Abstract
A literature review was carried out to identify the key challenges in the implementation of telehealth. This was followed by a survey of organisations in England involved in telehealth projects in order to understand the challenges they faced. Ten of the 13 health or local authority organisations surveyed had telehealth projects and three were at the planning stage. The analysis revealed seven key challenges facing implementers of telehealth in England. Based on the findings from the literature review and the survey, a model was constructed and a checklist drawn up. The model contained the following elements: identifying issues, needs and partners; producing a strategy; securing funding; implementing changes; and monitoring and evaluating a telehealth project. The checklist was validated by using key informants from the organisations originally surveyed. The checklist may be useful to guide telehealth development and implementation in the future.
Introduction
In England, the government has recognised that telehealth has the potential to provide better and less expensive care, while promoting self-care and patients' independence. 1 The Audit Commission has estimated potential savings of £50 million from bed-days avoided by the use of telehealth for chronic obstructive pulmonary disease (COPD) patients; and £118 million for congestive heart failure patients in England. 1 However, there is limited information about the cost-effectiveness of telehealth in other health-care situations. 2,3
The Doncaster Primary Care Trust started a pilot trial of telehealth for COPD patients in 2007. The study design was a randomized controlled trial (RCT) involving 40 patients. However, a number of challenges were encountered, including the study design (RCT) and the recruitment of cases. As a result, the project was re-planned as an observational study. The project is managed by community matron teams, each with administrative support provided by a health-care assistant. There is now a dedicated full-time telehealth coordinator.
Difficulties with telehealth trials are not uncommon. The aim of the present study was to identify the key challenges associated with telehealth projects and to produce a model and a checklist to ensure success. The main objectives were to:
Identify the main challenges faced by organisations involved in the implementation of telehealth projects in England; Identify the factors associated with successful implementation of telehealth projects around the world; Draw some lessons for the future implementation of telehealth projects; Produce a model and a checklist for use by practitioners of telehealth.
Methods
A literature review was carried out to identify the key challenges in the implementation of telehealth. This was followed by a survey of organisations in England involved in telehealth projects in order to understand the challenges they faced. Based on the findings from the literature review and the survey, a model and a checklist were drawn up. The checklist was validated using key informants from the organisations originally surveyed.
Literature review
An online search of the NHS Library, which contains Medline, EMBASE and evidence-based reviews was carried out. 4 In addition, an Internet search (Google) was performed using the search words ‘telehealth OR telemedicine AND challenges OR success factors’. Further references were traced, including books on telehealth through libraries at the University of Leeds and in Doncaster. Websites of specialist telehealth centres were reviewed for online resources and publication. Telehealth centres were accessed for information related to key challenges in implementing telehealth. 5–8 Attempts were also made to contact leaders at the centres for their views on key challenges in implementing telehealth, and two successful telephone interviews were conducted.
Survey of organisations in England involved in telehealth projects
Fourteen Primary Care Trusts in the Yorkshire and Humber Strategic Health Authority area were contacted. The aim was to find out if each health organisation had a telehealth project running in their area, and if so, who were the contacts for further information. The contacts provided were then followed up.
A report by the Commission for Social Care Inspection on Telecare in England covering 150 Local Authorities was reviewed to identify projects that extended to telehealth. 9 Similarly, conference programmes on telehealth in England were screened for presenters on telehealth, and attempts were made to contact them for details about their telehealth project.
A list of 40 other health and/or local authority organisations that were supplied by Tunstall (the supplier for Doncaster) was checked and 10 projects that were related to COPD were followed up wherever possible. Attempts were made to contact at least one organisation per region in England.
Key challenges
A qualitative analysis of the survey results was undertaken by extracting key themes from the responses. To do this, an interview note was made for each discussion following a semi-structured format. The analysis was then collated manually, to identify the key challenges and these were then grouped into logical categories.
Development of model and checklist
Information gathered from the literature review and survey was used to develop a model and a checklist for telehealth.
Validation of the checklist
The same organisations initially surveyed were subsequently approached in order to validate the checklist that was derived. A semi-structured questionnaire was used for the telephone interviews. The key informants had a good understanding of telehealth, based on their experiences of being involved in its planning or delivery in their respective organisations. They were able to describe disease areas targeted, health-care professionals involved, and suppliers of telehealth. Most of the organisations surveyed were either reported to have telehealth activities as part of a national initiative to promote assistive technology; and/or were listed as actively undertaking telehealth by a telehealth supplier.
One organisation could not be included in the validation exercise because they completed the initial questionnaire late. The purpose of the validation exercise was for these organisations to comment on the importance of the items on the checklist. The questionnaires were sent out by email and a follow-up was sent by post. A reminder was sent out to participants by email, telephone and post after an interval of four weeks. For each one of the 41 items on the checklist, respondents were asked to rate their importance choosing one of the following five options: very important, fairly important, not important, not at all important or don't know. In addition, respondents were given the option to make any comments on any other key telehealth challenges that they felt should be included in the essential checklist. The analysis of the responses from the validation exercise on importance of the items was carried out using an Excel spreadsheet; and results for the options grouped as follows: ‘very important’ and ‘fairly important’ were grouped as one under, ‘important’. The results of options ‘not important’ and ‘not at all important’ were grouped as one ‘not important’. Responses under ‘don't know’ remained a separate category.
Results
Ten of the 13 health or local authority organisations in England had telehealth projects and three were at the planning stage. Seven of the organisations were from the Yorkshire and Humber Region and the rest were from North West, South West, South East and East Midlands. There were five different suppliers of telehealth equipment (Table 1). The size of the telehealth projects ranged from 10 to 300 telehealth units and all organisations had commenced telehealth activities within the previous four years (from 2005). Only two organisations were planning an RCT and their projects were related to COPD. A third organisation had been conducting an RCT for heart failure patients.
Telehealth projects and key challenges identified in the survey
Telehealth projects and key challenges identified in the survey
*Key challenges: 1 = Staff-related challenges (training, winning hearts and minds, capacity); 2 = Patient (selection and provision of support); 3 = Technological problems (software, compatibility with telephone line); 4 = Lack of partnership; 5 = Lack of funding; 6 = Lack of a strategic plan
Key challenges in implementing telehealth in England
The analysis revealed seven key challenges facing implementers of telehealth in England:
All organisations (n = 9) had experienced challenges related to staff training. Scepticism about telehealth was expressed by some staff. Some nurses feared that technology would make them redundant. However, some informants had observed that as the usage of telehealth increased among nurses, such fears disappeared gradually. Some social care staff were reported to be more pessimistic at the early stage of telehealth implementation than patients. There were worries from staff about the potential increased workload resulting from the technology implementation.
Recruiting clinical champions, such as community matrons, was considered to be crucial. In other areas surveyed, it was noted that there were difficulties in getting general practitioners (GPs) on board, and in particular, overcoming the views of some GPs who were cynical about telehealth.
Generating interest in telehealth among decision makers, e.g. board-level managers, was considered important. Few senior staff, especially at board level, were thought to have understood telehealth well enough to make informed strategic decisions about it.
Project management
Lack of a dedicated project manager was identified as an important factor in the implementation process and the amount of staff time to carry out telehealth work was often underestimated. Some organisations experienced difficulty in finding storage for the telehealth equipment and in gaining access to computers for staff involved in telehealth.
Patients and provision of support
Recruiting the right patients for telehealth was an important factor identified in its implementation. Although some patients declined telehealth, others were reported to have embraced telehealth more readily than health-care professionals. Initial adjustment of machines by users generated a lot of calls in the first two weeks. These were mainly due to incorrect usage of in-built customised questions on the telehealth units. Patients also required regular feedback from health-care professionals monitoring their conditions. Appropriate peripheral equipment units were required for patients with co-morbidities such as COPD and diabetes.
Technology
Telehealth units needed to be compatible with the telephone systems at patients' homes. For example, in one area, the units from one supplier were not compatible with one company's network, but worked properly with the telephone network of another company.
Some users encountered software problems. There was reported under-utilisation of telehealth monitoring units by patients. As can be seen in Table 1, not all equipment bought by respective organisations was being used. Other problems encountered were related to decontamination of equipment units after use; installation of equipment, which needed someone other than a nurse; and the fact that not all the telehealth units were portable.
Setting the appropriate alert levels for individual patients was important. In one area, telehealth monitoring units from a few COPD patients were continually transmitting red alert messages when in fact there was no need for any intervention. These were false alerts, a problem mainly related to the patient's understanding of customised questions in the machine. Maintenance of telehealth equipment needed to be considered as part of the project implementation.
Partnership working
According to the respondents, getting the Local Authority engaged in telehealth was a key factor in successful implementation. Hence, integrating telehealth and telecare systems was one of the challenges being explored by a number of health and local authorities.
Funding
Most telehealth projects lacked recurrent funding and were supported by short-term (non-recurrent) funding. This was considered to be one of the main limitations in successful implementation.
Strategic plan
None of the organisations had a long-term plan, lasting 3–5 years. Projects were limited to about one-year's duration. Only one organisation that did not yet have a telehealth project was considering developing a long-term plan.
Models of organisation and management of telehealth
The survey revealed that three organisational models were in use:
Community matron led, with administrative support. The most common model for implementation involved a team of community matrons leading the telehealth programme. The community matrons selected the appropriate patients to be offered telehealth. They also responded to patients' readings. Administrative support consisted of a project manager with or without assistants. Some of the assistants helped by identifying red alert cases, for a community matron to examine further. GP practice led. In one organisation, the project started off being led by a GP practice and cases were identified by GPs. It was soon found that there were difficulties in recruiting patients with this model, and it was also felt to be a medical model different from that envisaged by the service planners. This model was subsequently abandoned for the community matron-led option above. Joint hospital and community led. In this model, the service was run by the community matron team and the acute specialists' team based in the hospital. Both teams worked closely together and identified patients suitable for telehealth. Patients were monitored remotely by staff nurses, both in the community setting and at the hospital. Monitoring was conducted for an average of two weeks (range 10 days to 3 weeks).
Model and checklist
The model and the checklist took into account the challenges encountered in the field by telehealth practitioners, as well as conforming to public health perspectives on reducing health inequalities using a health equity audit tool. 10,11 The model consisted of six components: (1) identifying issues, needs and partners; (2) producing a strategy; (3) securing funding; (4) implementing changes in service delivery; (5) monitoring and evaluation; and (6) leadership and training. The initial version of the checklist had 41 items.
Validation of checklist
Three of the organisations did not have an active telehealth project and did not respond. Of the remaining nine organisations with active telehealth projects, seven (78%) completed and returned their validation questionnaire. Forty of the 41 items (98%) on the checklist were supported by the majority of the respondents. There was a divided view of importance on only one item relating to subsidising telehealth below market price; of the seven responders to this item, one did not know, and three considered it important, while the remaining three thought it was unimportant.
The comments made by respondents were taken into account. Three items on the initial version of the checklist were amended. Two additional items were included and one of the original items related to subsidising telehealth below market price was deleted. The final checklist for developing and implementing telehealth consisted of 42 items (Table 2).
Checklist for successfully developing and implementing a telehealth project
Y, Yes; N, No; N/A, Not applicable
Discussion
The key telehealth challenges from around the world are summarised in Table 3. These challenges, and those identified from the literature, were mainly in the form of lists of problems without any logical framework or categories to group them. For example, in Norway there were five key steps identified, 2 while a systematic review conducted by the Norwegian Centre for Telemedicine identified six main categories; 16 and a dermatology project elsewhere identified 17 steps. 13 The differing number of steps and categories of challenges makes it difficult for practitioners to identify which categories or steps to choose. It would be more helpful if the authors were to identify the main categories and minor categories under them to guide policy makers and implementers of telehealth projects. The present study helps by proposing a model and checklist for telehealth practitioners.
Key challenges in the development and implementation of telehealth from around the world
Implication of findings
One limitation of the present study is that it drew on only 13 organisations surveyed in England, although it was supplemented with local experience in Doncaster, and evidence from international work on telehealth. One strength is that it provides a comprehensive list of challenges and a checklist to guide practitioners of telehealth.
There are lessons from non-telehealth areas, regarding the best model for implementing telehealth. For example, the health equity audit (HEA) tool developed by the Department of Health in England, along with its self-assessment based on red, amber and green ratings provides a useful framework. 10 The HEA tool was further refined by NHS Doncaster and also found to be useful. 11 Gaps identified (reds and ambers) from self-assessment could be used to formulate an appropriate course of action. One of the key lessons from telehealth projects is that most of the interventions involved are complex and multi-faceted.
The main drawback of a checklist approach is that it may limit full consideration of a telehealth project. It could falsely give the impression that should all the questions be answered in the affirmative, then the project will succeed. Therefore, the outcome of a checklist approach needs to be considered with caution.
Conclusion
The challenges faced in the implementation of telehealth in Doncaster are not specific to that environment, but are similar to those encountered in other areas in England and in other countries. Various organisations in different places described key challenges facing the implementation of telehealth and essential steps in that process. These steps were narrowed down in the present study, into a simple model for health-care organisations accompanied by a checklist to guide telehealth development and implementation.
Footnotes
Acknowledgements
This work was part of a study funded by NHS Doncaster and initially by the Neighbour Renewal Fund (DMBC), with ethics approval reference number 6/Q1105/64).