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A qualitative study of the key factors in implementing telemedical monitoring of diabetic foot ulcer patients B.S.B. Rasmussen a,b,∗ , L.K. Jensen b , J. Froekjaer c , K. Kidholm b , F. Kensing d , K.B. Yderstraede a a

Department of Medical Endocrinology, Odense University Hospital, Denmark Center for Innovative Medical Technology, Odense University Hospital, Denmark c Department of Orthopaedic surgery, Odense University Hospital, Denmark d Center for IT Innovation, University of Copenhagen, Denmark b

a r t i c l e

i n f o

Article history: Received 11 September 2014 Received in revised form 22 May 2015 Accepted 23 May 2015 Available online xxx Keywords: Telemedicine Qualitative analysis Organization Diabetes care Diabetes Wound MAST Evaluation

a b s t r a c t Introduction: The implementation of telemedicine often introduces major organizational changes in the affected healthcare sector. The objective of this study was to examine the organizational changes through the perception of the healthcare professionals regarding the implementation of a telemedical intervention. We posed the following research question: What are the key organizational factors in the implementation of telemedicine in wound care? Methods: In connection with a randomized controlled trial of telemedical intervention for patients with diabetic foot ulcers in the region of Southern Denmark, we conducted an organizational analysis. The trial was designed as a multidisciplinary assessment of outcomes using the Model of ASsessment of Telemedicine (MAST). We conducted eight semi-structured interviews including individual interviews with leaders, and an IT specialist as well as focus group interviews with the clinical staff. A qualitative data analysis of the interviews was performed in order to analyze the healthcare professionals and leaders perception of the organizational changes caused by the implementation of the intervention. Results: The telemedical setup enhanced confidence among collaborators and improved the wound care skills of the visiting nurses from the municipality. The effect was related to the direct communication between visiting nurses and specialist doctors. Focus on the training of the visiting nurses was highlighted as a key factor in the success to securing implementation. Concerns regarding lack of multidisciplinary wound care teams, patient responsibility and lack of patient interaction with the physician were raised. Furthermore, the need for clinical guidelines in future implementation was underlined. Conclusions: Several influential factors were demonstrated in the analysis including visiting nurses wound care training, focus on management, economy, periods with absence from work and clinical care. However, the technology used here could provide an additional option to offer patients after an individual assessment of their health condition. © 2015 Elsevier Ireland Ltd. All rights reserved.

1. Introduction Telemedicine is put forward as a potential solution to future challenges in the healthcare sector caused by demographic changes [1]. Telemedicine can be used in the delivery of healthcare services through the use of information and communication technologies, in situations where the participants are at different locations [2]. The term telemedicine applies to the overall intervention or service and not just to the telemedical device used as part of the service.

∗ Corresponding author at: Department of Medical Endocrinology, Odense University Hospital Denmark, Sdr. Boulevard 29, 5000 Odense C, Denmark. Tel.: +45 66 11 33 33. E-mail address: [email protected] (B.S.B. Rasmussen).

The implementation of telemedicine often introduces organizational changes in the healthcare sector. Changes that can be overlooked due to lack of knowledge in the planning of a project. However, these modifications in the clinical handling may have severe impact on the effectiveness and outcome measurements [3]. The application of telemedicine is widespread and has been used in rural areas and geographical areas with large distances not sufficiently covered by healthcare. Numerous examples in the use of telemedicine include digital imaging of acute wounds (e.g., burn wounds) to aid in the visitation process and initial treatment [4,5]. Often, the cost-effectiveness of these applications are less well demonstrated and questions relating to qualitative analysis of the level of satisfaction among healthcare professionals, patients and relatives are unresolved.

http://dx.doi.org/10.1016/j.ijmedinf.2015.05.012 1386-5056/© 2015 Elsevier Ireland Ltd. All rights reserved.

Please cite this article in press as: B.S.B. Rasmussen, et al., A qualitative study of the key factors in implementing telemedical monitoring of diabetic foot ulcer patients, Int. J. Med. Inform. (2015), http://dx.doi.org/10.1016/j.ijmedinf.2015.05.012

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Major areas of telemedical applications also include dermatology (i.e., teledermatology) in which it has been applied for several years and found acceptable as a diagnostic and monitoring tool [6]. Research in the field of telemedicine has grown extensively over the last decade and the majority of the literature on wound care is focusing on image technology and its feasibility. The current literature is very heterogenic in areas including wound etiology, scientific approach, level of evidence and areas of concern. Several researchers recommend further studies, especially well-planned randomized controlled trials [7,8]. Terry et al. suggest that the effect of telemedicine varies with different types of wounds, and the study outcome thus depends on the etiology (i.e., diabetic, pressure or surgical wounds) [8]. Most of the studies are focusing only on the feasibility of the technology and not other aspects of telemedicine in the care of patients. Healthcare organizations are complex systems and often consist of more than one contributor (e.g., several municipalities and variable hospital setups). Introduction of telemedicine will affect the workflow, but often also the distribution of tasks and responsibilities between healthcare professionals [9]. Few published studies have analyzed organizational aspects of introducing telemedical wound care [10,11]. In this study, the aspects of introducing telemedicine to patients with diabetic foot ulcers were investigated as part of a randomized controlled trial (clinicaltrials.govid: NCT01608425). Patients included in the trial were randomized to either usual care in specialized hospital-based units or to receive two of three consultations in their own homes, based on store and forward telemedicine [12]. In both cases the actual treatment was the same whereas the workflow differed. A recent publication by the European Wound Management Association has recommended using the Model for ASsessment of Telemedicine (MAST) when evaluating telemedicine in wound care [13]. This approach was undertaken in this paper. To our knowledge this is the first qualitative organizational investigation of large-scale telemedicine implementation in patients treated for diabetic foot ulcers. The objective was to examine the organizational changes through the perception of the healthcare professionals, regarding the implementation of the telemedical intervention. Our research question was as followed: What are the key organizational factors in the implementation of telemedicine in wound care? 2. Materials and methods 2.1. Study setting The study was carried out in the Region of Southern Denmark (RSD) between October 2010 and November 2014, an area comprising approximately 1.2 million residents. The project included all 22 municipalities and the five general hospitals in the region. Standard monitoring of patients with diabetic foot ulcers included a series of consultations in cross-disciplinary hospital-based outpatient clinics. The study was carried out as a pragmatic randomized controlled trial (reported elsewhere). The pragmatic approach is designed to test interventions in a real life setting allowing applicability and generalizability. It allows some flexibility and individually tailoring of the treatment in intervention as well as control group (standard care) [14]. 2.2. Intervention The telemedical intervention was designed as a randomized controlled trial. Patients were randomly assigned to either intervention (i.e., telemedical monitoring) or control in outpatient clinics (standard care). Participants were surgically and medically

stratified according to standard clinical guidelines [15] prior to randomization. All staff members at the hospital and in the municipality involved in the study were trained in wound care, ensuring that no difference was made in the care of the patients between the intervention and the standard monitoring. All healthcare professionals (i.e., hospital and municipality staff) involved received basic training in use of the telemedical system. The training consisted of a one-day hands-on training session providing skills in addressing the online database and the smartphone. A group of professionals who were intended to function as Powerusers received training at a more advanced level. The training sessions also presented an opportunity for the visiting nurses and hospital staff to meet and get to know each other prior to cooperating in the project. Telemedical monitoring was used as a supplementary tool in the monitoring of diabetic foot ulcers. An online-database (www. pleje.net – Dansk Telemedicin Inc., Copenhagen, Denmark) and smartphones constituted the technological platform supporting exchange of healthcare data and clinical images. The system has been used clinically for several years in other parts of Denmark. Prior studies proved the setup feasible, but has not been evaluated as thoroughly as presented here [16]. Fig. 1 displays the intervention (telemedical) and the standard workflow. Left: the telemedical visit schedule for patients in the intervention group. Right: the outpatient visit schedule for patients in the standard care group. The daily care, if needed, was provided by nurses under supervision of a nurse specialized in ulcer care in both groups. No frequency of telemedicine consultations and/or clinic visits was predefined by the protocol but was driven by a clinical judgment at every consultation, be it telemedical or control.

2.2.1. intervention workflow The per protocol telemedical monitoring consisted of two consultations in the patient’s own home using telemedicine, and one consultation at the outpatient clinic. The three-visit cycle was repeated until endpoint. Patients monitored with telemedicine were monitored according to the algorithm displayed in Fig. 1 (left side). The telemedical consultations were conducted by telephone or online written consultations as contact between the specialized municipal nurse and doctors at the outpatient clinic. These consultations were supplemented by an uploaded image of the ulcer and a detailed written assessment via the online database. If needed, the treatment strategy was revised. The next consultation (i.e., telemedical or standard) and the indication for further images were agreed upon by the nurse and physician in common. If the treatment or the patient’s health condition needed closer supervision by a hospital specialist (i.e., doctor, podiatrist or specialist nurse), deviation from the workflow algorithm was allowed. In the municipality, the visiting nurses conducted two of every three consultations telemedically. The telemedical workflow included examination of the diabetic foot ulcers, provided clinical images with smartphones and uploaded the images, as well as any other relevant patient information, to the online database. Subsequently, the hospital staff was consulted, mostly by means of telephone consultations, and in some cases by means of written communication via the online database. The consultations were held asynchronously in the sense that the nurse would call the specialists while being away from the patient. After the consultation, the visiting nurse conveyed the results to the patient, either by means of a phone call or returning to the patients home the same day or the day after. In case of complications discovered in the consultation however, the patient was referred to the outpatient clinic on an acute basis.

Please cite this article in press as: B.S.B. Rasmussen, et al., A qualitative study of the key factors in implementing telemedical monitoring of diabetic foot ulcer patients, Int. J. Med. Inform. (2015), http://dx.doi.org/10.1016/j.ijmedinf.2015.05.012

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Fig. 1. Generic workflow in the hospital with telemedicine and standard workflow. Left: displaying the Intervention consisting of two consultations in the patient’s own home using telemedicine, and one consultation at the outpatient clinic. Right: displaying the standard workflow, in which patient visited the outpatient clinic every time.

2.2.2. Standard workflow All visits and consultations took place in the outpatient clinics and followed the standard practice and treatment. Hospital staff in the outpatient clinic conducted consultations with the patient present. They prescribed wound care with appropriate products and a new appointment was scheduled at the outpatient clinic. The municipally was advised as to the treatment plan after each outpatient visit via a local text based notification system. At the municipality a notification of the treatment plan was received after each outpatient visit. Visiting nurses treated the patients as advised by the hospital specialists. In acute cases of complications the outpatient clinic was contacted, but otherwise there was no contact between the hospital and the municipality. When other issues occurred the general practitioner was contacted. 2.3. Evaluation method MAST (Model for ASsessment of Telemedicine) was used as a framework for the assessment of outcomes of the telemedicine intervention in this study. MAST includes a multidisciplinary assessment within seven domains [17]. • Health problem and characteristics of the application

• • • • • •

Safety Clinical effectiveness Patient perspectives Economical aspects Organizational aspects Socio-cultural, ethical and legal aspects

The result within the organizational domain is the focus of this paper. Clinical, safety, patient perspective and economics will be presented elsewhere. 2.4. Interviews To answer the research question, we conducted a qualitative survey consisting of focus group and individual interviews with clinical staff as well as individual interviews of key persons in the trial. The individual interviews were chosen to reveal knowledge from key project individuals, local clinical leaders and administrative leaders. These interviews were expected to yield unique knowledge and provide topics for the focus groups. The focus group interviews were chosen because they were expected to yield more information than individual interviews due to group dynamics

Please cite this article in press as: B.S.B. Rasmussen, et al., A qualitative study of the key factors in implementing telemedical monitoring of diabetic foot ulcer patients, Int. J. Med. Inform. (2015), http://dx.doi.org/10.1016/j.ijmedinf.2015.05.012

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among participants [18]. The interviews were semi-structured. The semi-structured approach with the interviewer as the facilitator was chosen for focused, conversational, two-way communication. The method allows the respondents to provide not just answers, but the reasons for the answers and works as a forum for discussing sensitive issues. The individual interview questions were based on the common protocol (online Supplementary material) in the Renewing Health project [19], of which this telemedicine intervention is a part. The focus group interview questions were also based on the protocol, the individual interviews and topics that were identified as important in the implementation process during meetings with the staff and leaders involved from hospitals and municipalities. All interviews were conducted and transcribed in Danish, and an experienced professional translated selected quotes into English. An interview guide was constructed for each participant group and individual respondent. The guides provided topics and a number of questions aligned to each subject. The interviewer secured that every subject was covered, although not necessarily in the stated order. For practical reasons, and in order to avoid problems related to asymmetry in the relation between interviewer and respondents, the locations of the group interviews were in a neutral surrounding, suggested by the participants. The individual interviews were located according to the respondents’ own choice. The interviewer explained the themes, storage and analyses of data and the right to anonymity, and to decline answering. The interviewer would ask open questions, cover every aspect of the guide, and ask for elaboration when necessary. Each participant was allowed time to state his or her opinion. An observer took notes and commented if necessary. Toward the end of the interview, the interviewer would ask whether there was anything further the respondents would like to cover. In order to adjust the style of the interview, immediately after the interview, the interviewer and the observer took notes on the experience (i.e., the impression and assessment of the respondent and the role of the interviewer, what was good or/and bad about the interview, what was included and was anything left out). The average length of the interviews was 60 min. 2.4.1. Respondents Participants in the individual interviews were chosen strictly on the basis of their key function and knowledge of the process in the implementation of telemedicine. Respondents for the focus group interviews were selected from a list of healthcare staff participating in the project. Formal invitations were sent to participants at every site in order to secure an even geographical distribution of project participants. Six visiting nurses from six different municipalities, two medical doctors and four nurses from six different outpatient clinics volunteered to take part. This corresponds to approximately 70% of the invited respondents. All participants were trained individuals with many years of wound experience. Training in the system was an iterative process (e.g., optimizing digital photos for the web-database, several meetings with the involved partners throughout the period and a training part of the database where individual ulcer patients could be uploaded to gain knowledge in handling the system).

2. Structure including “spread of technology, centralization or decentralization”, “economy”. 3. Culture, including attitude and culture. 4. Management. The approach was aiming to identify how the telemedical wound monitoring was experienced by healthcare professionals. Data were analyzed by a phenomenological and inductive approach in order to describe the meaning of several individuals experience and included the following steps [20,21]. 1. Common themes mentioned in the interview were identified. 2. Parts/units of the interviews, which were supportive of the identified themes, were organized (coded), and the final themes and sub-groups were developed. 3. The group of codes was condensed by summarizing the content of all the units, supportive of the meaning for the individual group of codes. 4. An index describing the contents of each group of codes was developed, and the group of codes, including interview quotes, was assigned one of the four headings as described in the MASTmanual. The findings were discussed within the research group and within a group of qualitative researchers outside the field of telemedicine to assist in data synthesis and interpretation. 2.5.1. Data and storage The interviews were recorded on two smartphones in order to preserve the exact expressions. The interviews were fully transcribed for the analysis. 2.5.2. Software To analyze and structure data, Nvivo Version 10.0.1 (916) was used. 2.6. Ethical considerations The study was performed according to the declaration of Helsinki II. Approval from the regional ethic committees in Denmark was not required for this kind of study (committee consulted). Approved by the Danish Data Protection Agency (case number: 2008-58-0035). Clinicaltrials.gov identifier NCT01608425 2.7. Funding Regional implementation of telemedicine in wound management is under the auspices of three funds: (1) ABT Fund (Applied Citizen Technology) Ministry of Finance, Denmark. (2) ‘ABT funds’ from the Region of Southern Denmark. (3) EU project RENEWING HEALTH.

2.5. Data analysis

3. Results

The MAST framework recommends the following topics to be included in the organizational aspect [17]:

The analysis first describes the situation of each paragraph, if any. For each category, we present the factors that achieved a strong consensus among our respondents either positive or negative. For each of the factors identified, we present interview quotes that clearly illustrate the kind of comments made by our respondents.

1. Process which included “workflow”, “staff, training and resources” and “interaction and communication”.

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3.1. Process New work routines were introduced by the telemedical workflow and these led to task shifting. The head nurse was concerned whether the specialists were loosing hands on experience when mostly treating patients via telemedicine thus gaining less experience in treatment. Likewise, a physician said that in the telemedical setup often only one of the physicians made the decisions for the patient, which is in opposition to the evidence toward better treatment via multidisciplinary treatment teams (i.e., physicians specialized in endocrinology, plastic/orthopedic/vascular surgery or nurses and podiatrists) [22]. “If you, as a clinician, are to be an expert in something, you need to see a lot (of it) and get some practical experience. I am a little bit concerned about how we can maintain the expertise. It is the constant flow of patients that provides us with experience in relation to our treatment. This is something we share with each other and it becomes a little bit more difficult to share with each other when it’s all done via telemedicine somewhere else. It might be difficult, and it can be a bit worrying whether we can maintain our expertise in the same way” (head nurse, outpatient clinic). “We need to ensure the same quality of care and offer the multidisciplinary approach toward which the evidence is pointing” (Physician, outpatient clinic). The respondents also found that the podiatrists possess a key role in the treatment and were concerned that this type of care could not be handled using telemedicine. “It is difficult to use telemedicine because podiatrists have to customize shoes etc. {. . .} we cannot offer the same level of treatment via telemedicine as we can in the outpatient clinic – it’s hard” (nurse, outpatient clinic). There was a general consensus by the visiting nurses that they had achieved a higher level of experience, knowledge and skills in treating diabetic ulcers. They felt that the direct feedback from a specialist was valuable. “I can say that while we have been running this project I have become a better wound nurse” (Visiting nurse, municipality). Unlike previously, the visiting nurses communicate with the outpatient clinic on wound care and they felt that the new communication form was clinically qualifying. “We communicate with skilled people and to me that is the very best thing about it, and that it is typically the same physician we correspond with” (visiting nurse, municipality). The hospital staff agreed that the level of quality in care had improved during the trial. “They think it’s great to be contacted by the physician treating the patient and thus get the experience via communication with the physician directly. They really felt recognized and experienced as collaborators” (Physician, outpatient clinic). All respondents agreed that in case of acute worsening of a wound condition, the telemedical application should not be used. Instead, the visiting nurses would call the outpatient clinic for an acute appointment. No images or other information were uploaded to the online-database in such cases, since the experts would typically see the patient on the same day. This is the standard procedure, similar for both telemedicine and usual care patients. “If we have something urgent we call the specialist and then you are sure to get in contact” (visiting nurse, municipality).

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Some of the respondents in the municipality ask for clinical guidelines concerning telemedicine treatment. “We must be sure that there are some guidelines and some requirements that we all meet, and not only in the hospital” (leader, municipality). The topic of responsibility for the patient was mentioned and the responsibility for the clinical care when workflow is changed likewise “What about the patients who need monitoring after healing, who is the responsible part? – This needs to be standardized so that we do not let the patients suffer” (visiting nurse, municipality). The hospital-based clinicians and the leaders from the municipalities emphasized that the wound care training of the visiting nurses is essential in the clinical care based on telemedicine. The knowledge, and thereby the ability to communicate correctly, is crucial to the telemedical setup. Thus, it is important that the municipality’s focus on the number of qualified nurses needed. “I think it is important to focus on the municipality part. Do the visiting nurses have the skills and the time that it takes – wound care training is the key” (head physician, outpatient clinic). “The visiting nurses need to have some wound care training in order to be updated {. . .} I think it has clearly given the visiting nurses in the municipalities a boost” (head physician, outpatient clinic). “We (our municipality) already have a strong focus on wound care training, but if you have a municipality without specialized nurses {. . .} progress will be completely different in those municipalities and I think that it will make a difference” (leader, municipality). The general experience was that e-Health training is an important matter; it was beneficial not only on the technical site, but also enhanced communication between collaborators. “Yes I certainly needed to learn how to use the new equipment. We were offered training in collaboration with our municipalities; we spent some days together where we just talked about workflows and agreed how to communicate with one another. Technically, also how the images are uploaded, and how do we provide optimal photos. It was certainly new to me” (nurse, outpatient clinic). “It worked well with the preparation, it was fine we got to see each other – our new partners, and there was a whole day reserved for learning from a technical expert” (visiting nurse, municipality). The technology did not lead to any noteworthy difficulties. However, some practical education was needed in order to provide images of a sufficient clinical quality, and not all types of smartphones worked equally well for this purpose. The visiting nurses stated that most of the difficulties were due to image quality and poor light conditions in the patient’s home. Respondents in the hospital and the municipality complained about having an additional IT system i.e., the on-line database. The new technology induced double registration when using the local electronic patient record and the new online-database. The general experience in the telemedical setup was that the system was challenged when facing holidays or sick leaves. Often, the municipalities had only one or two visiting nurses educated to handle the telemedical consultations with the hospital specialist, which made holidays or sick leaves problematic.

Please cite this article in press as: B.S.B. Rasmussen, et al., A qualitative study of the key factors in implementing telemedical monitoring of diabetic foot ulcer patients, Int. J. Med. Inform. (2015), http://dx.doi.org/10.1016/j.ijmedinf.2015.05.012

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“When the specialized visiting nurses are on vacation another randomly chosen nurse – who does not know anything about wound care – attends the patient and sometimes we have to see the patient in the outpatient clinic more than intended” (physician, outpatient clinic). In neither of the focus groups did respondents feel that time in general was saved as a result of the telemedical intervention. The visiting nurses spent a lot of time updating the online database. They also felt that the third consultation comprising the visit to the patients home, the consultation with the hospital based specialists and finally a second contact with the patient, was rather time consuming. In the hospital group none of the staff members felt that less time was spent on consultations or that fewer consultations took place.

3.2. Structure The telemedical setup forced a new workflow and a new communication platform to be established. The decentralization of knowledge from the outpatient clinics to the visiting nurses was acknowledged and described in Section (3.1). Local challenges in introducing telemedicine in the area of wound care were discussed “There’s no doubt that local conditions have an influence on how the operation of such a project is going to be” (physician, outpatient clinic). “In the hospitals which have centralized wound healing centers treatment it is easy to use telemedicine, but if the wound treatment is in four different departments it is difficult – it should not be a problem. It’s just important to have some local arrangement” (regional leader).

“Of course, there is an increased burden from each visit, when we need to work with telemedicine and especially when we have to work with a research project, because it needs an increased data collection, and there will be some double entries when running projects on patients” (visiting nurse, municipality).

Although it is possible to manage with different departments involved, the general wish was to have centralized wound healing centers to support not only telemedical monitoring but to enforce the treatment of the patients.

The new communication form enhanced confidence between collaborators. The head nurse stated that:

“We would like to have a multidisciplinary hospital based wound healing center”. (head physician, outpatient clinic)

“The more we (healthcare professionals) know about each other, the more dialogue we have and the more we work together, it is a process, and we cannot have great confidence in each other in the beginning without knowing each other” (head nurse, outpatient clinic).

The leader from the municipality said that a municipality centralization of wound treatment could be a possible solution in the future with patients visiting the municipality wound healing center instead of nurses visiting the patients as a part of the telemedical setup. The leaders pointed out economy as one of the major barriers in implementing telemedical wound treatment. When evaluating a project that alters the daily workflow or shifts tasks between organizations (e.g., from a hospital to a municipality), it is important to know where and how the economy is effected before taking the risk of implementing.

The visiting nurses all agreed that the direct communication facilitated the way of working and eliminated time-consuming phone calls via switchboards. Furthermore, all municipality respondents found that the direct contact enriched collaboration and confidence between healthcare staff across the municipality and hospital. “I have become better acquainted with the staff in the outpatient clinic and they also know me, so if I call with something that one of my colleagues might not have been able to get through with, I’ll call out and say it’s Mary then something happens- it’s just easier” (visiting nurse, municipality). At the hospital level respondents stated that “I think that we have got to know them better as they should know us better. It is easier for them to pick up the phone, call in and ask for something, and easier to meet them and talk about things, because we know each other, but there are just not enough specialized visiting nurses” (nurse, outpatient clinic). Some of the respondents agreed that they already cooperated very well before the project, giving second opinions and substituting for each other when needed. One respondent, a physician, stated that although he found the whole project very interesting, he saw the face-to-face meeting with his patients as an important part of his job, and he had difficulties imagining himself switching to solely computer-based consultations in the future. “You will never find a surgeon who is willing to spend his entire day looking at a computer screen” (physician, outpatient clinic).

“The economy and finance factor in relation to the task shifting is important. Where are the economical benefits?” (chief medical officer). “We’ve got to know where the gains/profits are and who benefits financially and who carries the expenses, all that needs to be in the DRG reimbursement scheme” (leader, municipality).

3.3. Culture When asked whether they could imagine the current telemedical setup being the standard solution in the future, the respondents seemed to agree that the setup should be an extra option rather than the only solution. Everyone agreed that the choice should be based on an individual assessment of each patient. “I also see it as an extra option like other respondents, they have to be evaluated by a physician and be treated and then if you can use telemedicine it should be provided. Telemedicine is not a new treatment form; it’s a new way of communicating” (physician, outpatient clinic).

“Some patients have some concerns over the lack of direct communication with a physician”. (visiting nurse, municipality)

Some patients benefit from not having to travel to the hospital, whereas others feel that they are missing out on an important part of their treatment. The interaction between the physician and the patient was changed by the telemedical setup. Some of the patients missed the interaction with the physician.

None of the respondents thought that communication within the organizations (e.g. between municipalities or between different hospitals) had been influenced by telemedicine.

“I think there are many patients who are really excited about it because they avoid the time spend on transport” (nurse, outpatient clinic).

It corresponds to some statements from the visiting nurses.

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“In fact many have complained that they do not get to talk to a physician every time and they think that they lack a bit of the medical consultation” (visiting nurse, municipality). Some nurses felt that the asynchronous telemedical consultations changed the patients role, leaving them less responsible and empowered in handling their own disease, as the conversations about their treatment took place between the visiting nurse and the hospital staff without the patient’s direct involvement. “They’re loosing ownership to their own treatment in their everyday lives” (nurse, outpatient clinic). “I think it makes a big difference if you are with the patient and the patient is participating in the communication, then the patients have some sense of self-care responsibility, so I definitely think that it will make a big difference, but the local situation just does not allow using telemedicine synchronously at this time” (visiting nurse, municipality). The respondents who have tried the synchronous consultations consider going back to this solution once the project period is over, since they see this as a better service for the patients.

3.4. Management The leaders stated that common ground was important when testing the new telemedical organization, and the key to success was to ensure that everybody had a sense of ownership in every aspect from the clinical participant to the administrative leaders. One of the key factors in the success of the telemedical setup was the willingness to cooperate between all the hospitals and the 22 municipalities. “When we are all together, then we all have the opportunity to give inputs and opinions, and then you have a much higher degree of ownership. {. . .} I think it facilitated collaboration that we were all together from the start” (regional leader). However, the chief medical officer stated that it had been difficult with the line of command in the project not in the hospitals but with all the municipalities. “What is really going on in each of the municipalities has been virtually impossible for me to figure out {. . .} at the senior management level communication between the municipalities and the region is too loose” (chief medical officer). Management is important to keep every level informed at all time. “It’s hard to keep the whole leadership system constantly informed of how it goes. We may not be so good at it. I think information keeps the fire going for all those who are participating” (chief medical officer). In most cases respondents felt that there had been support from every level of leadership in the region, municipality and hospital. Although some visiting nurses stated that it felt like the municipality leaders had not planned for the project to be part of the daily work routines “We may be experiencing that the municipality had accepted a project but probably not considered it as part of the daily work flow” (visiting nurse, municipality). “I think, especially from our hospital area, that there has been huge support from the management of the project. It has been one of the things that has helped promote the project” (ITspecialist).

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4. Discussion The aim of this qualitative study was to examine the organizational changes caused by the implementation of a telemedical intervention seen from the perspective of the healthcare professionals and key participants. The participants’ perspectives and experiences were identified for the four main themes: process, structure, culture and management. The participants’ perspectives on telemedical wound monitoring were subdivided into themes. The new workflow translated into new working routines and thus task-shifting in an outpatient clinic and the municipality. The most significant change was the new kind of communication between the visiting nurses and the outpatient clinical staff. This lead to direct communication between wound specialists (i.e., physicians) and visiting nurses as opposed to communication between general practitioners and visiting nurses. The visiting nurses felt that the new form of communication was an educationally and professionally invigorating process. This perception is in line with other studies Ameen et al. found significant improvement in areas of dressings, management and claim, along with Quinn et al., that this translates into a potential beneficial patient related outcome [23–25]. The outpatient clinic endorsed the invigorating process among the visiting nurses, but some concerns were raised as to whether the telemedical approach could reduce the hands-on skills and the multidisciplinary approach in the specialized wound healing centers. No other studies have raised concerns about this, but we find that they are important issues to address when implementing telemedicine. The new workflow created changes in interaction along with the changes in communication. The interaction between visiting nurses and the outpatient clinical staff enhanced confidence and facilitated a direct way of communication. The interaction between the physician and the patient was changed by the telemedical setup from direct interaction at each consultation to direct interaction in only one out of three consultations according to the protocol tested in this setup. The visiting nurses noted that some of the patients requested the interaction with the physician, similar to findings of other studies [26]. An important issue regarding patient empowerment was brought to attention. When using asynchronous telemedical consultations, the visiting nurses felt that the patients lacked the interaction with the physician and thus were less empowered. Synchronous telemedical consultations seem to allow patients to actively participate, due to the direct interaction with the physician from the outpatient clinic. The asynchronous telemedical consultation allows the patients to benefit from any progress via the patients online health record and this could give a significant psychological boost [27,28]. The visiting nurses in this setup were trained in wound care but the level of competence among the visiting nurses differed. Wound care training was stressed as one of the most important individual factors in telemedical wound handling. The specialist at the outpatient clinic needs to communicate with a visiting nurse having a basic knowledge of wound care, ensuring the correct information and wound care. The telemedical setup (i.e., the online database and mobile phones) did not constitute major difficulties. However, the challenging part was the clinical images, which demanded some practice in relation to the light source. Furthermore, not all smartphones performed equally well in providing high quality photos. The quality issue was addressed by recommending specific smartphones when updating to a new model. All participants were offered training in the use of telemedical equipment. This did not only lead to confidence in use but, due to the mixture of participants including municipalities and the outpatient clinics, it enhanced collaboration and confidence across sectors. In the literature, it is

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describes that anxiety toward implementing and using new technologies is a matter of concern. Litzinger et al. also suggest proper training in the handling of new technologies [12,29]. Barrett et al. concluded that a shortage of staff was one of the key factors in failing the implementation of the telemedical setup [11]. The participants in this study experienced a similar challenge during holidays or sick leaves. The number of visiting nurses trained in wound care and telemedicine in each municipality was limited, and thus in case of these situations no other visiting nurse could conduct the telemedical consultation. None of the respondents felt that time was saved by using telemedicine, which is similar to findings from other studies [30]. The visiting nurses experienced spending a lot of time doing the paperwork and communication with patients and hospital specialists. At the hospital level, the staff did not find that the number of consultations decreased, although they handled teleconsultations with the visiting nurses, in principle replacing two in every three consultations. Part of the extra time spent may be due to the patients being part of a research project. Data concerning time used and the number of in-hospital stays and outpatient consultations have been collected and will be reported elsewhere as a part of MAST domain five. The amount of paperwork required may be reduced if the project activities are implemented as a supplementary tool monitoring diabetic foot ulcer patients. However, there is not enough solid evidence to support this. The telemedical setup was challenged due to different structures within the wound healing clinics. Some clinics were multidisciplinary (i.e., with all the relevant medical specialties available) and others only dedicated wound care clinics with multidisciplinary approaches. Others again only had one surgical specialty. Current evidence suggests that multidisciplinary hospital units constitute an optimal way of improving clinical outcome as also noted in this study [22]. The respondents from the outpatient clinics felt that they had solid support at the management level regarding the implementation although, at the municipality, not every aspect was addressed and considered in daily practice. The CMO mentioned that is was almost impossible to figure out the management structure of the 22 different municipalities leading to a weakening of the line of command in the project. This emphasizes the difficulties in managing a large project with this high number of participants from different organizations. The literature describes the champions’ role in leadership and emphasizes the importance of supportive leader ownership [10]. The study included a sample size of 17 health professionals selected from the hospitals and municipalities participating in the randomized controlled trial. The empirical data and the methodological approach aimed at analyzing the perspective of the participants in an explorative way. Our research approach could have benefited from a supplementary qualitatively approach to validate our results. Likewise, the pragmatic randomized controlled design could have influenced our respondents’ opinions and experience of the telemedical setup due to small diversities in the intervention and workflow in the municipality and outpatient clinics. We considered the sample size large enough to explore our research question. The findings should be evaluated in relation to sample size, and cannot directly be applied to other contexts. The selection of participants was based on email invitation to selected clinicians and other key players in the project. The participating respondents could have chosen to do so because they were in favor of the telemedical setup and thus less critical to the telemedical approach. We chose to mix nurses and physicians in the outpatient focus group, which may have affected the overall attitude due to social relations between the two groups.

Summary points What was already known? • Decentralization of knowledge from specialist to municipality nurse works. • Overall good acceptance of telemedicine. • Training in technology reduces anxiety among healthcare professionals. What this study adds? • It is crucial to the telemedical setup that the municipality nurses are educated as wound specialist. • It is mandatory to assure that telemedicine can deliver the best quality of care using specialists in a multidisciplinary approach. • Visiting nurses are empowered by telemedicine. • Telemedicine canintroduce a broader team-based care.

5. Conclusion The organizational changes caused by introducing telemedicine in wound care were analyzed through the perception of the healthcare staff. Several key factors related to our research question were envisaged including visiting nurses wound care training, focus on management, economy, absence of work periods and clinical care. The technology used here could provide an additional option to be offered to relevant patients after an individual assessment of their health conditions. Contributions Conceived and designed the experiments: B.S.B.R, K.B.Y., J.F., F.K., K.K. Performed the experiments: B.S.B.R., L.K.J. Analyzed the data: B.S.B.R., L.K.J. Contributed reagents/materials/analysis tools: F.K., K.K., L.K.J wrote the paper: B.S.B.R., L.K.J. Manuscript Review: B.S.B.R, K.B.Y, J.F., F.K., K.K., L.K.J. immediate Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.ijmedinf.2015. 05.012 References [1] P.J. Heinzelmann, N.E. Lugn, J.C. Kvedar, Telemedicine in the future, J. Telemed. Telecare 11 (8) (2005) 384–390. [2] Editorial telemedicine: fad or future?, Lancet, 345 (8942), (1995), 73–74. [3] I.H. Aas, The future of telemedicine-take the organizational challenge, J. Telemed. Telecare 13 (8) (2007) 379–381. [4] E. Turk, E. Karagulle, C. Aydogan, H. Oguz, A. Tarim, H. Karakayali, et al., Use of telemedicine and telephone consultation in decision-making and follow-up of burn patients: initial experience from two burn units, Burns: J. Int. Soc. Burn Injuries 37 (3) (2011) 415–419. [5] D.L. Wallace, A. Hussain, N. Khan, Y.T. Wilson, A systematic review of the evidence for telemedicine in burn care: with a uk perspective, Burns: J. Int. Soc. Burn Injuries 38 (4) (2012) 465–480. [6] E. Warshaw, N. Greer, Y. Hillman, E. Hagel, R. MacDonald, I. Rutks, et al., Teledermatology for diagnosis and management of skin conditions: a systematic review of the evidence. VA Evidence-based Synthesis Program Reports. Washington, DC, 2010. [7] C. Chanussot-Deprez, J. Contreras-Ruiz, Telemedicine in wound care: a review, Adv. Skin Wound Care 26 (2) (2013) 78–82. [8] M. Terry, L.S. Halstead, P. O’Hare, C. Gaskill, P.S. Ho, J. Obecny, et al., Feasibility study of home care wound management using telemedicine, Adv. Skin Wound Care 22 (8) (2009) 358–364 http://onlinelibrary.wiley.com/o/ cochrane/clcentral/articles/410/CN-00759410/frame.html [9] I.H. Aas, A qualitative study of the organizational consequences of telemedicine, J. Telemed. Telecare 7 (1) (2001) 18–26.

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G Model IJB-3201; No. of Pages 9

ARTICLE IN PRESS B.S.B. Rasmussen et al. / International Journal of Medical Informatics xxx (2015) xxx–xxx

[10] I. Ellis, The clinical champion role in the development of a successful telehealth wound care project for remote australia, J. Telemed. Telecare 11 (Suppl. 2) (2005) S26–28. [11] M. Barrett, A. Larson, K. Carville, I. Ellis, Challenges faced in implementation of a telehealth enabled chronic wound care system, Rural Remote Health 9 (3) (2009) 1154. [12] R.K. Chittoria, Telemedicine for wound management, Indian J. Plastic Surg.: Off. Publ. Assoc. Plastic Surg. India 45 (2) (2012) 412–417. [13] Z. Moore, D. Angel, J. Bjerregaard, T. O´ıconnor, W. McGuiness, K. Kröger, et al., Ehealth in wound care-overview and key is-sues to consider before implementation, J. Wound Care 24 (5) (2015) 1–44. [14] N.A. Patsopoulos, A pragmatic view on pragmatic trials, Dialogues Clin. Neurosci. 13 (2) (2011) 217–224. [15] Danish Health and Medicines Authority, National clinical guideline for diagnosis and treatment of diabetic foot ulcers, In: Authority DHaM, (Ed.), 1st ed, Axel Heides Gade 1 2300 København S, Denmark Danish Health and Medicines Authority, 47, 2013. [16] S.B. Larsen, J. Clemensen, N. Ejskjaer, A feasibility study of umts mobile phones for supporting nurses doing home visits to patients with diabetic foot ulcers, J. Telemed. Telecare 12 (7) (2006) 358–362. [17] K. Kidholm, A.G. Ekeland, L.K. Jensen, J. Rasmussen, C.D. Pedersen, A. Bowes, et al., A model for assessment of telemedicine applications: mast, Int. J. Technol. Assess. Health Care 28 (1) (2012) 44–51. [18] J. Kitzinger, Qualitative research. Introducing focus groups, BMJ 311 (7000) (1995) 299–302. [19] R. Health, Regions of Europe Working Together for HEALTH, 2009. Available from: . [20] D.R. Thomas, A general inductive approach for analyzing qualitative evaluation data, Am. J. Eval. 27 (June) (2006) 237–246.

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[21] D. Tuohy, A. Cooney, M. Dowling, K. Murphy, J. Sixsmith, An overview of interpretive phenomenology as a research methodology, Nurse Res. 20 (6) (2013) 17–20. [22] F. Gottrup, P. Holstein, B. Jorgensen, M. Lohmann, T. Karlsmar, A new concept of a multidisciplinary wound healing center and a national expert function of wound healing, Arch. Surg. 136 (7) (2001) 765–772. [23] E.M. Quinn, M.A. Corrigan, J. O’Mullane, D. Murphy, E.A. Lehane, P. Leahy-Warren, et al., Clinical unity and community empowerment: the use of smartphone technology to empower community management of chronic venous ulcers through the support of a tertiary unit, Plos One 8 (11) (2013). [24] A. Kinsella, Advanced telecare for wound care delivery, Home Healthc. Nurse 20 (7) (2002) 457–461. [25] J. Ameen, A.M. Coll, M. Peters, Impact of tele-advice on community nurses’ knowledge of venous leg ulcer care, J. Adv. Nurs. 50 (6) (2005) 583–594. [26] H.M. Kim, J.C. Lowery, J.B. Hamill, E.G. Wilkins, Patient attitudes toward a web-based system for monitoring chronic wounds, Telemed. J. E-health: Off. J. Am. Telemed. Assoc. 10 (Suppl. 2) (2004) S-26–34. [27] S. Hayes, S. Dodds, Telemedicine a new model of care, Nurs. Times 99 (5) (2003) 48–49. [28] C.R. Ratliff, W. Forch, Telehealth for wound management in long-term care, Ostomy/wound Manage. 51 (2005) 40–45. [29] G. Litzinger, T. Rossman, B. Demuth, J. Roberts, In-home wound care management utilizing information technology, Home Healthc. Nurse 25 (2) (2007) 119–130. [30] R. Hofmann-Wellenhof, W. Salmhofer, B. Binder, A. Okcu, H. Kerl, H.P. Soyer, Feasibility and acceptance of telemedicine for wound care in patients with chronic leg ulcers, J. telemed. telecare 12 (2006) 15–17, Suppl 1.

Please cite this article in press as: B.S.B. Rasmussen, et al., A qualitative study of the key factors in implementing telemedical monitoring of diabetic foot ulcer patients, Int. J. Med. Inform. (2015), http://dx.doi.org/10.1016/j.ijmedinf.2015.05.012

A qualitative study of the key factors in implementing telemedical monitoring of diabetic foot ulcer patients.

The implementation of telemedicine often introduces major organizational changes in the affected healthcare sector. The objective of this study was to...
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