tele-healthcare in the routinely healthcare setting

Sabina De Rosis, PhD Candidate

TELE-HEALTHCAREIN THE ROUTINELY HEALTHCARE

SETTINGDETERMINANT FACTORS OF SUCCESS AND FAILURE

FROM A SINGLE CASE STUDY IN ITALY

XX NATIONAL CONFERENCEFOSTERING AND GOVERNING INNOVATION

IN HEALTHCARE BASED ON EVIDENCEUniversità degli studi di Sassari

16 October 2015

What is exactly the Tele-Healthcare?

…it could be generally defined as the ability to provide interactive healthcare services utilizing modern technology and telecommunications.

Adapt from: Ministero della Salute (2014). TELEMEDICINA, Linee di indirizzo nazionali

Tele-medicineprovidedby specialists

Tele-healthcare

Tele-monitoring

CONTINUITY OF CARE

Diagnosis

What is exactly the Tele-Healthcare?

Systems supporting formal healthcare institutions/processes (i.e. in a registered healthcare setting under medically qualified professional care).

Public Health System

Wellness and Consumer Health

Home Care Systems

EHR

s / H

IEs

HospitalProviderSystem

Paye

r Sys

tem

s

Primary Care System

Community Care System

Wellness Prevention Treatment Monitoring

Tele-HealthCare as an Innovation

We refer to tele-healthcare interventions as innovative solutions.

Innovation meant as any object, idea, technology, or practice that is NEW.

Rogers EM. Diffusion of Innovations. New York: The Free Press, 1995.

VARIABILITYFRAGMENTATION

CONTEXT-SPECIFICITY

We are assisting to A PROLIFERATION OF TELE-HEALTHCARE PROJECTS.

However,• their use is actually LESS DIFFUSE than expected.• their deployment in the real routinely healthcare

settings seems to be still relatively LOW.

A. D. Black, J. Car, C. Pagliari, C. Anandan, K. Cresswell, T. Bokun, et al., "The impact of eHealth on the quality and safety of health care: a systematic overview," PLoS Med, vol. 8, p. e1000387, 2011.Dobrev, M. Haesner, T. Hüsing, W. Korte, and I. Meyer, "Benchmarking ICT use among General Practitioners in Europe. Final Report for European Commission," Information Society and Media Directorate General., Bonn2008 J. Walker and S. Whetton, "The diffusion of innovation: factors influencing the uptake of telehealth," J Telemed Telecare, vol. 8 Suppl 3, pp. S3:73-5, 2002.…

The Integration of Tele-healthcarein the routinely healthcare setting


We have assisted to a growing and growing interest of scholars, managers and policy makers on this issue, which can be translated into a huge number of scientific pubblications on the introduction of innovations in the healthcare systems (a few on the specific field of tele-healthcare).

Papers mainly focus on the first phases of the innovation introduction:

Greenhalgh,T, Robert, G, Macfarlane, et al. Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations. Milbank Q. 2004 Dec; 82(4): 581–629.

Introduction(dissemination and

diffusion)

Adoption and assimilation

Implementation(integration in the routinely

practice, scaling-up and deployment)

We focused on the IMPLEMENTATION, DEPLOYMENT AND SCALING-UP phases.

Rogers EM. Diffusion of Innovations. New York: The Free Press, 1995.


The introduction of innovations in a health care system is recognised per se a COMPLEX PROCESS in a COMPLEX SYSTEM.

Tele-healthcare is both seen as

• a SOLUTION to healthcare system challenges, and

• a CHALLENGE for the healthcare system in terms of establishment into the practice as routinely services.

Several factors may influence the deployment of these solutions in the “real life”.

There is wide debate on the reasons why tele-healthcare has stalled.


The topic

The Integration of Tele-healthcare in the routinely healthcare: Determinant factors of success and failure from a single case study in Italy.

• Why does tele-healthcare innovation present a slow deployment and remain at (fragmented diffused) experimental-phase?

• What are barriers and levers of successful deployment in the voice of all the stakeholders?

• How to spread and sustain tele-healthcare innovations in healthcare service delivery and organization?

The Research

Methodology

Literature analysis

The theoretical background is based on existing frameworks of determinant factors of technological and organizational innovation in the healthcare sector.

Case study

A single case study, design exploring several typologies of tele-healthcare innovations in the continuity of care setting in the Region of Tuscany (Italy).

Methodology – Literature Review

Diffusion of Innovation

Model

Rogers 1962, Rogers 1980, Cain and Mittman 2002

Metaphor of the

knowledge barrier

Attewell 1992, Tanriverdi and Iacono 1999

Complexity models

Van de Ven, Polley et al. 1999, Denis, Hébert et al. 2002, Greenhalgh, Robert

et al. 2004 et 2005

“Six forces” of innovation

Herzlinger 2006

Authors and modelsDomains of determinant factors

Technology Individual Organisation Context

Diffusion of Innovation Model (Rogers 1962, Rogers 1980, Cain and Mittman 2002)

Innovation's attributes

Characteristics of adopters

Communication channels

Social system

Re-invention Time and process

Metaphor of the knowledge barrier (Attewell 1992, Tanriverdi and Iacono 1999)

Technically feasible, medically valid, reimbursable, and institutionally supported applications

Technical knowledge

Economic barrier

Organisational barrier

Economicbarrier

Behavioural barrier

Behavioural barrier

Knowledge transfer’s practices

Methodology – Literature Review(general framework)

Authors and modelsDomains of determinant factors

Technology Individual Organisation Context

Complexity models (Van de Ven, Polley et al. 1999, Denis, Hébert et al. 2002, Greenhalgh, Robert et al. 2004 et 2005)

Technology features

Individual aspects Organizational structure and system

Socio-political situation

Strategies and mandates

Incentives

Cross-organizational relationships

Industry and society infrastructures

Perceived benefits and outcomes.

Innovation process formCommunication channels, learning processesManagement support

Taskcharacteristics

Path-dependenceof innovation

“Six forces” of innovation (Herzlinger 2006)

Characteristics of technology.

Actors of the system (players and customers)

Funding models Funding models

Accountability Policies

Methodology – Literature Review(general framework)

Methodology – Case Study

In depth interviews in Tuscany Region

Data were collected through semi-structured in depth interviews.A purposive sample was used, with snowballing approach, over different stages to identify a multi-level and multi-stakeholder sample.

We interviewed 32 informants

0246

6

2 36 6

24 3

Determinant factors of Tele-healthcare - Results

• Determinant factors were nearly always reported as being IMPEDING

• The most of barriers seems to be at ORGANIZATIONAL and MANAGERIAL levels


DUM ROMAE CONSULITUR, SAGUNTUM EXPUGNATURTransl: While Rome decides, Sagunto is conquered

(medical manager)

A DECADE OF EXPERIMENTATIONS(non-medical manager)

Determinant factors of Tele-healthcare –Results compared with the theoretical background


Domains of determinant

factors Determinant factors

Present in the

literature

Emerged from our results

Technology

Technically feasible. X

Trialable. X

Definition of tele-healthcare and difference in respect to ICT. X

Typology of target-population for which the solution is designed (i.e. niches, restricted areas).

X

Different time-horizon between innovation and available observable results (i.e. through trials), and decision processes.

X

Need of both generalizable evidence and “local” evidence. X

Objective advantages (economic benefits, social prestige, convenience, or satisfaction)

X X

Fit with existing values and practices. X X

Simplicity and ease of use. X X

With observable results. X X

Re-invention (to fit the needs of individuals and groups). X X

Medically valid / evidence-based. X X

Reimbursable. X X

Institutionally supported. X X

The problem is not the technology(chief executive officer)

The technology is ready(medical manager)

We have all the technology we need(non-medical manager)

Only some initial problems, then technology was not a problem (aged patient)



factors Determinant factors

Present in the

literature


Technology

Technically feasible. X

Trialable. X

Definition of tele-healthcare and difference in respect to ICT. X

Typology of target-population for which the solution is designed (i.e. niches, restricted areas).

X

Different time-horizon between innovation and available observable results (i.e. through trials), and decision processes.

X

Need of both generalizable evidence and “local” evidence. X

Objective advantages (economic benefits, social prestige, convenience, or satisfaction)

X X

Fit with existing values and practices. X X

Simplicity and ease of use. X X

With observable results. X X

Re-invention (to fit the needs of individuals and groups). X X

Medically valid / evidence-based. X X

Reimbursable. X X

Institutionally supported. X X


WHAT ARE WE TALKING ABOUT?PROBLEMS OF DEFINITIONS


FOR WHO IS IT?PROBLEMS OF TARGET-POPULATION

“A diffused wrong conceptual link between tele-healthcare and disadvantages places o niche populations”

“Tele-healthcare is useful if targeted to specific populations with particular problems of mobility or with disadvantaged conditions.”


FROM WHERE DOES IT COME?PROBLEMS OF AVAILABLE EVIDENCE

Tele-healthcare makes sense today and needs evidence tomorrow.(technician)

PROBLEMS OF FIT BETWEEN AVAILABLE EVIDENCE AND LOCAL CONDITIONS

Yes, it works there*…but who can guarantee that it works here? [*organisations/department or country where evidence was produced]



factorsDeterminant factors

Present in the

literature


Individual

Personal networks. X Perception of and participation to innovation process. X Characteristics of stakeholders. X XTechnical knowledge and skills. X XRelative benefits and expectations (economic and none). X XPsychological antecedents (i.e. behaviours, needs, motivations, values)

X X

Attitudes towards assimilation process (i.e. readiness to change, risk-adversity).

X X

Perception of and participation to decision-making process. X X


WHO DOES PROMOTE THE INNOVATION?THE ROLE OF THE CHAMPION

AND THE PERSONAL NETWORKS

Everything is left to local initiatives and to the single individual(non-medical manager)


WHO PARTICIPATE TO THE INNOVATION PROCESS?REAL WILLING TO BE INVOLVED

Co-production meant as sharing of knowledge, know-how,but also of needs, can be very useful

(clinician)




Present in the

literature


Organisa-tional

Accountability. X Multi-disciplinary teams. XNetworks and collaboration among teams. XHTA support for decision-making and innovation-making. XSkills of managers (i.e. strategic, organizational, on innovation and evaluation).

X

Structural and non-structural characteristics of the organization. X XSub-organizational levels characteristics and structure. X XTask characteristics. X XBudget, time and resources (economic and none). X XOrganizational behaviour and learning processes (i.e. culture, norms, absorptive and adaptive capacity, readiness for innovation).

X X

Communication channels. X XKnowledge transfer processes. X XManagement support. X XCharacteristics of innovation process (i.e. imitation, evidence-based)

X X

Decision-making process (i.e. consensus, participation vs hierarchy and power).

X X


WHO ACCOUNTS FOR TELE?RESPONSIBILITY ISSUES




Present in the

literature


Organisa-tional

Accountability. X Multi-disciplinary teams. XNetworks and collaboration among teams. XHTA support for decision-making and innovation-making. XSkills of managers (i.e. strategic, organizational, on innovation and evaluation).

X

Structural and non-structural characteristics of the organization. X XSub-organizational levels characteristics and structure. X XTask characteristics. X XBudget, time and resources (economic and none). X XOrganizational behaviour and learning processes (i.e. culture, norms, absorptive and adaptive capacity, readiness for innovation).

X X

Communication channels. X XKnowledge transfer processes. X XManagement support. X XCharacteristics of innovation process (i.e. imitation, evidence-based)

X X

Decision-making process (i.e. consensus, participation vs hierarchy and power).

X X


A NEW FORM OF ORGANISATION?MULTI-DISCIPLINARY NETWORKS AND TEAMWORKS


A NEW MANAGEMENT?MULTI-DISCIPLINARY SKILLS AND CAPABILITIES

We should analytically study each process and pay attentionto the daily practice of professionals

(non-medical manager)

The healthcare management should have competences for assessing(medical manager)


A NEW HTA?HTA FOR NON-PHARMACEUTICAL TECHNOLOGIES

Not only Cochrane, but also evaluation along all the life-cycle in the context of real implementation…

(medical manager)




Present in the

literature


Outer Context

Social system. X External networks. X Mandates, strategies and policies. X XIncentives and funding. X XNorms among organizations. X X

Environmental stability. X X


WHAT CRISIS?POLITICAL MORE THAN ECONOMIC STABILITY


WHAT INTER-ORGANISATIONAL NORMS?METAPHORE OF SAN GIMIGNANO

The pride of diversity rather than objective reasons of diversity(medical manager)


Managerial and Policy Implications

A common ICT architecture and infrastructure for tele-healthcare, a PLATFORM.

INTEROPERABILITY standards.

Development and management of COMMUNICATION channels, COORDINATION tools and PARTICIPATION environments could facilitate the internal visibility of tele-healthcare solutions.

A DOUBLE PROCESS of innovation introduction and implementation: bottom-up, and top-down.

A clear national or regional PLAN, with indication of needs, priorities, funds and reimbursement policies.


CENTRALISATION


Organisation should present a PARTNERSHIP FORM.

Re-organization and changes produced by innovation are obtained through CONSENSUS, COMMUNICATION AND PARTICIPATION.

Healthcare managers should more operate “on the ground”.

Processes in support of the continuity of care present peculiar characteristics: huge variability, fragmentation, local-specificity, horizontal organization

Need to “CUSTOMIZE” innovative interventions in this specific healthcare setting.


LOCAL APPROACH


TRANSVERSAL ECO-SYSTEMS could create networks within and among organizations, facilitate the knowledge sharing and use, promote participation and co-creation in the innovation processes.

INCREMENTAL vs DISRUPTIVE INNOVATIONS


GLOCAL AND MULTI-LEVEL APPROACHbalancing centralization and local autonomy


The KNOWLEDGE

EVIDENCE Organizational know-how Different competences to be represented in a multidisciplinary

team Solutions and experimentations “from inside” HTA results Second learning approach


INVESTMENTS & DIS-INVESTMENTS

Benefits for society or end-beneficiaries + ADVANTAGES FOR PHYSICIANS, health workers, ...

COMMITMENT (intention to support) & MEDICO-LEGAL ASPECTS (action to support)

New models of FINANCING, REFUND and REIMBURSEMENT

Sabina De Rosis | [email protected]

Sabina De Rosis, PhD Candidate

TELE-HEALTHCAREIN THE ROUTINELY HEALTHCARE

SETTINGDETERMINANT FACTORS OF SUCCESS AND FAILURE

FROM A SINGLE CASE STUDY IN ITALY

XX NATIONAL CONFERENCEFOSTERING AND GOVERNING INNOVATION

IN HEALTHCARE BASED ON EVIDENCEUniversità degli studi di Sassari

16 October 2015

tele-healthcare in the routinely healthcare setting

Health & Medicine