Lessons Learned from the Field

The lessons learned are not different for telecardiology than for any other service implemented through telehealth technologies. With the exception of not locating stethoscopy in-band (in case the network system goes down, this exam technique can continue, particularly if critical to the diagnosis), few of the lessons learned in

implementing telecardiology are technology based. Most of the lessons learned fall into the following categories:

1) Telehealth is not about technology – it is about the clinical care of patients.

2) The development of relationships is the most critical factor in the success of a telehealth initiative.

3) Maintaining the human factors present in in-person visits through telehealth access is vital to patient and provider satisfaction.

4) Telehealth business planning is about more than return-on-investment or covering expenses – it is about the moral and economic incentives that health care systems and providers have in reducing the barriers to access to care for remote based populations.

5) A well-trained presenter is key to the efficient, effective and accurate practice of the provider via telehealth technologies.

6) Operational planning must include an assessment of current practice patterns and identification of variables that must be amended for telehealth. The question is not “How can my practice fit into telehealth,” but rather the question is “What is it about telehealth that must be changed to fit this practice?”

To put it quite simply, telehealth is not about technology, it is about people. Once an organization wishing to embark on a telehealth initiative realizes this important point, the implementation becomes easier. Building and sustaining relationships is the heart of telehealth. Telecardiology must be built based on a match of unmet needs and resource availability. Once a need is identified in a rural or remote community, a resource needs to be obtained and matched to the unmet service need. Simply using telecardiology for the sake of saying one is doing so does not create a successful program. Focusing on bringing human resources together with the needs other people is an excellent use of telecardiology, because it bridges the gap between distance/time and the

patient/provider. Following traditional referral patterns is key to success in this area. A thorough investigation of what relationships exist prior to the implementation of

telecardiology and whether those relationships can be maintained and enhanced after the implementation of telecardiology leads to a higher rate of adoption by both referring

and consulting providers as well as a high utilization by patients. Forcing “non-community member” viewpoints on how this system of access should work, by members who are not of the community, leads to resistance and low utilization.

Adopting a philosophy that telehealth mirrors services provided in-person is key to success. Find out what it is about the use of telecardiology technology as a tool for care that needs to change in order to fit into the provider’s practice – not what does the provider have to change about their practice to use telehealth strategies. Spend time observing provider’s practices and outlining the organization of care in each specialty practice by individual providers. Analyze that organization of care with respect to providing the same care via telehealth technologies. Mapping out processes/systems and recreating them in a pilot clinic to directly observe how each part of the organization of care might be delivered via telehealth is a valuable exercise. This systematic

delineation of steps includes information prior to the start of the visit, who collects that information, exam techniques necessary to make a diagnosis, information exchange during the visit, documentation principles, prescription dispensing, patient education materials needed, and any and all processes for discharge and follow-up. This observational study is imperative in order to make consultations via telehealth time neutral for the provider. The success of programs is driven by this customization of telehealth processes to specialty services. In addition, providers who review

procedures prior to implementation and conduct pilot clinics with known patients should be offered help to work out any concerns prior to implementing real consultations.

Individual attention to the development and operationalization of clinical services based on the organization of care leads to a higher success rate with providers using

telecardiology as a part of their daily practice.

The same principles are applied to the originating site. Programs that spend

considerable time studying and understanding the patient experience as they access and participate in health care encounters will be more successful. Patient flow

processes including check-in, registration, waiting area locations, exam room setups, medical records flow, follow-up appointing and any process included in the care of the patient at the remote site is evaluated using observational studies. Processes are

mimicked as close as possible to in-person care for patients receiving care via

telehealth. Patients have the sense that they are coming to their local clinic for care, will be seen in comfortable, traditional exam rooms, and will have their primary care

providers close by. Programs should use special framing techniques, color, and lighting to create the in-person experience over telehealth technologies. Minimizing the

presence of the technology and focusing on promoting patient comfort leads to high patient utilization rates.

The other lesson learned in this area is the use of a specially trained telehealth nurse clinician. It is extremely important to have a well-trained presenter on the patient end.

Provider time neutrality depends on the ability of the presenter to predict what the consultant may need during a consult, the camera skill and expertise of the presenter, and the creation of “a caring” environment by the presenter for both the patient and the provider.

The final lesson learned is in the area of sustainability. The key to sustainability begins with relationships – recognizing the existing relationships between patients and

providers, between providers and providers, and between communities and communities. Respecting and building upon these relationships helps to create a network that adds value to a community’s health system and prevents redundancy and duplication of services. Using telecardiology strategies as a part of an integrated service delivery network rather than a stand-alone system also supports sustainability. The use of telecardiology is not the use of technology; it is the use of tools for access. Access is the availability and accessibility of services to remote based populations.

Telecardiology helps to transcend the barriers of distance and time between people – people who need health care resources and people who can provide those resources (services). Maintaining the human factor in all that we do, both for patients and providers, and consistent support and contact with both referring and consulting providers is critical to sustainability. In addition, telehealth solutions must be easy to use and available right in the provider’s clinical work area. The tools of telehealth should be as indispensable as the telephone or PC to clinical practice.