Vision, Structure and Leadership of a

Sustainable Telehealth Program

Executive Summary

As accountable care and bundled payments are already on our way, all healthcare

providers are expected to provide the best care while containing the cost. Telehealth had

been acknowledged and proved in many cases that, it not only improves the patient

care, but also reduces the cost. Even though many health care organizations would like

to start a telehealth program, they are not sure of how to organize a sustainable

program. Vision, program structure and leadership are keys to sustainability. Finding

the best vision, structure and leadership that meets every organization’s needs is

impossible. But while analyzing some of the successful telehealth programs, there are

some common themes shared among them. A physician led, centrally administered

telehealth program with the goal of patient access improvement seem to have greater

success and sustainability. These common themes could be considered while designing

a Telehealth program.

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Vision, Structure and Leadership of a

Sustainable Telehealth Program

Introduction

Recently, Telehealth is a major focus of the healthcare industry. In a 2011 market

research report, Technavio predicted that Telehealth market is expected to grow at a

compound annual growth rate of 19 percent [1]. Frost and Sullivan’s recent market

research also concluded that telehealth has upswing demand and has taken huge

strides forward [2]. This year, American Telemedicine Association’s ( ATA) annual

conference attracted close to 5000 attendees in Florida, making it one of top 10 well

attended healthcare conferences [3].

In a 2010 Intel sponsored survey 89% (i.e. 9 in 10) of healthcare decision makers

believed, telehealth will transform healthcare in next 10 years [4]. Based on Manhattan

Research’s recent study, 7% of U.S Physicians are using video conferencing to

communicate with their patients, 42% of Physicians used online to communicate with

patients, more than 9 million consumers had email communication with their patients,

and additional 80 million consumers are interested in online visit [5, 6].

From regulatory perspective also, FDA recently proposed regulations for mobile medical

applications [7]. Center for Medicare and Medicaid Services (CMS) showed its support

to telehealth by recently relaxing it rules on physician credentialing to engage in

consultations across the country [8]. CMS had been expanding the CPT procedures

covered under telehealth services [9]. Healthcare reform recommends ACO to use

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telehealth and remote patient monitoring to improve the quality of care [10]. HITECH Act

also included $2 billion to expand the broadband infrastructure to support telehealth [11].

Due to these favorable conditions, today every healthcare organization is thinking of

having their own telehealth program. But many of them are not sure how to organize

their program. In order to have sustainable Telehealth program, a well planned vision,

organization structure and leadership are important [12-14]. This paper analyses some

of the successful telehealth programs and tries to extract the common themes among

them. See appendix 1.

Vision of a telehealth program

Organizations would like to develop the Telehealth program for different strategic

reasons. It could be either to improve access to care or cost savings or access to market

[14]. But when analyzing some of the programs, it is clear that those programs with the

vision of improving access to care and addressing patient needs seem to have higher

success rates than others. Dr. Darkins with VA telehealth program affirms that the main

reason behind the success of their program is their vision [15]. VA telehealth program

was developed to expand access and provide care as close as possible to the patients’

community [16]. Ontario Telemedicine network (OTN) is one of the world largest tele

network, and their vision is “It’s about having the right provider in the right place at the

right time” [17]. But both these programs have realized cost savings and access to

market as indirect benefits. Between 2003 and 2007, using telehealth VA showed

benefits of a 25% reduction in no. of bed days of care and 19% reduction in no. of

hospital admissions which is a huge cost savings for them [18]. If the program is

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beginning for cost savings or market expansion, it may be hard to show the success

during the early stages [19, 20]. The main reason is because cost effectiveness of

telehealth depends on three factors: cost sharing by adequate patient volume and

sharing of infrastructure, effectiveness of telehealth in terms of utility and satisfaction,

and finally the cost savings accrued by the decreasing the patient loss of productivity

[21]. Tracking and measuring these factors are difficult. When the underlying vision is

cost savings or expansion of market, and the program expects the providers/patients to

change the way they deliver/receive the healthcare, the program suffers with lot of

resistance [22]. So focusing the vision on long term sustainability than short term

revenues will help to realize the success of the program. Dr. Whitten’s 2010 study shows

that 63.8% of telehealth programs believed Access to Care as their main organizational

goal [12].

Another reason behind the emergence of telehealth program could be technology, that is

organizations with rich technology and tech savvy resources would like to use those

technologies to improve the patient care. If this is the case, you may need to step back

and think again. Dr. Darkins, VA says that “If somebody comes along and says, “I have a

technology which I believe is really going to make this difference,” then that is usually a

recipe for failure. But if someone comes along and says, “I have this particular issue,

challenge, problem with delivery of care, and I think that we could use technology to

support care to manage those people,” then that is a clear vision allied to the delivery of

care.” [15]. Technology should be considered as a facilitator of the relationship between

the patient and the physician not as a driver behind the program. In 1990s, Dr. Whitten

et al mentioned that telehealth needs to be developed as a program under medicine,

rather as technology [13]. One of the thinking points out of FSMB symposium is “adding

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‘tele’ to any form of medicine delivered across the distance is it own barrier to progress

forward” [19]. So, it is recommended not to include ‘tele’ in program name. Recently

Massachusetts based Partners healthcare changed it s name from Partners

Telemedicine into Partners Connected Health to emphasize on healthcare [23]. UPMC

also call its telehealth program as a center for Connected Medicine [24].

Structure of Telehealth Program

In an article Dr. Whitten et al quoted Paul Maakestad, then Project Director at MRTC

saying that, "Don’t underestimate the amount of administrative support needed to make

a program function smoothly. Think out structures completely, before beginning the

program.” [13]. So it very important to find the best structure that would suffice the need

of the organization. Today there are various forms of telehealth program adopted

throughout the country. Some of the programs are part of the individual medical

department like Mayo Telestroke department, some of them are under Information

Technology department ( IT) like Cleveland Clinic and some other are centralized stand

alone departments like VA, partners healthcare etc. So which one would be best for the

organization?

If we analyze in depth, telehealth doesn’t belong to any individual clinical department as

it could serve almost all clinical services in an organization. See appendix 2. Apart from

clinical services, it could also be used for medical education/training and conferencing

among healthcare workers. If telehealth is a small, orphaned program, then its only hope

is to develop as a kind of new silo [15]. So developing it as a centralized, free standing

department, helps the program to stand aloof from infighting of the various departments.

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In a 2010 research study of 92 telehealth programs, 72.3 percent of them had their

telehealth program defined as a distinct entity [12]. Centralization helps to implement

universal standards across the organization. It leverage economies of scale in

contracting and purchasing, eliminates redundant functions and utilizes successful

information delivery models, systems, and devices across projects [11, 25]. Centralized

management is essential to control and secure the fast paced telehealth technology. The

main disadvantage of centralization is lack of partnership between the central team and

the individual departments [25]. When the program is very hierarchical and completely

centralized, Individual service lines (ex. Psychiatry, radiology, dermatology etc) won’t

take ownerships and may lack the commitment to make the program successful. Only

when the power is distributed across the organization, employees feel empowered and

take pride in ownership. When front end employees are included in the decision making

process, it helps to improve their commitment and encourage them to use their first hand

knowledge and experience to improve the overall program. Other issues with

centralization are bureaucracy and lack of responsiveness. There is no ‘perfect’ answer

to how a telehealth program should be structured. Since telehealth requires both

centralized oversight and decentralized ownership it is highly recommended to get the

best of both worlds by decentralized centralization. This can be done by deciding on who

gets to make what decisions. Common rule of thumb is individual departments decide

on what services could be delivered, and the central team decided on how those

services could be delivered [26]. Organization’s executive governance committee could

finalize the roles and responsibilities of the central team and individual departments.

Common roles of central team

Develop clinical, technical and business process standards

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For telehealth services, today there are no technical standards (speed, redundancy,

connectivity) developed by any state or national level organization [19]. Until such

standards are developed central team would have to be responsible for developing such

standards. But unless otherwise the clinical and business standards are clear,

technology will fail [19]. So focusing on clinical and business standardization is very

important. Irrespective where the patients are, they should feel the same standard of

care [27]. Clinical protocols help to reduce practice variation and clinical risks, formalize

training, enhance billing and reimbursement and help educate patients [22].

Long range strategic planning

Strategic planning for the telehealth program is the most important role of the central

team. Central team needs to work with their executive committee on an ongoing basis

and figure out the path for their program in the near future [28]. This planning process

should include goal setting and periodic updating of vision and mission statements.

Program’s strategy should strongly in alignment with the organization’s strategy. It is

central team’s responsibility to make sure that individual telehealth services are

developed to meet the program’s strategic vision. It is also important for the central team

to market these strategic goals to the patients, providers and the community in order to

achieve the program growth.

Act as a knowledge expert and provide consulting

Even though telehealth is in the industry for more than decades, it is not easy to find the

experts and knowledge resources on this field. Currently American Telemedicine

Association (ATA) is a good resource base. In order to develop a sustainable program, it

is very important to grow an internal knowledge base [22]. Central team has the high

stake in developing and fostering such a knowledgebase. Instead of reinventing the

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wheel, the central team could learn from the external organizations like ATA, OTN, and

VA and adopt best policies. Another service from central team could be project

management. Applying project management for implementation of teleservices has been

proved successful. Many of teleservices would require same set to implementation steps

[14, 22]. Repetition helps to master the skill. So it makes sense to employ the project

managers centrally and use them to implement multiple telehealth services

simultaneously.

Monitor and evaluate individual services and the overall program

Telehealth programs should evaluate their performances ranging from quality of services

to financial ability on an ongoing basis. Financial assessments need to include

evaluations of costs and benefits, coding issues, reimbursement, account receivables,

bad debt and network utilization [28]. Before assessments, it is very important to develop

the performance monitoring plan with the help of individual teleservice lines.

Performance assessment initiatives can help support the cost effectiveness of telehealth

program [29]. Only by gathering, analyzing and communicating the performance scores,

the presence of telehealth program could be justified.

Train and educate

Training is a critical element of the telehealth program. One of the important lessons

from VA telehealth program are normal methods of clinical consultation do not

automatically transpose into teleconsultations; Clinicians need training and education in

teleconsultation irrespective their experience in normal setting [22]. Training needs to

well thought out and developed before implementing any individual service. To sustain

and grow the program, required skills and competencies should be provided to the

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staffs. In order to maintain the standards across the organization, central team needs to

develop and manage the training programs.

Contract and procure resources

Apart from human resources, Telehealth involves lot of hardware and software

resources. In order to benefit from economy of scale it makes lot of sense for the central

team to assume contracting and procurement roles. While choosing technologies, there

are some basic rules to be considered. For example, goal of setting up telehealth

applications is to deliver healthcare differently. So organizations need to go as simple as

they can because the more complicated it gets, the more in the way it gets, and the

acceptance level drops [30]. Following bleeding technologies is a high risk, because

practitioners need to focus on the patient care rather than the technical issues. So it is

recommended to use the simple, tried and used technologies. It is also recommended

not to focus on the Emergency services during the initial stages as the current

technology is not yet robust enough to support those acute interventions [15]. For

organizations who are novice and do not have access to high tech resources, it may be

wise to lease the devices and solutions, at least until the knowledge is gained.

Maintaining the system at the central level helps to leverage economy of scale.

Integrate Information and clinical services between departments

While individual teleservices focusing on their individual unit’s performance and

management, it is the central team’s responsibility to make sure, the information is

Integrated with existing EMR and other IT systems to achieve best returns. Integration

between the clinical services is also important. Lot of time telehealth services would

require other clinical services intervention to complete their clinical care path. For

example in order to do a teledermatology service, it might require the internal medicine

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or family practice physician’s help to get the biopsies. In such cases, central team needs

to intervene and make sure there is a solution without compromising their existing

policies and procedures.

Manage Risks

Since there are lot of state, federal and industrial regulatory requirements associated

with telehealth, there is a need for central oversight and guidance, to run the program

successful.

Common roles of individual Service lines

Determine the teleservice need and develop business case

Individual clinical team needs to be responsible for determining the need for telehealth

services in their department and develop the business case for it. As part of the business

case, individual team would come up with their functional and resource needs. This

helps the individual team to accept the ownership for the success of the program. But

the business case needs to be reviewed and approved by the central team to make sure

there is a strategic alignment.

Develop clinical care pathway

Delivering care with telehealth should be the same as delivering care without telehealth

[14, 15]. It is about integrating current resources to manage and expand the program,

rather than creating a whole new clinical silo. Providers and patients should not feel

major changes between the face to face consultation and tele consultation. Fewer the

changes, greater the success of the program. For example, if patients are asked to call

a different phone number for a tele visit than a face to face visit, it may be a barrier to

use the program. So individual teams, providing this care would need to adopt the

appropriate clinical care pathway for their telehealth.

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Fund the teleservice.

From the funding perspective, it is recommended that individual departments provide

and manage the funding for the individual telehealth services under their own

department. This way individual clinical services would make sure, they are investing on

a service, where they would see positive outcomes. This will also help to discourage the

individual departments from asking for shooting stars and moon from technical and

manual resources perspective. Overhead costs incurred by the central team needs to be

shared among the individual services, based on their usage.

Manage Staffs

Management of telehealth service providers need to be under the individual

departments, to reinforce the fact that telehealth is just another way of delivering their

service, not a new clinical silo. Individual departments need to finalize the scheduling,

compensation/ benefits for the services providers including physicians, nurses and etc.

Leader of Telehealth Program

Many struggling programs seem to under estimate the personal requirements to

implement a successful telehealth program [12]. Leadership is key to getting buy-in and

enthusiasm further down the organization for successful, systematic telehealth program

implementation. Unpopularity of telehealth for a long time is due to lack of commitment

and the absence of necessary organization structure and people to make it happen [15]

Many researches and surveys have found that Physicians resistance had always been

the no.1 barrier to the promotion of telehealth [15, 19, 22] and today’s physician

education and practice does not embrace use of technology. According to Dr. Darkins,

Telehealth Project’s Success = Quality of Service and access to health care services /

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cost of services and professional objection [22]. VA also found that one of the biggest

challenges of implementing a telehealth program was persuading doctors to use it [30].

Telehealth program leader’s main responsibility is cultivating a can-do attitude among

the providers. This person needs lot of enthusiasm about improving patient access and

quality of care using technology, and create a free environment where everyone is able

to share aspirations and interests with each other. So the best choice to lead the

telehealth program would be a senior level, technology loving physician. This is mainly

because, physicians listen to another physician. If no physician in the organization

believes that Telehealth would address the patient needs in the organization, then it is

not yet time to start the telehealth program. According to VA, emphasizing the potential

for doctors to treat more patients in a way that added minimal strain to their schedules

was the most persuasive case [27].

Physician leader might be able to drive the clinical and business processes well. Since

telehealth involves equal amount of technology, he needs strong support from the

technology officer. This technology officer need not to be same as the CIO ( Chief

Information Officer). Since telehealth has strong connection with IT, having dotted report

line with the CIO helps to connect the dots. Today telehealth technologies are grouped

into 3 categories; 1. Store and Forward technology 2. Video Conferencing technology

3.Telehomecare technology. Technology officer would be responsible for finalizing

technical infrastructure, developing technical process standards, supporting day to day

technical issues and managing telehealth applications. Apart from managing the

hardware and software systems, this individual would also be responsible for seamless

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integration of the telehealth systems with the hospital’s EMR system and other IT

systems. See appendix 3 for sample telehealth program structure.

Conclusion:

Even though there are still some barriers like lack of reimbursement, complex licensing

and credentialing requirements, lack of standards and regulatory requirements there are

growing evidences that telehealth will be major game changer in healthcare services.

Today technology is not a huge barrier. We already have much of the technologies

needed to support telehealth program. The key issue is increasing the adoption and

usage of technologies [15].With a proper vision, strong leadership and well planned

organization structure, adoption of telehealth today will set the stage for smart growth

tomorrow.

References

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Appendices

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Appendix 1:

Program Goal Leader Structure SourceCleaveland Clinic CIO Centralized SG2

Mayo Telestroke Improve access to care Physician

Part of existing ( Neurology)

http://www.mayoclinic.org/stroke-telemedicine/about.html

OTN

It’s about having the right provider in the right place at the right time. Physician Centralized http://otn.ca/en/

Partners Healthcare/ Center for Connected Health Changing Healthcare Delivery Physician Centralized

http://www.connected-health.org/

UPMC/ Center for Connected Medicine

transform healthcare into a system that facilitates communication, collaboration and coordination among all stakeholders along the care continuum Physician Centralized

http://connectedmed.com/

Veterans Affiars

Apply communication and health information technologies to provide specialty care, services and education to veterans at VA clinics closest to their homes Physician Centralized

http://www.telehealth.va.gov/

Appendix 2:

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Appendix: 3

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