Journal of Telemedicine and Telecare http://jtt.sagepub.com/
A qualitative case study of telehealth for in-home monitoring to support the management of type 2 diabetes Karen Carlisle and Robin Warren J Telemed Telecare 2013 19: 372 DOI: 10.1177/1357633X13506512 The online version of this article can be found at: http://jtt.sagepub.com/content/19/7/372
Published by: http://www.sagepublications.com
Additional services and information for Journal of Telemedicine and Telecare can be found at: Email Alerts: http://jtt.sagepub.com/cgi/alerts Subscriptions: http://jtt.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Nov 10, 2013 What is This?
Downloaded from jtt.sagepub.com at Dokuz Eylul Universitesi on November 1, 2014
RESEARCH/Original article
A qualitative case study of telehealth for in-home monitoring to support the management of type 2 diabetes
Journal of Telemedicine and Telecare 19(7) 372–375 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1357633X13506512 jtt.sagepub.com
Karen Carlisle and Robin Warren
Summary The present study formed part of a randomised controlled trial of telehealth for in-home monitoring to support people with poorly controlled type 2 diabetes. We explored the experiences of patients and healthcare practitioners, and their perceptions of the telehealth model of care used in the trial. In addition to their usual diabetes care, participants receive diabetes care from a diabetes educator nurse via an in-home broadband communication device. On average, each patient participated in 14 videoconferences with a diabetes care coordinator during the 12-month trial period. Qualitative data was collected from two general practices and included semi-structured interviews and document review of patient clinical notes. A total of 12 people were interviewed: 8 health practitioners and 4 patients. Patients and health practitioners expressed a high level of satisfaction with the model of care provided. Patients also reported positive health and social outcomes as a result of being involved in the trial and indicated that in the main they had achieved their goals and were happy with their progress over the 12-month period. Analysis of interviews revealed three broad elements associated with the implementation of telehealth: interpersonal factors, operational problems and the wider health system context within which the general practices and trial team were operating. The findings suggest that adopting telehealth in the management of type 2 diabetes can lead to improved diabetes control, but more support is required to ensure sustainability and widespread implementation. Accepted: 18 August 2013
Introduction Research suggests that countries with stronger primary care systems and effective management of chronic disease systemic factors have better health outcomes and lower costs.1–4 A systematic review of interventions directed at diabetes reported that active patient monitoring and encouragement of self-management behaviours improved disease management in the short term.5 However this cannot be achieved solely by conventional methods. Telehealth is potentially useful in chronic disease management because it can assist a person manage their condition at a time and place which is convenient for them. Research from large scale programmes in the US and UK has shown that the use of telehealth combined with care coordination can be effective in helping people to manage their chronic health condition.6,7 The benefits of telehealth include greater access to healthcare services, improved health outcomes and more cost effective service delivery.8 However, the dearth of robust evidence for the value of telehealth remains a barrier.9–11 In addition, the implementation costs, the additional workload and a preference for the conventional approach to care have implications for the uptake of telehealth.12 Research has also identified the lack of
appropriate equipment, poor technology infrastructure and unreliable internet access particularly outside metropolitan areas as affecting the extensive use of telehealth.13,14 The present study formed part of a randomised controlled trial (RCT) of telehealth for in-home monitoring to support people with poorly controlled type 2 diabetes. The aim of the study was to explore the experiences of patients and healthcare practitioners, and their perceptions of the telehealth model of care used in the trial.
Methods The research was conducted in a regional area of Queensland from mid-2012 until early 2013. The research protocol for the RCT has been described elsewhere.15 In summary, the model of service delivery included telehealth monitoring of various diabetes health indicators,
Townsville-Mackay Medicare Local, Townsville, Queensland, Australia Corresponding author: Karen Carlisle, Townsville-Mackay Medicare Local, PO Box 7780, Garbutt BC, QLD 4814, Australia. Email: [email protected]
Downloaded from jtt.sagepub.com at Dokuz Eylul Universitesi on November 1, 2014
Carlisle and Warren
373
home management, education and support for 12 months. The services were primarily delivered by care coordinator nurses. In addition to the collection of quantitative data, qualitative case studies were conducted in two general practices. The aim of the case studies was to explore the in-home monitoring trial in more depth and in its natural context. The general practices selected for case study were located in urban settings and had consented to participate in the trial. Practice A was a small practice with less than 10 general practitioners (GPs) and a few nursing staff, including a chronic disease management nurse. The practice did not provide allied health services on-site. Practice B was a large practice with more than 10 GPs and a team of nurses including a chronic disease management nurse and mental health nurse. The practice provided allied health services across a broad spectrum of healthcare and offered a weekly diabetes clinic. Data collection was primarily through semi structured interviews with health practitioners (including general practitioners, allied health professionals, practice managers and nurses) and a sample of patients in the two case study practices. An opportunity sample of health practitioners with patients involved in the trial within each of the general practices were approached to participate in semi-structured interviews. GP interviewees were a pre-requisite for the selection of patients for interview, i.e. patients selected for interviews normally attended the GPs participating in the case studies. Health practitioners were interviewed towards the end of the 12-month intervention and patients were interviewed three times (within the first 3 months, at 6 months and at the end of 12 months). Interviews were supplemented by a document review of patient notes collected by care coordinator nurses during the trial. Interviews were conducted by the authors and audio-recorded. On average, the interviews lasted for 30–60 min and involved a discussion about the participants’ experiences of the trial which covered in more detail the implementation of the trial, benefits, supports and challenges of the experience and learning gained through their participation in a telehealth trial.
where there was not always adequate time for patients with chronic conditions. Therefore the telehealth model of care complemented the work they were already doing. Patients also reported positive health and social outcomes as a result of being involved in the trial and indicated that in the main they had achieved their goals and were happy with their progress over the 12-month period. All patients who were interviewed referred to learning more about their type 2 diabetes, particularly in terms of education about diet, movement and the importance of regular monitoring of their condition. Whilst the application of the new knowledge about managing their diabetes was at times difficult, patients recounted changes made to their daily routines, for example, reducing portion size, increasing incidental activity and making healthier food choices. A recurring theme from patient interviews was the reassurance they felt knowing that their health was being monitored and followed up by a health professional. After some initial reluctance to engage in regular monitoring of their blood glucose and blood pressure, patients acknowledged that they benefited from having the care coordinator follow up on daily readings. Linked to this was the social interaction facilitated by the telehealth technology. When asked to identify the key positive aspect of the trial all patients cited the importance of the regular videoconferences with the diabetes care coordinator. On average, each patient participated in 14 videoconferences with a diabetes care coordinator during the 12-month trial period. Patients commented that the additional support provided by the care coordinators complemented their regular diabetes care, echoing the perception of health practitioners that the model of care worked in conjunction with services provided by the general practice. Both patients and health practitioners recognised that it could be a useful tool to support patients, such as elderly patients and people experiencing difficulties with transport and travelling to the surgery. Indeed, the overall perspective from interviewees was that their participation in the trial was a positive experience.
Results
Factors for effective implementation of telehealth
A total of 12 people were interviewed: 8 health practitioners and 4 patients.
The in-home monitoring trial was the first experience of telehealth for all the health practitioners and patients interviewed. Analysis of interviews revealed three broad elements associated with the implementation of telehealth: interpersonal factors, operational problems and the wider health system context within which the general practices and trial team were operating. The elements and conditions for effective implementation which were raised during the interviews are summarised in Table 1. The most commonly cited factor associated with effective implementation of the trial was the importance of inter-personal relationships to gain clinical support (‘‘buy-in’’) for the trial. Underpinning much of the early work in the implementation of the trial was the existing positive working relationship between the trial team and
Satisfaction All patients and health care practitioners expressed a high level of satisfaction with the model of care used and viewed telehealth as an effective tool for the management of type 2 diabetes and also more widely for other chronic conditions. There was a broad consensus from health practitioners that their decision to participate in the trial was patient driven, and that their patients benefited from the in-home monitoring and remote support provided by the diabetes care coordinator. Some people interviewed acknowledged that general practices were busy places
Downloaded from jtt.sagepub.com at Dokuz Eylul Universitesi on November 1, 2014
374
Journal of Telemedicine and Telecare 19(7)
Table 1. Elements of effective implementation of telehealth. Elements
Conditions for effective implementation
Interpersonal Positive working relationships Clinical buy-in Motivation and commitment from implementation team and health practitioners Operational Integration of telehealth work into daily practice Reliable and user friendly technology systems and structures Appropriate human capacity and resources dedicated to telehealth operations Health system-wide Adequate remuneration structures System of primary health care that enables telehealth to be used as part of coordinated chronic disease management
healthcare practitioners. Practitioners with prior experience working with the trial team were early supporters and actively promoted the trial within their workplace and to the wider community. It was crucial for the healthcare practitioners with limited experience that positive working relationships with the trial team were fostered, particularly when outcomes were still to be realised. Operational problems were frequently alluded to by health practitioners and patients. Unsurprisingly, both case study practices felt that the additional workload for screening patients and recruitment into the trial could be an additional stress on time and resources. Comments from health professionals suggest that this process could have been more streamlined and integrated into normal practice. A second operational problem was the technology and IT structures used in the trial. The use of home monitoring and videoconferencing was very new to all participants, and as a result, there were difficulties during early installation, in learning to use the equipment and with the availability of the services for the trial. All participants were trained to use the equipment. Reflections on the technical aspects of the trial indicated that it was important that the appropriate equipment, training to use the technology, IT structures and human capacity to manage the technology for the trial were provided. Although the wider context did not feature highly in discussions about the telehealth intervention, it did emerge when interviewees considered the sustainability of telehealth. Health practitioners felt that it was significant that the Australian government recognised the contribution that telehealth could make to the health system. However they suggested that more legislation and structural change was necessary for sustainable services to develop. Some health practitioners felt that the public health service reimbursement for telehealth (Medicare Benefits Schedule, MBS items) facilitated the implementation of telehealth, but did not go far enough. Healthcare staff such as allied health practitioners and nurse practitioners are not reimbursed under MBS items
for telehealth consultations. The exclusion of these health practitioners could create barriers to the provision of coordinated care, which is important for chronic disease management.
Discussion The present paper reports one of the first qualitative studies from Australia to explore the implementation of a telehealth service within a coordinated model of care for chronic disease management. Due to the limited sample size, definitive conclusions are not possible. However the results allow some reflections about telehealth in home monitoring. First, the evidence from our case studies showed that all participants were satisfied with the model of care and were keen to engage in telehealth. Second, in line with previous research, a number of inter-personal and operational factors were identified as key enablers.14,16 Conditions such as positive working relationships and ensuring clinical buy-in were identified as important for sustaining engagement with telehealth, which agrees with findings reported by Wade and Eliott17 who argued that telehealth requires the development of relationships between clinicians. Logistical and practical factors associated with the introduction of telehealth suggest that telehealth systems should adapt and link in to the day to day operations of the practice and not vice versa.18 Furthermore, similar to other studies,12,13 our data indicated that technical problems may reduce the availability and success of services supported by telehealth. Finally, the findings highlight the challenges for policy makers and health practitioners in respect of the potential of telehealth as a mechanism for coordinated chronic disease management. In Australia the National E-health Strategy19 and the National Digital Economy Strategy20 both make reference to the implementation of telehealth to enable a safer, higher quality, more equitable and sustainable health system. However system-wide changes to encourage the use of telehealth such as the publication of standards for
Downloaded from jtt.sagepub.com at Dokuz Eylul Universitesi on November 1, 2014
Carlisle and Warren
375
GPs offering video consultations21 and MBS reimbursement for video consultation22 may not be sufficient to encourage the widespread adoption of telehealth within a model of care for chronic disease management. Acknowledgements We are grateful for financial and other support from the Australian Government under the Digital Regions Initiative National Partnership Agreement and the Queensland Government.
References 1. Australian Institute for Primary Care. System Reform and Development for Chronic Disease Management. See http:// www.health.gov.au/internet/nhhrc/publishing.nsf/Content/ 038-aipclatrobe/$FILE/038%20Australian%20Institute%20 for%20Primary%20Care,%20La%20Trobe%20University %20Attachment%20B.pdf (last checked 15 August 2013). 2. National Health and Hospital Reform Commission. A Healthier Future for All Australians. See http://www. health.gov.au/internet/nhhrc/publishing.nsf/content/1AFDE AF1FB76A1D8CA257600000B5BE2/$File/Final_Report_ of_the%20nhhrc_June_2009.pdf (last checked 15 August 2013). 3. Productivity Commission. Australia’s Health Workforce. See http://www.pc.gov.au/__data/assets/pdf_file/0003/9480/ healthworkforce.pdf (last checked 15 August 2013). 4. Macinko J, Starfield B, Shi L. Quantifying the health benefits of primary care physician supply in the United States. Int J Health Serv 2007;37:111–126. 5. Norris SL, Engelgau MM, Narayan KM. Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care 2001;24:561–587. 6. Darkins A, Ryan P, Kobb R, et al. Care coordination/home telehealth: the systematic implementation of health informatics, home telehealth and disease management to support the care of veteran patients with chronic conditions. Telemed J E Health 2008;14:1118–1126. 7. Steventon A, Bardsley M, Billings J, et al. Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial. BMJ 2012;344:e3874. 8. World Health Organization. Telemedicine: opportunities and developments in member states. Available from http:// www.who.int/goe/publications/ehealth_series_vol2/en/ (last checked 7 August 2013).
9. Wootton R. Twenty years of telemedicine in chronic disease management – an evidence synthesis. J Telemed Telecare 2012;18:211–220. 10. Mistry H. Systematic review of studies of the cost effectiveness of telemedicine and telecare. Changes in the economic evidence over twenty years. J Telemed Telecare 2012;18:1–6. 11. Barlow J, Singh D, Bayer S, Curry R. A systematic review of the benefits of home telecare for frail and elderly people and those with long-term conditions. J Telemed Telecare 2007;13:172–179. 12. Moffat JJ, Eley DS. Barriers to the uptake of telemedicine in Australia – a view from the providers. Rural Remote Health 2010;11:1581. 13. Tracy J, Rheuban K, Waters RJ, DeVany M, Whitten P. Critical steps to scaling telehealth for national reform. Telemed J E Health 2008;14:990–994. 14. Watson J, Gasser L, Blignault I, Collins R. Taking telehealth to the bush: lessons from North Queensland. J Telemed Telecare 2001;7(Suppl. 2): 20–23. 15. Carlisle K, Warren R, Scuffham P, Cheffins T. Randomised controlled trial of an in-home monitoring intervention to improve health outcomes for type 2 diabetes: study protocol. Stud Health Technol Inform 2012;182:43–51. 16. Broen TH, Huis in’t Veld RM, Vollenbroek-Hutten MM, Hermens HJ, van Halteren AT, Nieuwenhuis LJ. Determinants of successful telemedicine implementation: a literature study. J Telemed Telecare 2007;13:303–309. 17. Wade V, Eliott J. The role of the champion in telehealth service development: a qualitative analysis. J Telemed Telecare 2012;18:490–492. 18. May CR, Finch TL, Cornford J, et al. Integrating telecare for chronic disease management in the community: what needs to be done? BMC Health Serv Res 2011;11:131. 19. Department of Health and Ageing. National E-health Strategy. See http://www.health.gov.au/internet/main/ publishing.nsf/Content/NationalþEhealthþStrategy (last checked 7 August 2013). 20. Department of Broadband, Communications and the Digital Economy. National Digital Economy Strategy. See http://www.nbn.gov.au/files/2011/05/National_Digital_ Economy_Strategy.pdf (last checked 15 August 2013). 21. Royal Australian College of General Practictioners. Guidelines for video consultations in general practice. Available from http://www.racgp.org.au/telehealth (last checked 7 August 2013). 22. Department of Health and Ageing. Specialist video consultations under Medicare See http://www.mbsonline.gov.au/ telehealth (last checked 7 August 2013).
Downloaded from jtt.sagepub.com at Dokuz Eylul Universitesi on November 1, 2014
A qualitative case study of telehealth for in-home monitoring to support the management of type 2 diabetes Karen Carlisle and Robin Warren J Telemed Telecare 2013 19: 372 DOI: 10.1177/1357633X13506512 The online version of this article can be found at: http://jtt.sagepub.com/content/19/7/372
Published by: http://www.sagepublications.com
Additional services and information for Journal of Telemedicine and Telecare can be found at: Email Alerts: http://jtt.sagepub.com/cgi/alerts Subscriptions: http://jtt.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Nov 10, 2013 What is This?
Downloaded from jtt.sagepub.com at Dokuz Eylul Universitesi on November 1, 2014
RESEARCH/Original article
A qualitative case study of telehealth for in-home monitoring to support the management of type 2 diabetes
Journal of Telemedicine and Telecare 19(7) 372–375 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1357633X13506512 jtt.sagepub.com
Karen Carlisle and Robin Warren
Summary The present study formed part of a randomised controlled trial of telehealth for in-home monitoring to support people with poorly controlled type 2 diabetes. We explored the experiences of patients and healthcare practitioners, and their perceptions of the telehealth model of care used in the trial. In addition to their usual diabetes care, participants receive diabetes care from a diabetes educator nurse via an in-home broadband communication device. On average, each patient participated in 14 videoconferences with a diabetes care coordinator during the 12-month trial period. Qualitative data was collected from two general practices and included semi-structured interviews and document review of patient clinical notes. A total of 12 people were interviewed: 8 health practitioners and 4 patients. Patients and health practitioners expressed a high level of satisfaction with the model of care provided. Patients also reported positive health and social outcomes as a result of being involved in the trial and indicated that in the main they had achieved their goals and were happy with their progress over the 12-month period. Analysis of interviews revealed three broad elements associated with the implementation of telehealth: interpersonal factors, operational problems and the wider health system context within which the general practices and trial team were operating. The findings suggest that adopting telehealth in the management of type 2 diabetes can lead to improved diabetes control, but more support is required to ensure sustainability and widespread implementation. Accepted: 18 August 2013
Introduction Research suggests that countries with stronger primary care systems and effective management of chronic disease systemic factors have better health outcomes and lower costs.1–4 A systematic review of interventions directed at diabetes reported that active patient monitoring and encouragement of self-management behaviours improved disease management in the short term.5 However this cannot be achieved solely by conventional methods. Telehealth is potentially useful in chronic disease management because it can assist a person manage their condition at a time and place which is convenient for them. Research from large scale programmes in the US and UK has shown that the use of telehealth combined with care coordination can be effective in helping people to manage their chronic health condition.6,7 The benefits of telehealth include greater access to healthcare services, improved health outcomes and more cost effective service delivery.8 However, the dearth of robust evidence for the value of telehealth remains a barrier.9–11 In addition, the implementation costs, the additional workload and a preference for the conventional approach to care have implications for the uptake of telehealth.12 Research has also identified the lack of
appropriate equipment, poor technology infrastructure and unreliable internet access particularly outside metropolitan areas as affecting the extensive use of telehealth.13,14 The present study formed part of a randomised controlled trial (RCT) of telehealth for in-home monitoring to support people with poorly controlled type 2 diabetes. The aim of the study was to explore the experiences of patients and healthcare practitioners, and their perceptions of the telehealth model of care used in the trial.
Methods The research was conducted in a regional area of Queensland from mid-2012 until early 2013. The research protocol for the RCT has been described elsewhere.15 In summary, the model of service delivery included telehealth monitoring of various diabetes health indicators,
Townsville-Mackay Medicare Local, Townsville, Queensland, Australia Corresponding author: Karen Carlisle, Townsville-Mackay Medicare Local, PO Box 7780, Garbutt BC, QLD 4814, Australia. Email: [email protected]
Downloaded from jtt.sagepub.com at Dokuz Eylul Universitesi on November 1, 2014
Carlisle and Warren
373
home management, education and support for 12 months. The services were primarily delivered by care coordinator nurses. In addition to the collection of quantitative data, qualitative case studies were conducted in two general practices. The aim of the case studies was to explore the in-home monitoring trial in more depth and in its natural context. The general practices selected for case study were located in urban settings and had consented to participate in the trial. Practice A was a small practice with less than 10 general practitioners (GPs) and a few nursing staff, including a chronic disease management nurse. The practice did not provide allied health services on-site. Practice B was a large practice with more than 10 GPs and a team of nurses including a chronic disease management nurse and mental health nurse. The practice provided allied health services across a broad spectrum of healthcare and offered a weekly diabetes clinic. Data collection was primarily through semi structured interviews with health practitioners (including general practitioners, allied health professionals, practice managers and nurses) and a sample of patients in the two case study practices. An opportunity sample of health practitioners with patients involved in the trial within each of the general practices were approached to participate in semi-structured interviews. GP interviewees were a pre-requisite for the selection of patients for interview, i.e. patients selected for interviews normally attended the GPs participating in the case studies. Health practitioners were interviewed towards the end of the 12-month intervention and patients were interviewed three times (within the first 3 months, at 6 months and at the end of 12 months). Interviews were supplemented by a document review of patient notes collected by care coordinator nurses during the trial. Interviews were conducted by the authors and audio-recorded. On average, the interviews lasted for 30–60 min and involved a discussion about the participants’ experiences of the trial which covered in more detail the implementation of the trial, benefits, supports and challenges of the experience and learning gained through their participation in a telehealth trial.
where there was not always adequate time for patients with chronic conditions. Therefore the telehealth model of care complemented the work they were already doing. Patients also reported positive health and social outcomes as a result of being involved in the trial and indicated that in the main they had achieved their goals and were happy with their progress over the 12-month period. All patients who were interviewed referred to learning more about their type 2 diabetes, particularly in terms of education about diet, movement and the importance of regular monitoring of their condition. Whilst the application of the new knowledge about managing their diabetes was at times difficult, patients recounted changes made to their daily routines, for example, reducing portion size, increasing incidental activity and making healthier food choices. A recurring theme from patient interviews was the reassurance they felt knowing that their health was being monitored and followed up by a health professional. After some initial reluctance to engage in regular monitoring of their blood glucose and blood pressure, patients acknowledged that they benefited from having the care coordinator follow up on daily readings. Linked to this was the social interaction facilitated by the telehealth technology. When asked to identify the key positive aspect of the trial all patients cited the importance of the regular videoconferences with the diabetes care coordinator. On average, each patient participated in 14 videoconferences with a diabetes care coordinator during the 12-month trial period. Patients commented that the additional support provided by the care coordinators complemented their regular diabetes care, echoing the perception of health practitioners that the model of care worked in conjunction with services provided by the general practice. Both patients and health practitioners recognised that it could be a useful tool to support patients, such as elderly patients and people experiencing difficulties with transport and travelling to the surgery. Indeed, the overall perspective from interviewees was that their participation in the trial was a positive experience.
Results
Factors for effective implementation of telehealth
A total of 12 people were interviewed: 8 health practitioners and 4 patients.
The in-home monitoring trial was the first experience of telehealth for all the health practitioners and patients interviewed. Analysis of interviews revealed three broad elements associated with the implementation of telehealth: interpersonal factors, operational problems and the wider health system context within which the general practices and trial team were operating. The elements and conditions for effective implementation which were raised during the interviews are summarised in Table 1. The most commonly cited factor associated with effective implementation of the trial was the importance of inter-personal relationships to gain clinical support (‘‘buy-in’’) for the trial. Underpinning much of the early work in the implementation of the trial was the existing positive working relationship between the trial team and
Satisfaction All patients and health care practitioners expressed a high level of satisfaction with the model of care used and viewed telehealth as an effective tool for the management of type 2 diabetes and also more widely for other chronic conditions. There was a broad consensus from health practitioners that their decision to participate in the trial was patient driven, and that their patients benefited from the in-home monitoring and remote support provided by the diabetes care coordinator. Some people interviewed acknowledged that general practices were busy places
Downloaded from jtt.sagepub.com at Dokuz Eylul Universitesi on November 1, 2014
374
Journal of Telemedicine and Telecare 19(7)
Table 1. Elements of effective implementation of telehealth. Elements
Conditions for effective implementation
Interpersonal Positive working relationships Clinical buy-in Motivation and commitment from implementation team and health practitioners Operational Integration of telehealth work into daily practice Reliable and user friendly technology systems and structures Appropriate human capacity and resources dedicated to telehealth operations Health system-wide Adequate remuneration structures System of primary health care that enables telehealth to be used as part of coordinated chronic disease management
healthcare practitioners. Practitioners with prior experience working with the trial team were early supporters and actively promoted the trial within their workplace and to the wider community. It was crucial for the healthcare practitioners with limited experience that positive working relationships with the trial team were fostered, particularly when outcomes were still to be realised. Operational problems were frequently alluded to by health practitioners and patients. Unsurprisingly, both case study practices felt that the additional workload for screening patients and recruitment into the trial could be an additional stress on time and resources. Comments from health professionals suggest that this process could have been more streamlined and integrated into normal practice. A second operational problem was the technology and IT structures used in the trial. The use of home monitoring and videoconferencing was very new to all participants, and as a result, there were difficulties during early installation, in learning to use the equipment and with the availability of the services for the trial. All participants were trained to use the equipment. Reflections on the technical aspects of the trial indicated that it was important that the appropriate equipment, training to use the technology, IT structures and human capacity to manage the technology for the trial were provided. Although the wider context did not feature highly in discussions about the telehealth intervention, it did emerge when interviewees considered the sustainability of telehealth. Health practitioners felt that it was significant that the Australian government recognised the contribution that telehealth could make to the health system. However they suggested that more legislation and structural change was necessary for sustainable services to develop. Some health practitioners felt that the public health service reimbursement for telehealth (Medicare Benefits Schedule, MBS items) facilitated the implementation of telehealth, but did not go far enough. Healthcare staff such as allied health practitioners and nurse practitioners are not reimbursed under MBS items
for telehealth consultations. The exclusion of these health practitioners could create barriers to the provision of coordinated care, which is important for chronic disease management.
Discussion The present paper reports one of the first qualitative studies from Australia to explore the implementation of a telehealth service within a coordinated model of care for chronic disease management. Due to the limited sample size, definitive conclusions are not possible. However the results allow some reflections about telehealth in home monitoring. First, the evidence from our case studies showed that all participants were satisfied with the model of care and were keen to engage in telehealth. Second, in line with previous research, a number of inter-personal and operational factors were identified as key enablers.14,16 Conditions such as positive working relationships and ensuring clinical buy-in were identified as important for sustaining engagement with telehealth, which agrees with findings reported by Wade and Eliott17 who argued that telehealth requires the development of relationships between clinicians. Logistical and practical factors associated with the introduction of telehealth suggest that telehealth systems should adapt and link in to the day to day operations of the practice and not vice versa.18 Furthermore, similar to other studies,12,13 our data indicated that technical problems may reduce the availability and success of services supported by telehealth. Finally, the findings highlight the challenges for policy makers and health practitioners in respect of the potential of telehealth as a mechanism for coordinated chronic disease management. In Australia the National E-health Strategy19 and the National Digital Economy Strategy20 both make reference to the implementation of telehealth to enable a safer, higher quality, more equitable and sustainable health system. However system-wide changes to encourage the use of telehealth such as the publication of standards for
Downloaded from jtt.sagepub.com at Dokuz Eylul Universitesi on November 1, 2014
Carlisle and Warren
375
GPs offering video consultations21 and MBS reimbursement for video consultation22 may not be sufficient to encourage the widespread adoption of telehealth within a model of care for chronic disease management. Acknowledgements We are grateful for financial and other support from the Australian Government under the Digital Regions Initiative National Partnership Agreement and the Queensland Government.
References 1. Australian Institute for Primary Care. System Reform and Development for Chronic Disease Management. See http:// www.health.gov.au/internet/nhhrc/publishing.nsf/Content/ 038-aipclatrobe/$FILE/038%20Australian%20Institute%20 for%20Primary%20Care,%20La%20Trobe%20University %20Attachment%20B.pdf (last checked 15 August 2013). 2. National Health and Hospital Reform Commission. A Healthier Future for All Australians. See http://www. health.gov.au/internet/nhhrc/publishing.nsf/content/1AFDE AF1FB76A1D8CA257600000B5BE2/$File/Final_Report_ of_the%20nhhrc_June_2009.pdf (last checked 15 August 2013). 3. Productivity Commission. Australia’s Health Workforce. See http://www.pc.gov.au/__data/assets/pdf_file/0003/9480/ healthworkforce.pdf (last checked 15 August 2013). 4. Macinko J, Starfield B, Shi L. Quantifying the health benefits of primary care physician supply in the United States. Int J Health Serv 2007;37:111–126. 5. Norris SL, Engelgau MM, Narayan KM. Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care 2001;24:561–587. 6. Darkins A, Ryan P, Kobb R, et al. Care coordination/home telehealth: the systematic implementation of health informatics, home telehealth and disease management to support the care of veteran patients with chronic conditions. Telemed J E Health 2008;14:1118–1126. 7. Steventon A, Bardsley M, Billings J, et al. Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial. BMJ 2012;344:e3874. 8. World Health Organization. Telemedicine: opportunities and developments in member states. Available from http:// www.who.int/goe/publications/ehealth_series_vol2/en/ (last checked 7 August 2013).
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