare in Australia?
Overall Approach:
• Interviews with people who have developed
and/or operated telehealth services
Today’s question:
• What impact does telehealth have on health
services delivery?
Interviewees
19 Clinicians: - 12 had multiple roles: 5
researchers, 4 telehealth coordinators
(part-time), and 3 managers
11 Researchers
4 Managers
2 Telehealth coordinators (full-time)
Data Analysis
Directed content analysis, applying concepts
from previous research to this data
Work:
work flow, work load and work roles
Interaction: communication, cooperation and
collaboration
Structure:
organisation and models of care
Power:
power relations and autonomy
Impact on Work Flow
• Major changes 15
• Minor changes 13
• No change
6
• Not classifiable
1
Impact on Work Flow
Major Change to Work Flow:
‘The scheduling is really tricky … two rooms need to be
scheduled, and the equipment … where you’ve got
to have somebody locally with the patient … it’s two
clinicians. So it really is quite a logistic exercise.’
No Change to Work Flow:
‘Switching [the equipment] on and having an extra
clinician there made no difference at all to our usual
practice of spending an hour a week talking about our
patients.’
Impact on Workload
• No change
15
• Increased workload
12
• Mixed impact
6
• Increased intensity of work
1
• Decreased workload
1
Impact on Workload
Increased Workload:
‘Support for the initiative wasn’t really
forthcoming from the unit manager at the time.
So it was just seen as extra work which we
didn’t have funding for.’
Decreased Workload:
‘It’s certainly more efficient than sitting in a
motor car, driving to a meeting and coming
back.’
Impact on Work Roles
• No change
14
• New staff
12
• New roles existing staff
9
Impact on Work Roles
No change to work roles:
‘I’ve tried as much as I can, to maintain it within the
conventional operating systems…If I tried to
introduce a change of role delineation as well, that
would cause further obstacles to uptake.’
New staff:
‘We’ve appointed a chronic illness nurse…she really
runs, helps to clinically coordinate those telehealth
clinics now, so she sort of supervises the registrars.’
Impact on Interaction
Amount of interaction
• Increase 27
• No change 7
• Not classifiable 1
Impact on Interaction
Increased communication
‘After the videoconference, the clinician would
ring the GP and discuss the case.’
Improved cooperation
‘Occasionally, we get outraged comments…and
these [video] meetings would smooth that
over…it just does keep the whole relationship
going.’
Impact on Organisational
Structure
•
•
•
•
•
No change 25
New unit 4
New network 3
Minor change existing structure 2
Not classifiable 1
Impact on Model of Care
• No change 15
• New model of care 13
• Minor changes 6
Types of Changes:
• Increased and/or improved patient services
• Upskilling and/or support for distant providers
• Increased clinical governance
Impact on Model of Care
Patient care:
‘The health outcome for the patient was a lot
better because we had immediate diagnosis
of whatever the problem was.’
Health provider support:
‘He stayed there because he had people to talk
to, I mean he had a circle of
colleagues…which otherwise would have
been totally missing.’
A New Model of Care
‘The telehealth side of things is the people in, wherever
the patient is…(1) they go out to see the patient, (2)
they take an image, and put in all the patient’s history
and data; (3) they then send that image to a [specialist]
consultant who may report on that image, yep, you’re
doing great or (4) gee this person needs to have a
review by the [specialist], or I’m going to send it off to
our [allied health worker] who then, they may have a
group of people who provide advice about this patient.
(5) Might have a case conference, which will be either
video case conference, or a telephone case
conference with the images. And then the on-the-site
carer; nurse, health worker, whoever, (6) will continue
to provide the care, and then that person’s [condition]
will be monitored.’
Impact on Power and
Autonomy
• No change 28
• Less power distant site 5
• More power nurses 1
• Not classifiable
Impact on Power and
Autonomy
Less power for distant sites:
‘They don’t videoconference with us… they felt that
they were being dictated to a little bit too much by the
[city hospital specialists].’
More autonomy for nurses:
‘Previously when the doctor at [rural hospital] wanted to
talk to the specialist , the doctor would go off into a
little room, ring up the specialist, have a private
conversation, come back and say…this is what we’ll
do…Now basically the specialist has a conversation
with the whole team…it does actually empower all
the people in the room to speak to the specialist.’
In Summary:
• Work: changes to work flow and new staff
roles were common. Work load increases
occurred in about one third of services
• Interaction: increases were very common
and positive, for patient care and for staff
• Structure: more than half the services
changed the model of care, far fewer
changed the organisation
• Power: mostly no changes. A minority of
distant sites became less autonomous
Conclusions:
• Most telehealth services changed the
organisation and delivery of health care
• Telehealth can be a small, safe
improvement
• Or a complex, disruptive
innovation
Implications:
• E-health and telehealth are coming
• The likely impact on health services
delivery should be taken into account
• Health care providers, governments and
the community should work together for
the best results