Developed by: Rob Woodward
Edited by: Janet Larson
C. THE FOUR STEPS:
|STEP 1 - STRATEGIC PLANNING|
|STEP 2 - RISK MANAGEMENT AND EVALUATION FEEDBACK|
|STEP 3 - PROGRAM DESIGN AND MANAGEMENT|
|STEP 4 - PROGRAM IMPLEMENTATION|
Definition of Telehealth
There is no single precise
definition of telehealth. The Telehealth/Telemedicine Coordination
Project Planning Committee adopted the following definition.
Telehealth is the use of electronic communication networks for the transmission of information and data focused on health promotion, disease prevention and the public's overall health, including patient/community education and information, population based data collection and management, as well as linkages for health care and referrals.
Definition of Telemedicine
The Committee adopted the
following working definition of telemedicine.
Telemedicine is the use of electronic communication networks for the transmission of information and data related to the diagnosis and treatment of medical conditions.
Definition of Telecommunity
A telecommunity need not be limited to health care providers or users. Schools, community colleges, businesses, governmental agencies, etc., may share the resources of a telecommunity.
A telecommunity is a community created through telecommunications that becomes a "virtual community" without physical boundaries within a region, an institution, or consortia.
A telecommunity can provide desired professional and educational opportunities for all members of a community by enabling more cost-effective, integrated health and human services to the members. The development of telehealth applications can become an important part of a community's economic development and well-being.
Telecommunities foster healthy communities by providing access to electronic tools that enable personal self-health care, availability of professional health services in an extended community, professional and paraprofessional educational opportunities, and an increased health knowledge and awareness for the entire community.
Purpose of Program Development Guide
The Guide is provided to those institutions, agencies, organizations, and individuals who are interested in developing telehealth and telemedicine programs in California. It is hoped that this Guide may stimulate program developers to consider a systems approach to incorporating telehealth and telemedicine into a comprehensive plan and to recognize that successful programs will involve a collaboration of diverse organizations and technologies.
Two Primary Purposes of Guide
The Guide has been developed for two primary purposes:
From this perspective, telehealth/telemedicine program development is not a stand-alone, technology-driven effort to provide medical treatment, but an integrated effort to provide system solutions within a complex and evolving health care environment.
Organization of the Guide
The Guide is organized into four steps: (See Figure 1).
A systems approach recognizes the need to address and
incorporate three related elements: (See Figure 2).
Strategic Planning includes the participants, the mission, goals and objectives, assessment, and development and marketing and operational strategies. (See Figure 3).
PDA Step 1 - Strategic Planning
Step 1 - Strategic Planning - Participants in the Planning Process
Four major groups are encouraged to participate in the Strategic Planning Process:
Identify the lead representatives from the following organizations:
The expected outcomes of the collaborative process are:
Each participant should develop a mission, goals and objectives for the organization's participation, e.g., what are the goals for the:
This will help clarify expectations and roles of the participants.
Step 1 - Strategic Planning - The Mission
Telehealth/telemedicine is a means to an applied business service end. Telehealth/telemedicine is a health care program involving strategic resources, risks, and reward, rather than a type of technology. In this context, a telehealth /telemedicine program must have a defined mission and purpose within the total business effort. Once identified and articulated, the Program's mission and purpose will consistently define the scope and direction of Program development.
Given telehealth/telemedicine's multi-discipline aspects, the Program mission must address multiple business focus areas for all participants:
Depending upon the participants' frame of reference, any or all of these elements can be included and prioritized within the Program's mission. Examples of possible missions follow.
The Program mission statement leads to the next activity: Setting measurable goals and objectives.
Identify the existing health care service and resource commitments that satisfy these needs. How well do the present health care services and the resources allocated to those services meet the needs? By evaluating each service, distinguish those health care services that must be addressed for further planning or resource allocation.
Step 1 - Strategic Planning - Goals, Objectives, Strategies
Once the Program's mission and purpose have been defined, it is time to create measurable goals and objectives. If telehealth/telemedicine is to be thought of as a means to a business achievement, then the goals should define that achievement. Within each goal, one or more specific objectives should quantitatively shape and clarify targets. Examples are:
The first acid test of strategic objectives is to determine how realistic they are and to identify inherent constraints by polling executive management and partners. If they want to pursue an ambitious goal, they must commit to taking a commensurate risk. In order for an objective to be realistic, it must have access to necessary resources.
Once the objectives have been quantified, reviewed, and deemed realistic, planners are ready for the next activity: Determining and testing Program strategies for achieving the objectives.
This activity identifies strategies for accomplishing the objectives of the Program. At this level, a strategy only requires a description of WHAT is to be done, not HOW it is to be accomplished. A strategy must:
Now armed with the strategies for accomplishing our objectives, planners can move to the next activity: Defining the primary target market and customers.
A strategic plan must include a detailed description of the intended market and specific customers within that market. This portion of the plan should include:
With this knowledge planners can focus further on the specific customer (individual or entity) of the Program's intended services. Once the customer's identity has been established, a statement of consumer needs must be developed with as much real-world input as possible, including addressing changing needs. Now move to the next activity of the process: Stating how the Program will address the identified needs of the customer.
Step 1 - Strategic Planning - Assessment
The most critical question
in Program development must be answered at this point:
The Strategic Plan must state which of the customer's needs it will address through specific actions or service offerings. It is important to review the organization's internal objectives, so there is no conflict between loyalty to internal objectives and the objectives of the Program. All Program partners and management resources should be involved in considering the question. Some partners may leave the program at this time. After reviewing and modifying the strategy and/or customers targets, move to the next activity: Identifying and mitigating any significant challenges from competitors.
By adequately researching the target market, specific customers and their identified needs, planners should have identified any pre-existing or likely competitors that overlap or directly involve the target market. An assessment of these potential competitors must include their target market. What is their:
Specific comparisons and insights into competitors' mission, market, customers, and specific service offerings will determine if the planners want to collaborate with them or reshape the Program plan to fend off competitor encroachment.
In addition to competitors, planners must also consider barriers to entry into the market. It is important to know if these barriers apply equally to all other potential competitors. If so, what abilities do the competitors have to clear these same barriers? Do the competitors have any other barriers that might impede their progress long enough for us to get a head start in the market? Do we have any specific advantages to overcoming these barriers? By clearing the barriers do we clear the barriers for our competitors as well? Ideally, such barriers will be significant enough to prevent competitors from easily overtaking the Program once it is underway.
Telemedicine is confronting emerging regulatory requirements, especially in areas of licensure and reimbursement. There are significant, dynamically changing barriers to entry that should be considered:
All of these challenges should be researched for current status and
considered from an informed position.
Step 1 - Strategic Planning - Business Development/Marketing Strategy
Business Development/Marketing Strategy
Building on the Program's definition
of market and strategies for fulfilling customer needs, planners must prepare a
plan of activities for regularly reaching this market and these customers. In
today's health care and media market, the number of marketing channels is
staggering. The ongoing effort and specialized resources required to promote
the Program successfully must be carefully weighed. Planners must decide
whether to resource the marketing function internally or out- source marketing
efforts partially or totally. Competition within the health care market gives
significant advantage to Programs that can more successfully reach, attract and
A significant factor in telehealth/telemedicine business development/marketing is the need to educate Program participants and prospective market customers. This education is made necessary, at least in part, by the change in paradigm of telehealth/telemedicine services and the use of technology in ways relatively unfamiliar to health care consumers.
After describing the Business Development/Marketing Strategy, define the Operational Strategy.
Step 1 - Strategic Planning - Operational Strategy
A critically important part of the Strategic Plan is the definition of an Operational Strategy, which is comprised of the following components:
With these operating characteristics outlined, define an overall organization structure.
The strategic plan does not detail the organization itself. It describes the structural relationship of key elements, including:
Additional detail can be overlaid regarding
Program organizational leadership, decision chain and operational
Standards of service and performance in critical operating areas must be included in the Operational Strategy:
Indicate priority of conducting outcomes analyses, method of analysis, customer/patient feedback methods, acceptable outcomes (90% patient approval rating, reduction of waiting times, growth of program enrollees, number of referrals/consultations, volume of patients/specific cases)
Maximize profit margin, minimize associated costs of goods/services, accurately capture ongoing costs of operation, compete aggressively for new contracts
Reduce paperwork, increase compliance with regulatory mandates, reduce redundant data entry, minimize data loss, maximize transferability and usefulness of patient data, reduce labor overhead associated with scheduling Telemedicine exams, referrals, and consults; maximize EDI benefits with trading partners to reduce overall care system expense and improve care system performance
Modernize critical health care information systems, improve access to data, make technology more user-friendly, use open systems technology to avoid obsolescence and promote interoperable health care systems, constantly test cost-benefit of newer technology through trials, pilots, and strategic alliances, promote technology as a tool to achieve target benefits, strive to integrate technologies and avoid proprietary, stand-alone solutions
Step 1 - Strategic Planning - Operational Strategy - Financial Performance
By setting standards for service and performance, the Strategic Plan spacing the guidelines for operation and can progress to forecasting critical financial performance.
The Program's financial performance plan will involve projections based on
market and operations assumptions. Telemedicine Programs need to operate on a
profitable, cost-effective basis. The measures performance will include
baselines of labor and materials costs, utilization reviews, service
demographics, and an understanding of treatment strategy/disease outcomes.
Because of the complexity of the health care service environment the
Strategic Plan should consider the need/advisability of strategic partnering.
This partnering could take the form of:
The Program must consider the advantages of:
These advantages are balanced by:
As a final piece to the Strategic Plan, the Program's mission statement and operational structure should be reviewed periodically for the best fit with other core programs. Telehealth/Telemedicine Programs have inherent organizational complexity and may span traditional clinical, financial, or technical organizational boundaries. Over time, this fit with other core programs may provide opportunities to combine, consolidate, or synergize efforts and resources.
Risk Management is a commitment to identifying performance risk areas and to creating a Program environment that anticipates and overcomes problems by using evaluated feedback to adaptively ensure Program success. (See Figure 4).
Step 2 - Risk Management and Evaluation Feedback- Risk Mitigation
Risk Mitigation describes a set of internal and external efforts to lower the risks of the Program operation. Risk management efforts impact the structure of the Program and how the Program involves and motivates its own personnel.
The following are internal Risk Mitigation actions:
The following actions can be taken to mitigate external risks:
Step 2 - Risk Management and Evaluation Feedback - Program Evaluation Feedback
Risk control measures should be linked to key performance areas and should employ metrics that are readily available and meaningful to operational personnel, management, and stakeholders. The process by which risk measures are determined requires that Program management work closely with operation staff and take actions that extend traditional management decision-making and responsibility boundaries. These actions include:
Once performance risk measures have been set by active participation and buy-in throughout the Program, it is possible to connect the measurement process with active Program decision-making.
The most direct way of involving Program staff in connecting performance risk management controls with active decision-making is through the use of routine Program Reviews and Evaluation. Program personnel collect, present, and participate in the analyses of the risk control metrics. Management and peer review are powerful reinforcers of the meaning, value and impact of these control measures on the Program.
Suggested risk control activities for routine Program Reviews and Evaluation include:
1. Earned Value Reporting
Progress credit is given only for the completion of incremental tasks or the attainment of performance milestones. This avoids the 90/10 rule where reporting is delayed until the last 10% of the schedule when many programs begin to report significant delays or problems. This method is effective against significant performance area failures.
2. Estimate-to-Completion (ETC)
Focus on performance risk and status reporting is shifted away from retrospective period reviews to a continual forward-looking reassessment of goal attainment. This method works well in dynamic event-driven programs, such as telehealth/telemedicine, since emphasis is placed on what must occur to meet Program objectives.
3. Risk Area Variances
Unlike traditional reviews in which adherence to meeting targets is stressed, this risk control stresses the knowledge gained from meaningful analyses of variances in performance data. The insights gained from the meaning of the variances supports a more dynamic decision-making process, which is critical to managing flexible, complex health care programs.
4. Quantifiable/Meaningful Measures of Program Performance
Such measures have the greatest risk control impact when matched to strategic objectives.
An Automated Information System is important for these Program reviews. These systems are used for gathering and presenting metrics for decision support during the reviews. Systems should be tailored to this purpose and make custom measures easy to configure and user-friendly. Poorly designed information systems may thwart a well-designed risk control program by becoming a barrier to routine use or by providing inaccurate and disassociated data.
The following are risk control actions for three major program performance Control risk areas:
One of the key performance risk areas is adherence to schedules, timeliness, and program component deadlines. A recommended action to guard against out of control Program implementation and operation slippage is Automated Project Management, preferably employing Critical Path Methodology (CPM). The key attributes of CPM are:
|to describe Program activities parts and estimate their individual timeliness|
|Event Linkages/Priorities||to determine precedent, parallel, and successor event relationships while indicating the priority order of Program activities to be accomplished, along with any slack time between scheduled events|
|Resources||to assign labor category resources and determine periods of work in each Program activity|
|Critical path||to compute all the above information to derive a single critical path of sequenced activities, along with event slippage that could delay the entire program|
Another risk control action to help eliminate schedule delays is creating cross-discipline problem solving teams tasked to remove obstacles and meet key deadlines. The teams should be hand-picked, representing a cross section of the Program's operational elements, and report directly to senior management for the duration of the effort.
2. Financial Control
Some financial control risks include failure to:
Guard against these financial performance risks by:
3. Program Quality
There are at least three possible risk dimensions of quality review:
|A specific risk control action to help structure more effective quality control is to determine Quality Categories. Specific Quality Categories might include:|
As Measured By
|Clinical effectiveness||case pre-and post-morbidity levels|
|Customer service||various service area ratings and willingness to refer new patients|
|Range of health care services||breadth and growth of service areas|
|Productivity||volume of patients|
|Access availability||waiting times and availability of physicians services|
|Savings||pre-and post-implementation measures of specific Programs areas (e.g., physician/patient travel, data entry, utilization review)|
|Cost-effectiveness||industry service comparison, reimbursement levels, relation of cost of goods/services to revenues|
In Program Design and Management, the Guide will describe HOW the strategies of Steps 1 and 2 will be carried out through execution of Program functions and creation of an operational telehealth/telemedicine program model. (See Figure 5)
Electronic Data Interchange
Step 3 - Program Design and Management - Authority and Responsibility
Each Program's internal structure
will vary, therefore the Guide will highlight critically important issues and
functions to address in creating a Program management structure.
Step 3 - Program Design and Management - Program Model Needs Assessment
The design of the Program Model begins with a multiple needs assessment and the selection of an appropriate Delivery System Alternative. Within the design, consider linkages to trading partners, specific application, clinical and operational protocols, applied technology, and interfaces to existing systems.
Since the needs assessments will define the context boundary of the Program, the developer should obtain input from constituents. Recommended need perspectives are:
Business trading partners (vendors/service suppliers)
Clinical trading partners (referring/consulting entities)
Each of these perspectives should be formally reviewed using systems methodology, such as Business Process Analysis. The business or clinical needs of each group or entity is defined and re-engineered as an optimized relationship with the new Program. This analysis and definition should include:
Following the needs assessment process and the construction of relationship models, the Program can use the information to select a proper Health Care Delivery System.
Step 3 - Program Design and Management - Delivery Systems
Each Program is a health care delivery system. As such, the Program may choose from several well-studied delivery system models. The choice of an appropriate delivery will depend on the Program's strategic definition of the service point of need. Because of current competition among health care programs, it is necessary to select the most cost-effective services closest to the physical and temporal point of need. Following is a discussion of current delivery system alternatives.
Distributed primary clinic(s) or provider(s) linked to regional tertiary facility specialists
Used for referrals, consultations, case management, and continuing education. This delivery system can be either a privately owned/managed intra-net (open only to affiliated or group members) or an open consortia operating under a contracted or voluntary Community Healthcare Network (CAN) to serve community or regional needs
Peer-to-peer entity relationship
Providers/entities trade complementary services and eliminate redundancies and costly duplication and competition of services
Private/public sector outsource relationships
Specialist providers/entities contract with larger commercial employers, health services plans, institutions (e.g., prison system, schools) or agencies to establish telemedically linked facilities in which the provider/entity service the examination and consultation needs of the customer at the local site and makes care triage decisions and local referrals. This model is increasingly attractive to local site entities who wish to focus on early health care intervention and avoid lost productively and costs involved in seeking off-site health care and patient transport.
Case utilization review
The Program operates as a linked consultant to help review case treatment decisions as a critically important component of cost control within managed care and capitated care systems. This relationship may exist within any of the above models.
Advanced consumer based models
Privately or publicly accessible health care Value Added Networks (VANS) are established (telephone hot lines, electronic bulletin boards, Internet and World Wide Web, interactive kiosks, interactive television and satellite broadcast, CD-ROM packages) that provide consumer education and triage instructions.
Home-based health care
Providers/entities are linked to private homes via telephone, data line, satellite dish, or cable television modem for services and information. While still largely experimental, these home health care models can compete with or augment the current extensive and labor-intensive home health care industry.
Step 3 - Program Design and Management - Applications
the choice of Delivery System, the Program can identify key Interchange-business
or clinical entities to bring in as trading partners. A trading partner is a
service or goods provider or recipient participating in a formal agreement in
which the respective partners work closely together to align procedures,
practices, and, ideally, information system components to meet common goals.
As each activity step of the Program Model continues, the model expands from defined customer needs and trading partners linkages to specific health care services and applications. The decision to offer specific services must once again be completely aligned with:
Step 1: Strategic Planning: Mission, Goals and Objectives, Customer Needs, Market and Operating Strategies
Step 2: Risk Management: Mitigation and Program Feedback
Any specific service or application candidates should fit closely with the requirements of these Program development activities. (See Figures 1 and 2) Candidates might be included within the following areas:
|Telemedicine outreach||direct primary or specialty care via remote examination and diagnosis, case consultation, referrals|
|Case management||reviewing and co-managing distant patients|
|Continuing medical education||providing or receiving accreditation and licensure course work, specialized train|
|Before proceeding, it is important to decide whether the issues that face telemedicine applications have been adequately considered. Many of these issues, unless fully addressed, will prove to be barriers to successful implementation. For example, until the Medicare reimbursement issues for telemedicine-based consultations have been clarified, it is unclear as to the long term financial feasibility of apply technology in medical consultation. The following issues should be addressed.|
|Review medical practice
standards set by local, state, and national boards and professional associations
for providing services using telemedicine technology, including:|
Review the specific types of telehealth/telemedicine technologies for patient services identified by local health care providers and institutions, including:
Review the evaluation system, established by health care providers, that includes criteria to evaluate the performance outcomes related to the telemedicine activities, including:
Review telemedicine patient care protocols, established by health care providers, that identify types of services provided, necessary referral information, diagnostics, necessary monitoring assessments, documentation criteria, and scope of the consultation modality.
Review the reimbursement program established by third party payers, both public and private, for "value added" services provided in a telemedicine environment.
Identify telemedicine applications that satisfy the following criteria for reimbursement:
Verify that the liability insurance policy protects against the consequences of data processing, telecommunication or other disasters.
Review state licensure statutes if the identified applications are for
inter-state telemedicine consultations, and review the procedures for the
necessity of having a health care practitioner present at the originating site
and when the attending physician or other health care provider is not present
for the consultation.
Review policies and procedures established by state licensing authorities, including situations in which licensure of individuals is required.
Review known health care and technology standards.
Prioritize and plan future telemedicine systems to fully support the mission and goals. When setting priorities, make sure that problems and opportunities (health care services) are addressed before setting the corresponding technologies (telemedicine applications).
Define the reason for considering the telemedicine application. For instance, a statement of opportunity for teleradiology might be:
To enable remote delivery and enhance diagnosis of radiological images to reduce the costs associated with transporting images, reduce the delays in the reading of images, increase the retention of local patients and improve the response of health care delivery.
A clear definition of the purpose of the application serves to focus the remaining activities and can be used in resolving differences of opinion and evaluating the effectiveness of the application.
This process addresses the feasibility of the application in great detail for technical, economic, and legal considerations. Consider also the political and human feasibility of the application. How accepted is the application among the organization, medical staff, medical community, and the general community? Assess the impact of the potential shifting of responsibilities and the redeployment of human resources to match those responsibilities. Also, consider the long term commitment required to insure effective use of the application and the expansion of the application.
Step 3 - Program Design and Management - Clinical and Operations Protocol Design
Each application requires a specific set of Clinical and Operations Protocols. This Guide defines such protocols as:
Pre-formatted instructions or templates that streamline and guide critical decision-making in the use and application of clinical and administrative services.
Because telemedicine involves personnel communicating over extended media, such guidelines permit consistently safe and efficient use of equipment, material, and other scarce resources, timely and correct triage of patient condition to the most appropriate care, and productive use of expensive and valuable provider personnel time.
Typically, clinical protocols would be developed primarily by attending
physicians and nursing staff, but telemedicine clinical systems will involve a
cross-discipline team of physicians, system users, and system
technician/integrators. Each clinical specialty (cardiology, dermatology,
ophthalmology, etc.) to be involved in the Program will need to develop a
consistent set of standard intake, examination, referral and treatment
guidelines for all clinical personnel. Clinical protocols are defined as:
The chief designer of the clinical protocol is the physician who details the correct and most efficient set of instructions to guide himself, his colleagues, and other health care personnel in the consistent application of care. These instructions will help initial examination and triage personnel in determining life-threatening or emergency conditions, appropriate referral and scheduling for non-emergency conditions, and the most critical/required intake data. The protocol should be thorough and clear enough to guide health care service with little or no direct supervision or consultation from the physician.
Telemedical systems extend clinical care and involve
a growing number and type of support personnel. With the assurance of expert
supervision only a telephone or data connection away, the role of primary care
personnel broaden to include a wider range of nursing and paraprofessional
Telemedicine systems usually extend the logistics of administration. New systems have relatively new guidelines for administrative procedure authorization, payor plan requirements, and complex utilization review. Telemedicine systems promote and accelerate the replication, update, and transfer of clinical information, including medical records, examination data, and financial information. As a result, administrative personnel must have input to be properly guided by clinical protocols that direct them to best support the case-by-case provision of telemedical care.
Telemedicine also involves the installation, operation, support, and evolution Integration Support of complex technology, including:
Clinical protocol development must include expert health care technology personnel to develop, install, and maintain software and computer-based protocols shared over complex telecommunications and data networks. The ultimate challenge for these technology professionals is to understand and integrate ever-changing technologies and tools while making their existence and use relatively transparent to users of the systems. Protocol-assisted decision support must not be constrained by after-the-fact technical complexity. Therefore, protocol development must involve these support personnel.
Step 3 - Program Design and Management - Advanced Applied Technology
This Guide will not attempt to address specific products or vendors. However, there are definite categories of technology which provide the typical building blocks of telemedicine. Similar to basic construction materials, these technology components must be systematically and expertly integrated to fit-to-need, end performance and ongoing flexibility.
Telecommunications is a very complex and rapidly changing environment ofissues, technological changes, and business competition. As a fundamental component of telehealth and/or telemedicine, it enables distant health care locations, various provider personnel, and consumers to communicate. The variable matrix services that can be offered are determined by:
Telecommunication possibilities grow almost daily with a trend toward wider accessibility to higher speed digital lines at lower costs.
The hardware component primarily involves the workstation, display, and server computer platforms required to provide processing power, inter-operability, and clinical display resolution. A turnkey system includes the subcomponents in the following chart:
Central Processing Unit (CPU) capacity
transistor density to support increasingly complex embedded instruction sets
Chip set architecture
transfer word and memory update speed
Data and Input/Output bus architecture
Internal bus slot type and availability
Disk and memory capacity and access speed
Image capture and videoconferencing board integration
size, pixel depth, lines of resolution, color balance, refresh rate, aspect ratio, etc.
Image processing/display board capabilities
Screen and presentation display characteristics
Electro-mechanical input device
keyboard, mouse, touch screen, voice activation
Each of these subcomponents will have a direct impact on end-workstation design and performance and require the integration of distinct and rapidly changing vendors and emerging standards. Issues also exist at the server hardware level, but involve different processing requirements to support larger data storage, multiple user access and network operating system support, extensive system security, advanced systems administration utilities, and multi-media record storage and retrieval engineering.
The connected clinical systems of the Program will involve some type of electronic examination/patient record management system, which requires an automated database engine to provide relational storage and retrieval of information. This engine may also be tasked with management of compound documents (voice, video images, data, graphics) representing the medical record. The preferred requirements of such an engine are:
The graphical interface (screen) has emerged as a key component in providing users with intelligently designed, data aware, icon driven interfaces. Touch screen interactivity and simpler, more powerful screen interfaces are in demand. Applications making such demands include:
Graphical User Interfaces must be developed using vendor toolkits that provide customized and very powerful interfaces with both middleware (software libraries, utilities for specialized performance, and structured query language or SQL algorithms for reading and updating databases) and database engines. The choice of development toolkit and integration with middleware and database engine will have a direct impact on Program application capabilities, user-friendliness, and performance.
Telemedicine requires that remote examination take place using instruments
that have been designed or retrofitted with sensor devices, typically cameras.
These cameras range from digital to video and span a wide range of image
resolution power and expense. Regardless of the sensor device, the image output
must be transmitted to the telehealth/telemedicine computer workstation via
cable or direct digital interface and be captured there for storage, processing,
retrieval, and/or transmission. The capture can occur as a static
high-resolution still image or a compressed multi-frame video clip. The
quality, clinical validity, and cost of image sensing represents a dynamic and
hotly debated issue.
The needs of the Program applications will determine the extent to which
clinical interaction between sites and providers/patients will need to be
accomplished via interactive videoconferencing. To address the Program needs
that will require interactive videoconferencing, it is necessary to understand
the component value of videoconferencing in telemedicine.
A final Program Model consideration is interfacing or bridging new Program applications with existing information systems. Typically, existing systems have not been designed using open systems technologies, are often proprietary, and difficult to interface. It is important to carefully analyze the cost benefit and quality of outcome of directly interfacing old and new software applications and data structure. Often, it is easier and more cost effective to off-load data from the old system or both systems and manipulate it with customized programs to get the desired results. If this cannot be done, the Program may have to resource the reverse engineering required to get the existing systems in order to be able to proceed with new system development or the Program may have to purchase new systems. Now move to the Program Implementation.
Program Implementation and Feedback will use a systems approach involving key leadership, process, change management, and technology teams. These teams will prepare the program for Pilot activities and cutover to full production.
(See Figure 6)
Step 4 - Program Implementation - Pilot Program
Program Pilot Activities should be of sufficient scope and duration to obtain adequate Program concept feedback and to gain operations experience for Program management and staff. This experience will also better define, redefine or clarify goals and expectations, structure more meaningful outcomes evaluations, permit evaluation of Risk controls and contingency plan investments and examine risk mitigation strategies such as partnering and alliances.
Once designed, the Program model can now be implemented on a trial basis as a Pilot Program. The objectives of a Pilot Program are:
The Program Pilot activities begin with the design and structure of the
effort. The design must encompass all the Steps:
Pilot Program activities should replicate production program model activities, including:
· Clinical, administrative, and technical operations
· Market, customer, and patient base
· Technology infrastructure and equipment
· Risk area constraints (schedule, finance quality)
· Outcomes expectations
· Program management review and decision-making
Determine Pilot sites by the systems approach: preparation and the potential of people, processes and technology. Ideal sites will combine exemplary needs and realistic resources to support the Pilot, combined with representative personnel, existing program processes, and technical expertise.
The Pilot site technical and equipment infrastructure should be reviewed for required upgrades, modifications, or installations. Site facilities personnel should be fully involved and buy into the facilities plan. Time should be allocated for ordering and installing equipment and telecommunications, infrastructure testing, and configuration management registration (site inventory of components and software versions). The facility's clinical floor space must be reviewed as part of facility design to optimize placement and work flow of the equipment.
Staffing and Personnel training requirements should be reviewed as part of the preparation. Program Model requirements for Program functions and services should be compared to site staffing and skill levels to determine any additional staffing or training requirements. Site staff must be involved in the training as detailed in Step 3 on Clinical and Operational Protocols. Once developed, these protocols form the basis for ongoing training for site staff on the nature and correct use and application of all Program equipment and operations procedures. Training should be conducted on-site, if possible, to better acquaint staff with changes to their environment. Ongoing site training and support can be supplied with refresher visits, videoconferencing, and/or interactive computer-based training modules. Training should simulate operational use, be personalized and closely related to specific responsibilities. The duration and frequency of training will vary by site, but should give adequate time for staff to feel comfortable with performing operations and pursuing Program objectives.
Communicating with alliance and trading partners should be part of the Program Pilot preparation activities. These organizations or individuals may have direct involvement in Clinical and Operations development (see Step 3 on Protocol development) and must be integrated into Pilot activities.
Once Pilot site preparation and
training have taken place, begin a limited schedule of service and operation,
concluding with a Program management review. Following this internal review and
corresponding adjustments, start a second period of service and operation,
concluding with a Program Development Review.
Step 4 - Program Implementation - Production Cutover
Once the Pilot Summary Activities Report, with plan adjustments and Production Cutover recommendations have been completed, the Production Cutover activities can begin. The immediate goal of these cutover activities is to build on Pilot feedback to prepare a plan for scaling the Pilot to Production levels. The Production Cutover Plan must address the Program's impact on people, processes, and technology and involve a methodology for production transition.
A recommended approach to implementing the Production Cutover involves the formation of transition and leadership support teams in five areas:
1. Leadership Team
2. Change Management Team
As the Program is cutover to production status, the Change
Management team must help the entire organization understand Program activities
and begin to understand and personalize their meaning and impact. This
perception change across the organization is the beginning of the cultural and
personnel change management process.
3. Clinical and Operational Processes Team
This team of process experts chosen from within the organization is critical to defining standards and maintaining responsibility for clinical and operational protocols. As the Pilot activities end, this team captures significant lessons learned from operations and clinical summary reports to establish baseline processes for production cutover. As production implementation of the Program proceeds, this team plays an active role within training and site preparation to help set up and familiarize site staff with Program protocols. During implementation this team also monitors process compliance and progress as part of the regular Program Reviews.
4. Information System Transition and Support Team
In Programs involving necessary interaction with older clinical or administrative information systems, this Information System Transition and Support Team provides continuity and assurance of smooth interaction of the new Program. This team must gain the trust and confidence of the personnel responsible for the older system who may feel threatened by the Program implementation and seek early guidance from the Strategic Plan to know of any intended phase down, transition, or replacement of the older system.
If these events are planned, then the Transition and Support team must help plan a migration strategy that is effective for every systems element (people, processes, technology). If coexistence of old and new systems is intended, then this team will help build interfaces or bridges between the systems to optimize total Program functionality.
5. Advanced Technology Implementation Team
Depending on the choice of Health Care Delivery System (see Step 3 Delivery Systems), the Program may choose to support its requirements with advanced technology. The Advanced Technology Implementation team coordinates planned technology infrastructure investments and activities, balancing impact on people, processes, and the technical environment. This team is also responsible for working with a systems integrator to evaluate off-the-shelf technology to recommend new systems purchases, old and new systems integration, or new systems development to meet unique Program requirements. Finally, this team plays a lead role in interacting with any technology partners or strategic allies.
Step 4 - Program Implementation - Production Cutover
As a final step for full production cutover, all significant external business partners must be kept involved in the planning and implementation process. If these external entities are participants in the Program, then they must have equivalent production cutover schedules and activities carefully coordinated with Program management. A failure in a key supplier, referral source, or trading partner to come on-line at the required time, could be disastrous to an otherwise carefully planned production cutover.
Step 4 - Program Implementation - Continuous Review
The systems approach is successful because of continuous feedback, review and course correction. It is important that not only Program staff, but all stakeholders are involved in the feedback and review process. If a telehealth and/or telemedicine program is part of a larger telecommunity, the Program should actively participate and provide feedback to the telecommunity Program. Periodically, all aspects, starting with Step 1, should be reviewed to ensure that the Program is still needed and on target.