Abstract
“Thing 1 and Thing 1 are chaos” said the Cat in the Hat. Theodor Geisel's (aka Dr. Seuss) classic children's book illustrates how chaos reigns against authority, but in the end is resolved by the Cat itself. 1 Chaos is all around us. It is disruptive, yet can lead to greater outcomes. 2 Chaos is a great word to describe where we are today. If you read the newspaper, get updates on your smartphone, watch television, listen to the radio, or breathe air, you can see and hear chaos all around us.
In the tale of the Cat in the Hat, a big red box is opened by the Cat, revealing the chaotic characters, Thing 1 and Thing 2, who begin to wreak havoc on Sally and her brother's home. Telehealth might be considered Pandora's Box, or something similar, in that it has caused lots of chaos. The only thing different is that there is no Cat to put chaos back in the box!
In our line of work as technology innovators and adopters, we understand that technology can be disruptive, and it can cause chaos in healthcare delivery. Chaos can also be driven by people and their opinions and attitudes. Lack of investment, or unwillingness to adapt and adopt, can cause chaos as well. In this day and age we also understand that rapid acceleration of technology, if left unabated, will overwhelm us and those larger “systems” that we have grown accustomed to cannot keep pace any longer—laws, policies, regulations, and so on. This may very well be a watershed moment where our “systems” must also evolve, and do so with significant rapidity, lest we fall behind and suffer the consequences of indignities and inequities in health and commerce.
As chaos is always present, we must figure out how best to address it and the changes it brings. We must choose the path that best fits our own altruistic interests and those of our patients, clients, and our society. Psychologists, including David Kahneman and Jonathan St. B.T. Evans have developed theories and concepts on cognitive processes. 3,4 We use those tools in decision-making as individuals. Known as System 1 and System 2, they underlay reasoning. These may also be referred to as “implicit” and “explicit,” although, they are not entirely the same.
In brief, System 1 is something that is autonomous and innate in all species. System 2 is evolutionary and distinctly human. System 2 permits us to think and reason. 4 In human beings, these two systems are in each of our brains and compete for control—in essence chaos. Evans posits that System 1 is fast, perhaps reactionary, and involuntary, whereas System 2 is slow and more thoughtful and cautious. We can see that in chaos one needs both systems in play. A reactionary may make an immediate decision, which could turn out to be the incorrect one, and then System 2 would come in to play. The same can be said about decision-making in all settings.
When it comes to telehealth and its integration into the workflow of a healthcare system, we have all come up against the gauntlet of System 1. It takes effort to convince the appropriate individuals to become engaged in meaningful discussion, and this is where System 2 comes into play. As experts in this field we want to fashion our approach as we want to teach and enable, not come across as telling someone to do it. We must engage colleagues by making them aware; they of course must have an interest. Similar to our Initiate Build Operate and Transfer (IBOT) Strategy, 5 evaluating a system and transitioning to an operational system is key.
Gagnon et al. studied the theory of adaptation of interpersonal behavior in relationship to telemedicine adoption by physicians. 6 They found that physicians would adopt telehealth if they had a perceived professional and social responsibility in their clinical setting, and if they had positive feelings toward adoption. These feelings are influenced by experiential learning, pedagogical interaction, and genuine interest.
The challenge in a chaotic world is to develop tools that engage all clinical personnel, not just physicians. Each person in the health continuum must see value in the integration of telehealth. We cannot just sit on our butts and wait for change. We also must be prepared for whatever comes through the door. It may be the Cat in the Hat with a box of things, so we should be prepared for chaos and how to decide on our response.
What's in this Issue?
There are some excellent research efforts reported in this issue from Australia, Brazil, Colombia, the United States, South Korea, and Switzerland. There is a blend of original research, communications, and case studies. Each article lays out how telemedicine and telehealth have been integrated into rural areas, palliative care, pulmonary disease, dermatology, glucose control, and technology.