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Presenter: Dr. Penny Jennett

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Title: Presenter: Dr. Penny Jennett


1
Successes and Failures in Telehealth
FACULTY OF MEDICINE
  • Organizational Readiness
  • Alliance for Building Capacity Project and
    National Initiative for Telehealth Guidelines

2
Overview
  • Introduction
  • Definitions
  • Purpose and Rationale
  • Methods
  • 2 studies Alliance for Building Capacity Project
    (ABC) and National Initiative for Telehealth
    Guidelines (NIFTE)
  • Background
  • Implementing Change Telehealth and New
    Technologies
  • What is Needed for Success?
  • Examples
  • Why Things Fail
  • Examples
  • Conclusions

3
Introduction
  • The process of implementing change
  • Successes and failures in telehealth
    implementation
  • Two studies of readiness Alliance for Building
    Capacity Project (ABC) and National Initiative
    for Telehealth Guidelines (NIFTE)
  • An organizational perspective

4
Definitions
  • Telehealth the use of advanced
    telecommunications technologies to exchange
    health information and provide health care
    services across geographic, time, social and
    cultural barriers (Reid, 1996)
  • Readiness the degree to which an organization is
    prepared to participate and succeed in telehealth
    implementation (Harvard, 2002)

5
Purpose and Rationale
  • Successful implementation of technological
    innovations in healthcare (i.e. telehealth)
    strongly depends on the organizational
    environment
  • Important to assess how ready an organization
    is
  • When readiness exists, an organization is
    prepared to accept change if an organization is
    not ready, the innovation may be rejected
  • The purpose of this presentation is to explore
    what is needed for successful telehealth
    implementation and to explain why implementation
    efforts often fail

6
Methods
  • 2 studies ABC and NIFTE
  • Key-informant, semi-structured interviews within
    the organizational domain
  • Data analysis focused on identifying factors of
    readiness at the organizational level and
    examples of success and failure in telehealth
    implementation
  • Examples of success and failure were also found
    in the literature

7
Alliance for Building Capacity Project
  • Goal to generate an understanding of the
    essence of telehealth readiness and to
    contribute to a framework that can be utilized by
    other rural and remote communities in the
    implementation of telehealth projects
  • The readiness of four domains (Patients,
    Practitioners, Organizations and the Public) was
    examined in a rural Canadian community
  • Core factors of telehealth readiness were
    identified
  • It is important that community members understand
    factors that promote or impede telehealth
    implementation before costly investments are made

8
National Initiative for Telehealth Guidelines
  • An interdisciplinary project aimed at developing
    a framework of national guidelines for telehealth
    services
  • Made up of four research teams Alberta Research
    Council, Dalhousie University, Laurentian
    University and the Health Telematics Unit (HTU),
    University of Calgary
  • The HTU was responsible for collecting
    accreditation relevant information concerning the
    organizational context
  • This information can contribute to an
    understanding of readiness and can provide
    explanations as to why telehealth initiatives
    succeed or fail

9
Background Implementing Change Telehealth and
New Technologies
  • When implementing telehealth systems, attention
    should be paid to organizational issues, as well
    as technical ones, as organizational attributes
    are important predictors of success
  • A telehealth may be successful in one
    environment, but not in another, due to the
    organizational context and conditions
  • Without a tight organizational fit, the
    implementation of new technologies will be
    problematic

10
An IT-Organizational Fit Analytic Framework
(Southon et al., 1997)
  • Emphasizes the organizational configuration in
    telehealth implementation
  • Operationalized as strategic planning and
    alignment
  • Strategic planning refers to processes that
    ensure IT plans are consistent with strategic
    business plans, priorities and initiatives
  • Strategic alignment refers to configuring the
    organization so that IT is aligned to the
    business strategy, structure and management
    processes
  • These types of strategies will assist in
    effectively adapting work practices, inventions,
    reorientations and organizational changes to new
    innovations

11
Change Agents (Armenakis et al., 1999)
  • Through their actions, change agents convey a
    message to other organizational members in order
    to build a commitment to telehealth
  • A change message is directed at 5 core questions
  • Is change really necessary?
  • Is the specific change being introduced an
    appropriate reaction to the discrepancy?
  • Can I/we successfully implement the change?
  • Is there organizational support for the change?
  • What is in it for me?
  • Adequate answers to these questions can determine
    and build the readiness of people to accept
    telehealth within an organization

12
Evaluation (Aas, 1999)
  • Evaluation of telehealth innovations is also an
    important element in successful telehealth
    services
  • Should address issues of quality, accessibility
    and cost
  • Through evaluation, one can see success and
    failure, and potentially determine the causes of
    both

13
A General Framework for Systematic Analysis of
Changes (Aas, 1999)
  • An evaluation framework will contribute to the
    knowledge and evidence surrounding the
    effectiveness of programs
  • General Framework for Systematic Analysis of
    Organizational
  • Changes Resulting from Telehealth Implementation
  • The starting point
  • Mapping of applications of telemedicine where
    organizational
  • consequences are possible
  • Characterizing the nature of larger
    organizational consequences
  • The consequences for the health sector in the
    chosen area
  • Possible consequences for the number and
    placement of geographical
  • subunits of the health sector
  • Possible consequences for health-sector
    organizational types
  • The consequences for the tools of health policy

14
What is Needed for Success?
  • Successful implementation of new technologies
    depends on
  • the readiness of the environment
  • a clear understanding of the existing health care
    system
  • systematic needs analyses
  • strategic business plans
  • collaborative partnerships
  • adequate equipment
  • program coordination
  • training of users
  • ongoing technical support
  • evaluation

15
What is Needed for Success?
  • A first step in successful implementation of
    telehealth is planning
  • Includes an assessment of readiness in the form
    of a needs analysis
  • The importance of using a needs analysis as a
    guide in telehealth implementation is emphasized
    in the following example from the NIFTE project

16
Example
  • One of the first activities that we did once we
    started the project was we did a needs analysis,
    and we didnt survey just the communities that
    were going to get telehealth, we surveyed all 25
    communities. We did that because if were going
    to develop a strategic document that says this is
    where we are today, this is what we will have
    done in two years when the project is over, and
    this is where wed like to be in three years
    following that, then we had to survey all our
    communities
  • (continued next slide)

17
Example
  • We basically asked what kinds of programs do you
    see that you need will you use telehealth and
    can you integrate it in your daily activities?
    The needs analysis has been our guide on what
    clinical programs we would need, what education
    programs we would need, and how we would equip
    our basic system based on what the community
    needs All those decisions were made at a
    community level, and I think that is a better way
    to go

18
What is Needed for Success?
  • Need to have in place
  • administrative standards for management
  • standards for policies and procedures
  • strong leadership
  • a clear comprehensive strategy
  • a common understanding of initiatives

19
What is Needed for Success?
  • Funding was seen as a key factor in successful
    implementation of telehealth innovations (ABC,
    NIFTE)
  • Necessary to support initial costs and to sustain
    the service beyond implementation
  • Example from the ABC Project
  • Success was possible with government funding
    when starting telehealth service in a remote area

20
Example
  • Well, I think that in place it wasnt just
    their local government but is was the federal
    government as well, and having funds available
    that could be accessed because I think that we
    need to recognize that place is rather small so
    that the financial resources are very limited and
    that, you know, if there was another organization
    that provided that kind of support, that we would
    be able to the use that as any kind of start-up
    So if you can apply those dollars toward the
    start-up then that would be a benefit.
    (Organization 3, page 6-7)

21
Case Analysis (Southon et al., 1997)
  • Implementation of a critical application in
    telehealth
  • While the final outcome was removal of the
    service, analysis demonstrates initial success
  • The problem lay in the organizational fit, rather
    than the technical issues
  • Factors that led to initial success
  • Identification of need and dissatisfaction with
    the existing system
  • Localization process
  • Teams allocated to the program
  • Training of staff
  • Commitment of organizational members
  • The presence of some immediate results

22
What is Needed for Success? (cont.)
  • The preparation of staff was also emphasized
    (ABC, NIFTE
  • ABC respondents indicated that users should be
    oriented, trained and educated so that telehealth
    becomes integrated into their everyday working
    lives
  • Example from the ABC Project
  • Successful implementation depends on services
    becoming part of routine health care

23
Example
  • Well, I think that its key that if it was
    going to be a successful telehealth service,
    that it becomes an integrated part of the health
    services delivery so that its not a separate
    program but that it is, you know, --the highly
    successful one is that they dont really see a
    differentiation any more, that telehealth is just
    a part of how you deliver the services, not
    looking at telehealth as a distinct program.
    (Organization 3, page 4)

24
What is Needed for Success? (cont.)
  • Allowing the creative use of telehealth equipment
  • Organizations should allow, and encourage, users
    to be creative when utilizing new services
  • Example from the ABC Project
  • Creative use of equipment can result in
    unexpected, successful telehealth applications

25
Example
  • Theres so many different applications around
    telehealth and the use of the ICTs in the
    delivery of telehealth that my experience has
    been that its one thing to plan applications and
    successful or unsuccessful pilot projects in
    telehealth, like in certain fields, certain
    specialties, and they always say only pick three
    types of things And what I end up seeing
    happening with these tools is people are using it
    for things that we have never anticipated It
    needs to be integrated within every project so
    that the projects can accommodate what the end
    users require and see as needed, instead of us as
    planners and technicians determining what we
    think might be the most successful.
    (Organization 2, page 5-6)

26
What is Needed for Success? (cont.)
  • Information technology diffusion in academic
    health sciences centres (Ash, 1997)
  • The following are important for successful
    adoption of an innovation
  • Controlled and careful project management
  • Appropriate reward systems
  • Decentralized decision-making
  • Top-management commitment and support
  • Strong social networks
  • Communication within, and outside of, and
    organization
  • The ABC and NIFTE Projects also emphasized
    inter-community cooperation, as seen in the
    following examples

27
Example
  • the role that our organization plays is I would
    say its like a liaison between both the end
    users and the institution and the profession. At
    the community level, at the First Nation level in
    particular, theres a whole other world that has
    to be addressed so that the liaison role is both
    educational a lot of support systems, a lot of
    policy development, procedures, trying to
    safeguard and ensure success as much as possible,
    and a successful experience for those people that
    are going to experience that. So I see that as
    our role and hopefully, you know, establishing
    and maintaining and supporting the planning
    committees. Making it as inclusive as possible
    for all participants to be able to have their say
    and be heard. (ABC, Organization 2, page 14-15)

28
Example
  • We had to enlist community involvement, so we
    had a lot of communication at the community
    level. We told them what we were doing. We
    actually went and traveled to different
    communities and did a show-and-tell of what
    telehealth was almost a year before they got it
    and weve had constant communication with them,
    so that they are never out of the loop If you
    dont have their support, youre lost. (NIFTE)

29
Why Things Fail
  • While information on what is needed for
    successful implementation of telehealth exists,
    there are still a number of projects that fail
  • Failure is often due to the fact that the entire
    change process is not followed through, monitored
    and managed from beginning to end
  • While there are always financial risks for
    organizations implementing telehealth, many
    failures are rather due to the lack of
    recognition of the human component in
    implementation

30
Why Things Fail
  • Lack of and actual needs assessment in the
    targeted community often leads to implementation
    failure
  • This example from the NIFTE Project supports this
    idea

31
Why Things Fail (cont.)
  • The ABC Project revealed failure of telehealth
    services resulting from equipment being dumped
  • The needs of the users were ignored and they were
    unable to use the equipment correctly or
    effectively
  • Important that staff are supported throughout the
    implementation process and that they are prepared
    to use the application
  • The following is an example of this situation

32
Example
  • The Docs knew very little about it. They hadnt
    been consulted about this Telehealth Network
    beforehand. It was dropped in. We were there to
    discuss with them what we could do to provide CME
    before we gave them the programs.
  • Was that a problem that they had just been
    dropped in?
  • I think it was because lots of times
    sometimes we would go there and they Docs they
    wouldnt know what room the equipment was in and
    once they found out they would say it
    shouldnt be there, what is the good of it
    there? I think under ideal circumstances it is
    only common sense that you would consult with the
    physicians and as many people as possible before
    putting equipment in. (Practitioner 2, page 3)

33
Why Things Fail (cont.)
  • Change is only successful when an entire
    organization participates in the effort
  • People resist change for a number of reasons,
    that can be categorized as dont need to
    change, cant change and wont change
    (Garside, 1998)
  • If a lack of need exists, implementation will not
    be successful
  • This is seen in the following example from the
    ABC Project

34
Example
  • Yeah, within our network we have two regions.
    We have place1, which is where we started, and
    we have place2. place1 is way ahead. Its
    just basically telemedicine is part of the fabric
    of health care in some of these towns. place2,
    which is more recent, is way behind. You have to
    ask yourself, you know, why?
  • Hm-mm
  • And basically I think that the driver there is
    that the needs arent as great. Theyre not that
    far, okay? They dont have the same needs.
    (Organization 4, page 17)

35
Why Things Fail (cont.)
  • The whole organizational culture needs to be
    receptive to the change
  • The focus needs to be on managing change through
    learning, communication, training and human
    resource support
  • Employees need to know that there is a
    predictable routine in place, that they will be
    treated fairly and that they can trust that those
    in charge are capable of delivering what they
    promise (Garside, 1998)

36
Why Things Fail (cont.)
  • Inadequate funding can result in failure of
    telehealth service
  • Example from the ABC Project
  • Even if the organizational members are on
    board, without funding, the application will
    not succeed

37
Example
  • The other issues are probably that we have not
    found the best champions to push this forward,
    and part of the reason for that is actually lack
    of funding. We did place on a shoestring so we
    couldnt pay medical directors, you know, more
    than a pittance and couldnt really get their
    support in the same way. Theyre all committed
    but they just dont have the time to do it.
    (Organization 4, page 17).

38
Southon et al., 1997
  • This case analysis can also be used as an example
    of failure
  • A critical application successfully implemented
    in the United States, was removed after
    implementation efforts in a large, divisional
    organization in New South Wales
  • Some factors that led to failure in the
    Australian organization were
  • Financial constraints
  • Focus on a cost-benefit analysis
  • Lack of involvement of organizational members
  • Minimum training for staff
  • System considered user unfriendly
  • Dependency on technical support
  • Difference between was the service provided and
    what people thought they needed

39
Conclusions
40
Summary
41
References
  • Aas, I,H.M. (1999). Telemedicine and the
    organization of the health sector. Journal of
    Telemedicine and Telecare, 5(S1), S126-S128
  • Aas, I.H.M. (2001). A qualitative study of the
    organizational consequences of telemedicine.
    Journal of Telemedicine and Telecare, 7(1),
    18-26.
  • Alliance for Building Capacity. (2002).
    Framework for rural and remote readiness in
    Telehealth (Project Report for CANARIE).
    Calgary, Alberta, Canada University of Calgary.
  • Armenakis, A.A., Harris, S.G. Feild, H.S.
    (1999). Making Change Permanent A Model for
    Institutionalizing Change Interventions. Auburn,
    Alabama Auburn University.

42
References
  • Ash, J. (1997). Organizational factors that
    influence information technology diffusion in
    academic health sciences centers. Journal of the
    American Medical Informatics Association, 4 (2),
    102-111.
  • Garside, P. (1998). Organizational context for
    quality lessons from the fields of organizational
    development and change management. Quality in
    Health Care, 7 (Suppl.), S8-S15.
  • Information Technologies Group, Center for
    International Development at Harvard University,
    (2002). Readiness for the Networked World A
    Guide for Developing Countries. Accessed at
    http//www.readinessguide.org/ on February 26,
    2002.

43
References
  • NIFTE
  • Southon, F.C.G., Sauer, C. Dampney, C.N.G.
    (1997). Information technology in complex health
    services Organizational impediments to
    successful technology transfer and diffusion.
    Journal of the American Medical Informatics
    Association, 4(2), 112-24.
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