Barriers to Telemedicine Implementation

Usually it's not technology issues that undermine a project--it's everything else.

by Steven H. Stumpf, Rod R. Zalunardo and Robert J. Chen

April 2002 - Healthcare Informatics

Telemedicine has turned a corner. The field experienced its first great surge in the 1990s with the marriage of computers and telecommunications, but recently, applications seem to have exploded regionally, nationally and globally. The number of telemedicine project implementations in California has grown substantially since 1998 as the state's private foundations and health organizations have been increasingly willing to fund demonstrations and applications. For example, the California Telehealth and Telemedicine Center alone has funded more than 90 grants in the past four years. And the Kaiser Permanente system has made a serious and continuing commitment (more than $1 billion) to integrating telemedicine and telehealthcare--the largest U.S. healthcare organization to do so.

"Bridging the digital divide" was originally the slogan for ensuring that telemedicine crossed over from engineering and clinical laboratories to community clinics. But the concept has expanded to include bringing up to speed a provider community often perceived as reluctant to accommodate telemedicine in routine practice.

Our group is a campus-based telemedicine systems deployment and evaluation shop at the University of Southern California Keck School of Medicine in Los Angeles and a grantee under the National Library of Medicine Telemedicine Initiative. Our experience includes community clinics, community health advocacy, funding organizations that support community telemedicine projects and the implementation planning teams for such projects. Since 1994, we have implemented six different telemedicine projects at six distinct community sites. Our projects have included a four-way international videoconference and transfer of images across an Internet platform at many sites, including our own medical school.

Evaluation of telemedicine remains a fairly narrowly focused endeavor, typically documenting satisfaction of providers and patients, frequency of usage, and economic impact. However, a trend is emerging within reporting that documents "everything else"--the nontechnology issues that are not so easily quantified but present barriers to implementation.

General barriers

Experience has taught us to expect a predictable set of barriers when planning implementation of any telemedicine project, especially at community sites. We have found that our experiences are not unusual--just undocumented--and that the following axioms apply to all telemedicine project implementations:

For example, many telemedicine projects are implemented before a feasibility study is conducted to anticipate and understand the barriers likely to be encountered. The typical course of development in evaluating telemedicine systems is considerably out of synch with how practice might occur if barriers to implementation were better anticipated.

Typically, projects are implemented, then feasibility is considered, policy is reviewed, and research is conducted. In contrast, the proper sequence, which will become increasingly important as telemedicine proliferates, is to begin with research, followed by feasibility studies and implementation, with policy review occurring at the end of the path.

Solutions to technology problems for telemedicine and telehealthcare projects are abundant and generic. Comparatively inexpensive, disposable off-the-shelf applications can be integrated to meet most project needs. Custom designed, proprietary and expensive solutions of the recent past are practically obsolete. Engineers make careers of solving technology problems routinely and quickly.

Nontechnology barriers

Solving the nontechnology problems facing telemedicine implementation teams is more complex. The challenges are widely experienced as endless and overwhelming. New systems implemented in old settings may require a significant change in skills, the way business is conducted, and ordinary routine, often generating resistance. The following are typical barriers, accompanied by coping strategies that may tilt the odds in favor of successful implementation, and some real-world vignettes.

Inadequate leadership: A project without a dedicated, local on-site project coordinator will lack leadership. The project coordinator should be a central resource with some understanding of all aspects of the project, from technology to the needs of patients and healthcare workers, but should not be the same person who called for the project. When the project coordinator role is parsed among different staff--such as the business manager, clinical coordinator, and consulting physician--the project will struggle from the start.

Example 1. A local site did not hire a project coordinator despite funds budgeted for the role. Project leadership defaulted in name to the external evaluator, who held no influence within the medical group. Responsibility for various tasks, from installation of on-site cable service to coordination of patient flow, was divided among individuals. Although they met monthly, none of them held management authority. The project languished, falling eight months behind schedule.

Example 2. The project was presented to a core group of community-based organization leaders who did not possess sophisticated knowledge of telecommunications or telemedicine. Our technology assessment called for significant equipment upgrades. The community organization director authorized the installation of a DSL line and the purchase of several new computers sufficient to manage the telemedicine system. A junior manager was appointed to be our project contact but left abruptly without notifying our technology team. The DSL line was installed in a different building than originally identified. The community organization director, upon learning of the mistake, questioned support for the installation and the entire project.

Lack of physician buy-in: Local physician endorsement is an absolute requirement of any healthcare project. A physician inside the local group has to bring the project to the community and be a flag-bearer and project advocate and champion. The physician champion lobbies the stakeholders, sponsoring institution and other physicians. If a champion cannot be identified or is insufficiently empowered to have an impact on policy and procedures, the project will become orphaned, left to fend for itself without sponsorship, and be at risk of cancellation.

Immediate and widespread implementation breakdown: Telemedicine projects implemented prematurely and without a feasibility study can quickly begin drifting in a sea of dashed expectations. Marketing promises for ease of use and instant results often fail to deliver. Electronic medical records, high-resolution digital images, faster bandwidth speeds, and processors that easily and quickly handle multimedia programs create the perception that telemedicine is a plug-and-play or point-and click-solution that can overcome access to care barriers, especially within underserved communities. Unfortunately, this is not the case.

Providers are hungry for simple solutions and implementation in community sites, where the digital divide is often the widest. But startup must be preceded by feasibility studies.

Example: A statewide project sought to install telemedicine systems in mostly rural sites serving the most vulnerable populations. The high-profile undertaking had support from a major foundation, a core of external champions and a coordinating committee. The correct collaborative partners were included and a set of initial implementation sites identified.

The system had been demonstrated as effective at a lower level of technology, with certain limitations, under a well-documented feasibility study by another group for a similar project. Differences for the proposed project were judged to be minor and manageable. They included a different version of supporting software, a different method of telemedicine delivery (plain old telephone service vs. the Internet), and an expansion from one site to ten. The new telemedicine equipment manufacturer also provided the software, so that was assumed to be sufficient. And though clinical coordination on a grander scale would be required, the project team believed problems and solutions would be generalizable. Reality proved different.

Technology needs varied by site, with bandwidth an issue at some. The email solution required an unanticipated modification in the new manufacturer's software. Complications compounded quickly, with subsequent loss of confidence on all fronts once it became clear that the vendor did not have a true software engineer. Installations fell seven months behind schedule, threatening the entire project. System feasibility became a sensitive subject.

Unavailability of technical expertise or support: It is essential to have an IT specialist on site to troubleshoot all the predictable problems that arise with use of the equipment. In some cases, this person will act as a local security officer.

In community sites especially, the level of technical knowledge among staff varies greatly. The admonition "a little knowledge is a dangerous thing" applies. Motivated staff often tamper with workstation settings, disrupting access to applications. Others use computers for personal interests, introducing viruses to the system or otherwise compromising the project. Having someone on site who can quickly return workstations to functional status is very beneficial.

Resistance to evaluation protocol: Evaluation is integral to all project implementations. Funding sources are entitled to know project impact and stakeholder value. However, evaluation experts often use familiar methods perceived as burdensome to the end users--satisfaction surveys being the most common, least informative and most intrusive. An evaluation strategy that is likely to be viewed as helpful and embraced by users gathers information that meets the needs of local interests, such as a format assessing quality-of-care indicators.

Example: In the first site visit, the external evaluator proposed that information be collected on patients not served by the new telemedicine system, intended to demonstrate a need for continued funding and subsequent expansion of the service. The local medical director did not want to document failure to provide treatment or service, because that might compromise the quality-of-care ranking, which would in turn potentially threaten the medical group's services contracts. This basic conflict of interests grew into a conflict of personalities, from which the project suffered.

Staff resistance to changing habits: The belief that one implementation strategy will succeed across multiple sites can be fatal to a project. Each site must be viewed as a unique system functioning according to established patterns. Different clinical sites often exhibit similar problems, but each responds differently and requires a separate approach. The most common solution is individualized training that anticipates or quickly responds to difficulties as they develop.

Example: An electronic patient record system implemented across multiple sites ran afoul of staff members at one site who maintained practices violating patient confidentiality that the system sought to overcome. The evaluator cautiously wrote, "At best, the work discipline thus entailed yields poor information security practices. At worst, staff disregards or overrides the requirements for confidentiality and integrity in their daily work. Achieving a thoughtful balance...requires training for everyone (staff, patients and vendors) in sound security practices."

Making progress

Some of the barriers we encountered were not as obvious and familiar as those we've described. This shows that we have learned from our mistakes, and systems integration and telemedicine implementations are becoming smoother. Of course, our list of barriers is not exhaustive. Issues related to streamlining data collection and adopting client-driven solutions that get around our best-laid plans are central to managing change. But as we encounter barriers to implementation--the old ones and new ones--we will apply our model: Take small steps before big ones, and document mistakes to devise better strategic solutions.

Steven H. Stumpf, Ed.D., is director of projects management; Rod R. Zalunardo, Ed.D., is executive administrator; and Robert J. Chen, MHA, is senior project manager; Advanced BioTelecommunications and BioInformatics Center, University of Southern California Keck School of Medicine, Los Angeles.