Local Issues
The local level of knowledge, skills and attitudes to information technology
is an important governing factor in the implementation of a system. Local health
workers and planners should be made aware of the potential benefits of telehealth
and the possibilities of developing appropriate services within the limitations
of available resources. Training of local health workers to achieve an appropriate
level of skills to operate and maintain the installed telehealth equipment should
be seen as a mandatory component of any telehealth implementation.
Resource accessibility is inversely proportional to distance from population
centres. When this principle is applied to information and communication technology,
communications companies will charge more for remote access to telecommunications
systems. A key implementation issue is responsibility for ongoing funding of
the service, in particular the recurrent communications costs, which must not
be detrimental to existing levels of local funding for health services. Rural
and remote communities should not be penalised with higher costs for accessing
telecommunications resource. It has been widespread economic practice to subsidise
rural and remote communities in many areas of infrastructure support e.g. roads,
water supply. The relative costs of equalising the cost of supply of telecommunications
and information are far less and the potential benefits are far greater.
However, it must be recognised that within the current economic structure of
most health care systems, the biggest savings from the implementation of telehealth
may be in travel costs for patients in remote areas. Where communities have
subsidised travel arrangements for the transfer of patients, this saving may
be easily identified. In health care systems that do not directly pay for travel
costs, and are the responsibility of the patient, it will be more difficult
to measure any direct saving.
The higher costs of implementing telehealth in rural areas can be reduced by
the application of suitable technological methods such as microwave and satellite
data transmission. Such media may still be too expensive to implement for many
regions of the world, but are relatively much more achievable than previous
methods of communication.
Recommendation 4
Rural communities must have access to the level of telecommunications
service and bandwidth capable of delivering at least the minimum level of telehealth
services for their identified needs.
Recommendation 5
Rural communities must not be penalised by any changes to the local economic
environment created when communication systems are installed to support telehealth
systems.
Local, Regional and Global Resource Sharing
Telehealth offers the possibility of building bridges to link rural communities,
health workers and others. Planning for implementation should also consider
the potential for resource sharing between the government and private sectors.
If the private sector has a vested interest in a rural area (eg mineral exploration),
then it will often develop excellent communications infrastructure to support
personnel. Local communities should consider forming liaisons with the private
sector where these opportunities exist and form cooperative ventures wherein
both can benefit from the improved communications. By making more efficient
use of scarce resources during the implementation of telehealth services, considerable
cost savings can be realised by organisations that share the use of broad-based
communications. These same cost saving issues apply to areas other than the
provision of health care. Municipal administrations, law enforcement agencies,
health service administrations, industrial administrations can all benefit from
improved communications infrastructure, and reduce the overall costs of telecommunications
services.
Implementation issues of partnering for developing countries have a global perspective.
All countries should be encouraged to seek regional and global partnering relationships
in telehealth. Mary Oakes Smith, 1997 World Bank Learning and Leadership Center
Fellow, Information Technology and Distance Learning in World Bank Bulletin
No 1 raise the concern of global outreach. This refers to "developing country
access to delivery of health, education, public information, commercial and
other services using appropriate communications technology - and it is outreach
to the poorer parts of the developing world that requires the strongest partnering
relationships." It is also important not to ignore the potential of regional
partnerships for developing countries. Regional partnerships, where practicable,
may result in significant savings on the cost of information and communications
infrastructure.
Oakes Smith emphasises the key issues of "partnering among industry, academia,
foundations, international organizations and with developing country stakeholders
will be needed to realize the potential for successful application of (telehealth)
in the poorer countries and among the poor that need health services the most."
In describing the impact of partnering, Oakes Smith envisages a "new partnering
relationship based on a networking of comparative but differing skills (that)
would support innovations in health service delivery and would spread the financial
risks that need to be taken to realize the potential for telemedicine applications
in the poorer parts of the globe". This view recognises the reality that "the
information age is interactive, instantaneous and networked, and above all global."
In telehealth, the sustainability of regional and global programs will depend
on the willingness of participants to share expertise and advice freely.
Recommendation 6
Rural communities should seek to work with other interested parties in
cooperative ventures to improve local communications infrastructure.
Recommendation 7
All countries, in particular developing countries, should be encouraged
to actively seek regional and global partnering relationships with Universities,
industry and foundations in other countries to develop and support telehealth
applications
Regulatory Issues
Planners of telehealth services must determine whether any regulatory barriers
exist to telehealth. These barriers may include:
* telecommunications policy that does not support subsidies for rural areas
* licensing issues for interstate or international health workers providing
consultative and diagnostic services by telehealth services
* policy governing legal liability for healthcare decisions by local and remote
health care workers based on information provided via telehealth services
* policy governing legal liability for interstate or international health workers
providing consultative and diagnostic services by telehealth services;
* policy governing privacy and security of health information that does not
recognise the use of telecommunications as a modality for health service delivery;
* regulations regarding sharing of medical information that do not recognise
the use of telecommunications as a modality for health service delivery;
* standards for information management;
* standards of technology;
* regional/district policies regarding funding arrangements for telehealth.
It is important that any decisions about the provision of telehealth services
to rural communities made on the basis of existing policy or policy designed
to overcome these regulatory barriers does not have an adverse impact on local
health services.
Recommendation 8
Policy issues and decisions relating to telehealth should not adversely
affect the local delivery of healthcare in rural communities.
Recommendation 9
Regulatory issues and barriers that may impact on interstate or international
delivery of telehealth services should be clearly identified and addressed at
a national level.
Reimbursement
In many countries fee for service is the predominant method for reimbursing
health practitioners. In these countries, the regulations of national governing
bodies usually prohibit reimbursement in cases where there has not been a physical
presence or contact between the physician and the patient. This principle was
designed to prevent the abuse of billing eg for telephone advice.
In those countries where there is a predominantly state health funded system,
reimbursement of health services is often on a national scale with provider-purchaser
splits regulating the level of payment. Where this health funding system is
in place, existing contractual and funding agreements may not address service
delivery by telehealth. Regulatory or legislative change may be necessary to
permit this. The administrators of managed care health systems will also need
to incorporate funding for telehealth services into their payment structures.
The maximum gain from the teleconsultation process is obtained when the referring
health worker is included in the process. If the referring health worker is
an independent practitioner, then consideration should be given to providing
adequate reimbursement of the referring worker. Objections to this principle
that are raised by the funding bodies on the basis that there is no precedent,
should be vigorously opposed with the observation that this is a totally new
mode of consultation.
Recommendation 10
Planning for and implementation of telehealth services should address
the issue of reimbursement of parties involved in the teleconsultation process.
Ongoing Support and Maintenance
Telehealth systems will need maintenance once installed and will quickly fall
into disrepair unless there is adequate technical support. Funders of rural
telehealth services must allocate sufficient levels of recurrent funding to
ensure that rural health workers have access to ongoing technical support. Wherever
practicable, this access should be at a cost of no greater than a local telephone
call to the rural health worker. Access to prompt repair and maintenance of
equipment is crucial.
It is also essential to allocate recurrent funds for ongoing maintenance, capital
depreciation, reinvestment in and upgrades of the information technology and
communications equipment installed in rural communities for telehealth services.
The cost of maintenance and upgrades should not be underestimated - total cost
of ownership figures for information and communications technology over a three
to five year term when broken down typically demonstrate that 80% of the total
cost is expenditure on maintenance and upgrades. Again, these costs must not
be borne disproportionately by the rural communities.
Recommendation 11
Funding for telehealth must include allocations to provide appropriate
levels of recurrent expenditure for technical support, and ongoing maintenance
and upgrading of equipment.
Awareness and Training
In addition to being provided with technical support, rural health workers must
be provided with appropriate education and training to enable them to operate
telehealth installations. It is important that the attitudes of rural health
workers be targeted in education and training to create realistic expectations
about the performance of telehealth services.
There is a general lack of awareness on the part of rural health workers regarding
the information and communication technologies available and their applications
to telehealth. Implementation strategies for telehealth should identify the
need for training in the:
* operation of the communication technologies for supporting telehealth applications;
* application of the technologies for the continuing education of health workers;
and
* application of the technologies to clinical health services.
Each of these areas has particular issues associated with them.
Recommendation 12
A comprehensive promotion and training program in the use and application
of information and communication technologies for health, including dissemination
of experiences from existing telehealth projects, is a mandatory component of
any telehealth project. Such programs should recognise the diverse and differing
needs of rural health workers and the clients and communities that they provide
services to.
Recommendation 13
All projects involving the application of information and communication
technologies to health which are funded by national health authorities should
be required to have training in the operation of the technology integrated within
the project and be educated in the cultural and organisational issues which
are an integral part of a succesful telehealth implementation.
Evaluation
There is very little international evidence evaluating the effectiveness of
telehealth activities in the delivery of primary health care services, particularly
to rural communities in developing countries. Evidence is needed to justify
the expenditure of scarce resources on expensive programs that may not improve
local health services. Evaluation criteria must be designed to measure the process,
outcomes and impact of the implementation and performance of telehealth services
installed in rural communities.
Recommendation 14
The development and measurement of process, impact and outcome evaluation
criteria for telehealth services must be a fundamental component of any telehealth
program.
Indicators to measure the performance of the development and delivery of telehealth
services are needed. The collection of data on telehealth services is critical
to ensuring that telehealth services are effective in meeting clinical, economic
and performance criteria. Research and development on data items for measuring
the evaluation criteria is essential.
Recommendation 15
Health authorities should increase the scope and level of research activities
for the use of information and communication technologies in health by establishing
research agendas for telehealth.
At the international level, there is a need for the establishment of an evaluation
resource that should be auspiced by organisations such as WONCA or WHO.