Abstract
The relationship between the clinical and technical aspects of a telehealth operation is frequently problematic, and technically-driven projects often fail to achieve sustainability. Qualitative data from a study of 37 Australian telehealth services were analysed to understand how the relationship between telehealth providers and information technology (IT) departments helps or hinders the development of telehealth. The most frequent difficulties reported were between telehealth services and the internal IT departments of health services, rather than with external vendors. The difficulties included barriers to installing telehealth over IT networks, a lack of priority given to telehealth services, and IT departments insisting on standardised approach. Alternatively, when IT staff were assigned to supporting clinical staff and had a close working relationship with them, they were major enablers of telehealth services. Authorising dedicated IT support and encouraging joint problem solving should provide a strong foundation for a healthy relationship which contributes to the growth and sustainability of telehealth.
Introduction
Information technology (IT) is an essential component in telehealth, yet the connection between the clinical and technical aspects of telehealth can be problematic. Previous research has indicated that the sustainability of telehealth relies on the service meeting genuine clinical needs1,2, and that when projects are driven primarily by the technical rollout of infrastructure, there is a danger that the equipment will fall into disuse.3,4 Research has focused on technology acceptance (i.e. the usability and ease of use of equipment 5 ), on diffusion of innovation 6 and on taking a sociotechnical approach. 7 However, there has been little attention to the nature of the organisational relationships between healthcare providers and technical service providers.
Technical providers can be divided into external vendors supplying services to healthcare organisations, and the internal IT staff and departments within the organisations. Two studies have investigated the relationship between external IT suppliers and telehealth services.8,9 Three problems were mentioned in both cases: information asymmetry, in which the health care providers did not have the expertise to assess or monitor what the technical providers were offering, instability and uncertain business viability in the vendor organisations, and difficulties with tendering and commissioning.
Research on the relationship with internal IT services is even more scarce. When it is reported at all, the main problem mentioned is the inadequacy of IT services in rural regions, where there is high staff turnover and lack of expertise. 10 A case study in rural Tasmania also noted the lack of a coherent IT strategy, and a lack of expertise in networking, which affected the implementation of the connectivity needed for telehealth. 11
The present study was part of a larger qualitative investigation on the uptake and sustainability of a diverse sample of telehealth services in Australia.12,13 In this investigation participants frequently described and commented on their relationships with IT services. We therefore undertook a separate qualitative analysis to understand how these relationships helped or hindered the development of telehealth services.
Methods
Telehealth clinicians, managers or researchers, who were associated with a diverse sample of Australian telehealth services, were approached to participate in a semi-structured interview concerning the initiation and sustainability of their services. After an initial round of interviews, follow up interviews were conducted with a subset of this group two years later, to gather longitudinal data on the progress of the services. The study was approved by the appropriate ethics committee, and the details of service selection and participant recruitment have been described elsewhere. 12 The interviews were audio recorded, transcribed and entered into NVivo software (QSR International), then the material concerning both technical issues and the relationship with technical service providers was extracted from the transcriptions, categorised and analysed thematically.
Results
The data collection took place over a three year period, from July 2009 to June 2012, when the last follow up interviews were completed. In total, 39 participants were interviewed about the operations of 37 telehealth services. Information on the operational status of all services was gathered at follow up. However full follow up interviews were only conducted on six services.
The 37 services delivered medical, surgical, mental health, nursing and allied health services in six Australian jurisdictions, with 30 (81%) primarily using videoconferencing. When the initial interviews were conducted, eight services were no longer functioning, and at follow up two more services (27% of the sample) had ceased operations.
In understanding the relationship between telehealth and IT, the initial distinction found was that the majority of participants spoke about their relationship with internal IT services, rather than with external IT vendors. Most responses indicated that the relationship was problematic, and these were categorised into three main themes:
Installation barriers At the operational level, participants reported barriers in obtaining permission from IT services to implement telehealth services. Protracted negotiations were needed to allow video communication over the health services’ networks, to reconfigure firewalls, or fulfill restrictive IT security criteria. Lengthy and usually unexplained delays occurred in the installation of additional connectivity. Participants reported that they had to push very hard to overcome these, needing to gain high level management support. One approach used was defining the telehealth service as a research project; “I argued that it was a research project, and we have to learn, and eventually that got through”, or even more bluntly, proposing to IT services that they would need to either assist or be seen as responsible for the failure of the project. Competing priorities Telehealth programmes were often regarded as part of the IT budget, and when decisions on resource allocation were made, telehealth could be squeezed out. For example, a healthcare manager noted that “[IT] didn’t want to commit money to something, ongoing money to something such as telehealth, when they knew they had commitments elsewhere.”, and a telehealth project officer stated “IT had to lose budget so they got rid of my position”. As well as budget, there were also issues of time and resource allocation; another telehealth project officer reported that there were long delays in telehealth services because “IT is such a huge part of what everyone does, that everyone needs their time.” Non-standard systems In the situation where a large organisation such as a government department had already implemented a videoconferencing network, tensions were reported between those operating this network and champions who had worked with clinicians to implement telehealth services tailored for particular clinical needs. The government preference was reported to be for a single unified approach. For example one interviewee explained “the State Health Department have their view of how telehealth should be delivered, including the brand of equipment and what it should look like” and another reported “not good cooperation from State Government existing telehealth services, being a problem when you come in from outside, putting in something which is not part of the overall strategy.” There was tension between operating a single standard system and being able to innovate to meet a variety of needs and models of service delivery. When there was more than one technical system, the inability of the networks to connect with each other became a subsequent problem.
Constructive partnerships
In contrast to the above difficulties, there were two particular circumstances where the relationships were perceived to run smoothly. Creative partnerships were described in the development phase of telehealth services when there was an initial source of funding; for example a remote area clinician reported “we had the IT guys on board, so really had a whole bunch of people who were very enthusiastic about seeing if we could get something to work.” It could, however, be difficult to continue this arrangement when funding was reduced, with one service closing when the Area Health Service became unwilling to pay for technical services. In the longer term, clinicians reported a positive experience when IT staff were assigned to telehealth as their specific responsibility: “We have a dedicated videoconferencing team, they’ve always been very helpful; no problems with IT support.”
External vendors
There was much less reported from interviewees about the relationship with external IT vendors. When they were mentioned, it was in the context of lack of technical support, for example: “If it went outside the hospital it was [Telco’s] responsibility, if you could find somebody, and then if there was a possible problem with the equipment you went to the supplier, and of course every one of them would say why don’t you try Fred before you come back to us.”
Telehealth governance
The issue of governance is relevant to all the above themes: who has the power and who controls telehealth services? Some clinicians saw IT services wanting control as a personal quality of IT staff: “technology people play power games because they want to be important”, but the broader issue was whether telehealth was primarily technically or primarily clinically driven. Our sample of interviewees were unanimous in wanting telehealth to be clinically driven. To put this in its clearest form, one participant commented: “in our State Health Department, they are technology driven, they’re an add-on to an IT department… for them, the uptake of telehealth is about access to technology. If you have access to technology, then you have a telehealth network. And in fact, you don’t.” Another participant suggested that the solution was to have telehealth incorporated into the generic costs of service delivery, rather than administered as a separate programme.
Discussion
The present study found that the major area of difficulty between telehealth and information technology services was not with IT vendors, but with internal IT services within healthcare organisations. The problem was common in this sample, yet has been little discussed in the literature. Our own experiences of initiating telehealth services corroborates these findings; from small rural health services with a single IT staff member, to large health departments, our experience has been that the IT staff rarely understand the requirements for telehealth.
One possible explanation for this is that the skills needed to support telehealth are found within telecommunications rather than in generic IT services. Traditionally, telecommunications has been managed to very high standards of reliability; typically aiming for 99.999% availability of the core services, or less than 6 minutes of down-time per year. Increasingly, however, telecommunications is conducted over IT networks and managed by IT departments that do not have the processes or expertise to achieve these levels of quality of service.
Another consideration is that there are cultural differences between IT and health systems. Healthcare is diverse and fragmented. Even in a large hospital, service delivery is conducted by a multitude of small units organised around clinical disciplines or health conditions, and each unit has its own culture and processes. IT is not organised in this way. Rather, the culture is of systematizing and unifying the services offered. Usually an IT department will only support one platform, assuming or demanding that all necessary work can be done within those constraints. Berg 14 pointed out that in health informatics more generally, IT-led approaches to standardising health service delivery lead to clinician resistance and sabotage, whereas taking a collaborative, iterative approach is more fruitful.
That these two cultures do not work together well may also be because the internal IT services staff see themselves, through their training and experience, as more closely aligned with the large external IT suppliers than they are with the health service clinicians. This is particularly the case when IT services are centralised and have little daily contact with clinicians, lacking the regular engagement which would bridge this divide. High level management support has been identified as another factor important for telehealth sustainability1,15 and the data from our study suggests that one of the reasons this is helpful is that managers have the authority to direct IT services to allow and expedite telehealth services. Without this, telehealth development, particularly smaller scale projects and innovations, can languish at the bottom of a priority list.
A limitation of the present research is that the sample was drawn solely from telehealth services in Australia, where there is a high proportion of real time video telehealth. Since this form of telehealth places higher demands on IT services, the problem may be more prevalent in this sample than in countries where asynchronous telehealth is more common. In addition, we have not yet interviewed IT staff and managers – this is planned for future research.
We recommend that the relationship between telehealth providers and IT services should be explicitly addressed early in the life of a telehealth service, and confirmed at the highest level of management possible. Authorising dedicated IT support and encouraging joint problem solving should provide a strong foundation for a healthy relationship which contributes to the growth and sustainability of telehealth.