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Pamela Whitten, Cand. Ph.D. and Ace Allen, M.D.
We have been fortunate to be involved with an active,
somewhat unruly telemedicine program, inching toward better ways of providing
medical care. We have had the opportunity to make lots of mistakes, to compare
notes with other practitioners around the country and the world, to enjoy some
modest successes, and to move forward. This article is part reminiscence, part
survey. We are trying to tie together the extra-technological elements that
augur a successful telemedicine program. This has been harder than we thought
when we first planned this article, and this issue of Telemedicine Today.
Telemedicine practice, organization, staffing, and administration are very
difficult to characterize, since they weave through so many fields and
administrative structures: health professional staffing, information
technology, hospital and clinic administration, professional education,
marketing, politics, vendor relations, funding... Perhaps as hard as anything
has been trying to determine what a "successful" telemedicine program is. If it
survives, is it a success? If it doesn’t survive, is it a failure? Must it
pay for itself? Two observers may call the same program a success or a failure,
depending on their vantage and prejudices.
This article does not pretend to be definitive. We are
doing our best to get a realistic snapshot of the ever-changing organizational
scaffolding that supports this work-in-progress called telemedicine. We start
with a look at our own program in Kansas, then move to a modest survey we did
of several programs throughout the U.S. We make some small observations, come
to some cautious conclusions, and hope this helps put together a few more
pieces of the big puzzle.
The Evolution of Telemedicine in Kansas
We would like to offer our experience in Kansas as a
lesson to newcomers, and as a balm of commiseration for the wounds and bruises
of the old timers. It is odd to think that this field is so new that an "old
timer" is any program that has been around more than three years. We believe
that the many mistakes we’ve made, and our efforts to overcome them, are
not unique to us, but have been encountered at many programs. Several
cross-institutional studies that we have done (including the survey that is
part of this issue) support this belief. Perhaps some details of our progress
can help you in thinking about your own telemedicine program.
The concept of telemedicine in Kansas originated with
Dr. Robert Cox, a pediatrician in Hays, in western Kansas. He had heard that
new technologies were becoming available that might make it less necessary for
sick kids to have to travel to a tertiary-hospital based specialist (all more
than 200 miles away), or to have to wait for one of the sporadic visits by a
"circuit riding" specialist. Bob began thinking about alternatives to long
patient drives and fly-in clinics in 1988, and managed to hook up with William
Mahler, Director of Information Technology at the U. of Kansas Medical Center
(KUMC). Working together, they connected Bob’s musings with the burgeoning
pan-Kansas system of interactive video teleconferencing sites that were being
established to link rural public schools and colleges. This system, with a
statewide leased T1 tele-communications backbone (the KANS-AN), provided a
ready-made infrastructure for telemedicine. Bill, a transplanted military man,
helped Bob develop a strategy, and took the project on as a personal challenge.
He and his staff became familiar with the technology options (much more limited
in those days!), solicited vendors to find the best equipment for the task,
negotiated with rural telephone service providers, and developed in-house
funding sources. In 1991 the first units were up. One was located at the
Information Technology office at KUMC. The other was at the Northwest Kansas
Area Health Education Center (AHEC) in Hays, one of several rural
state-supported sites for coordinating medical care and education.
It was a felicitous combination of people, need, and
resources: a passionately interested rural practitioner, a cooperative and
capable technology expediter, and a rural site (the AHEC) already set up for
coordinating rural subspecialty outreach and medical education, with excellent
local connections and a committed director (Dr. Calvina Thomas). The equipment
worked well, and by early 1992 there were frequent specialty consultations to
Hays, involving especially pediatric cardiology (Dr. Leone Mattioli), neurology
(Dr. Jean Hubble), pediatric neurology (Dr. Enrique Chaves), and child
psychiatry (Dr. Larry McDonald). Several new sites were added -- another in
Hays (Hays Medical Center), and in Ransom, Lakin, and Girard, KS. By 1993 there
were six rural sites and two tertiary deployments (at the KUMC campuses in
Kansas City and Wichita). In that year, 175 patient/physician consultations
were done, accounting for about 25% of the on-line time; the other 75% was used
for tele-education (still by far the most frequent use of the system) and
administrative teleconferencing.
By 1994 the telemedicine program had reached a
plateau. Patient / physician consultations were nearly the same (189) as
the year prior, and the core of specialists hadn’t enlarged. Several rural
hospitals were wondering openly about the wisdom of their decision to spend
$100,000 on equipment that was not being used more than a few times a week for
education, and hardly ever for patient consultations. Several studies had shown
that patients and physicians were satisfied with the technology, yet were not
using it much.
In 1994 we embarked on a major audit of our program.
This consisted of a series of questionnaires administered to virtually everyone
involved in the program. The findings from this study, combined with some less
scientific observations, led us to believe that the major problem was a lack of
central, universally recognized leadership and administration. A simple request
for a telemedicine consultation was hampered by the lack of an identified
scheduler, by a haphazard roster of participating subspecialists, and by the
fact that there was no system of accountability. The program was floundering
and rudderless.
At about this time it was becoming clear to all
involved, including the leadership of Information Technology, that the
telemedicine program no longer belonged in Information Technology. In a sense,
the telemedicine program had been an orphan, raised by the department that
first found it. However, it needed to move to a new home, where it would be
managed as a program rather than as a technology. The emphasis of telemedicine
needed to be on medicine rather than tele.
In May of 1995, the telemedicine program was
completely reorganized. The chair of Family Medicine, Dr. Jane Murray, made a
clear strategic decision to house the program within her department. This
proved felicitous, since most rural physicians are family practitioners, and
form the natural client base for a rural telemedicine program. Dr. Murray
received strong support from the Executive Vice Chancellor, and from Dr. David
Voran, who had taken over Information Technology upon Bill Mahler’s
retirement. The newly formed division within Family Medicine, called
Information Technology Services and Research (ITSR), was headed by
co-directors, the authors of this article. One (Whitten) became Director of
Services, with the tasks of assuring that physicians were entrained into the
consulting process, developing contracts for medical consultation services,
training and overseeing a full-time scheduler, supervising the technician, and
overseeing the budget. The other (Allen) became Director of Research and
Evaluation, charged with developing, implementing, and finding funding for
telemedicine research. Both Directors are charged with guiding strategic
planning and future directions for the program.
That reorganization occurred a little less than one
year ago. Since then, twelve regularly scheduled telemedicine clinics have been
established, in psychiatry, oncology, cardiology, neurology, infectious
disease, and other specialties. A central, single-source, dedicated phone line
has been established, staffed by a trained scheduler whose primary task is to
make the difficulties of scheduling as invisible as possible to the involved
physicians, nurses, and office staff. Contracts have been signed for ongoing
tele-oncology and telepsychiatry clinics. About 50 patients/month (600/year)
are now being seen. There are quarterly multipoint meetings of all
participating telemedicine sites (12 rural, 2 urban) to air grievances and
share ideas. There is now a regularly published schedule of CME/CNE/Allied
Health events available over the interactive video system, done in cooperation
with Continuing Education. A research associate has been hired to coordinate
the half-dozen or so studies that are going on at any given time, and to help
write research grants. About 20 articles and abstracts have been printed in
peer-reviewed journals.
Significant problems remain. Only Blue Cross/Blue
Shield of Kansas reimburses fully for telemedicine consultations. The
technology is still too expensive, and it is difficult to connect our leased
system to outside dial-up systems. Adequate funding of the ITSR continues to be
dicey, since the role of telemedicine in the overall financial picture of a
State-supported medical center is uncertain.
An overriding observation has been that our
telemedicine program, and others we are acquainted with, thrives largely
because of the enthusiasm and commitment of key personnel. The new
organizational structure has helped to channel those energies, but cannot
replace them. We are reminded of Margaret Mead’s comment about the
importance of individual contributions to an enterprise:
Never doubt that a small
group of committed citizens can change the world. Indeed, it is the only thing
that ever has.
Organizational Aspects of Interactive-Video
Mediated Telemedicine Programs: A Survey
About the Survey
We were interested in finding common and unique
elements within the organizational structures of telemedicine programs. To
pursue this, we administered a questionnaire to a dozen interactive-video
mediated programs in the U.S. and Canada. One interesting Canadian program was
not included in the final tabulation because it turned out to be a
teleradiology project. We recognize that store-and-forward (S&F) programs,
especially in dermatology, radiology, and pathology, are extremely important.
However, we chose to focus on interactive video projects for this survey.
Several programs that we queried were not able to give us enough information to
be useful; our final program tally is ten.
What We Found
Six of the programs are University-based. These are
placed in three different ways within their organizations:
- Family Medicine -- U. of KS
- Information Technology / Educational Technology
(Health Sciences Communication) -- ECU
- Free-standing departments, reporting directly to
the Dean of the Medical School or Vice-Chancellor -- Texas Tech, MDTV, Ohio
State, and MCG
A respondent from one of the free-standing departments
felt strongly that "(t)he benefit of being separate is that it lets the
telemedicine program stand aloof from the infighting of the various
departments. Also, being separate, you don’t have to filter your budget
requests through as many layers." In most cases, the respondents felt that the
organizational placement of the telemedicine placement fit the personalities
well, and was right for their program. It is apparent that in several of these
cases (including KUMC), the organizational structure was developed to make the
best fit for previously identified telemedicine leaders. As programs mature,
and second generation leaders come on board, it will be interesting to see if
they are asked to conform to the extant organizational structure, or whether
the structure will be altered to accomodate them.
The four private-hospital based projects fall under:
- Marketing and Strategic Planning -- Carle
Foundation
- Medical Education and Research -- Allina
- Physician Services -- MedCenter 1
Free-standing project overseen by an executive
committee composed of representatives from all involved hospitals -- MRTC
We were able to obtain "micro" organization charts
(relationships within the telemedicine project itself) for only three programs
(see below). Several sites were in the process of reorganizing. The ECU
program is clearly strong in technical staffing, with a plethora of engineers,
photographers, and illustrators. This reflects their emphasis on optimizing
telemedicine technologies.
We found that, in several cases, we were given
conflicting information about the number of hub (referral centers) and spoke
sites (referring sites, generally rural). We finally had to clarify that we
sought information only on actual, active sites -- not those to be implemented
in the future. Some of these figures may be out of date by the time you read
this. Two programs had a relatively high ratio of hubs to spokes. The Allina
system has five hubs to 17 spokes; MCG has 11 hubs to 21 spokes. The
significance of this is unclear. Perhaps there is not a universal understanding
of what it means to be a "hub" or "spoke." Perhaps we overestimate the
commonality of the language of telemedicine.
All programs did both clinical consultations and
medical education; several also used their systems for administrative
teleconferencing.
One of the most difficult questions concerned the
number of paid personnel (Full Time Equivalents = FTEs) devoted to the
telemedicine project. It became clear that, while there may be a core of
readily identifiable "telemedicine employees," there were also many personnel
who contributed some fraction of their time -- sometimes significant -- but who
were not formally accounted as telemedicine personnel. These might be
accountants, researchers, secretaries, information technologists and
technicians, grant writers, business and marketing personnel, administrators,
etc. We feel that our figures for "paid personnel" are not necessarily
reflective of the actual FTEs devoted to a given program. As an example, the
accounting of paid personnel at KUMC did not include administrators above the
program directors, nor did it include telemedicine coordinators and technicians
at spoke sites.
Program funding has come from many sources. Three
programs (Carle Foundation, The Ohio State University, and KUMC) are largely
independent of grant support, with equipment and infrastructure mostly paid for
by the main institution or by individual sites as they come aboard. At the
other end of the spectrum are the ECU, MDTV, and MCG programs, all with
enormous extramural (federal and state) funding sources. The other programs are
funded by a more or less equivalent combination of internal and external
monies.
Telemedicine services were mostly paid for through
fee-for-service under several guises -- prison contracts (Texas Tech); Medicaid
(MedCenter 1); straight BC/BS reimbursement (KUMC); and "discounted"
fee-for-service (Allina), referring to a negotiated contractual arrangement
that is not capitated. ECU has arranged a straight capitated-care contract with
the state prison system, and various grants reimburse for other services. Only
at the MRTC system is there no reimbursement at all; this will change in the
near future.
We asked each program whether private businesses could
rent out time on the system, as a way of recovering some costs. MRTC responded
"Yes, but we haven’t started doing it yet." ECU may in the future. All
others did not allow this. To date, the only program we are aware of that is
now renting out system time is the Eastern Montana Telemedicine Project, which
sells out about 10% of its system time to private interests.
A recurring conviction among respondents was that the
organizational aspects of telemedicine are important and tend to be
underestimated. As Paul Maakestad, Project Director at MRTC said, "Don’t
underestimate the amount of administrative support needed to make a program
function smoothly. Think out structures completely, before beginning the
program."
So what does this minisurvey and our experience at
KUMC contribute to our knowledgeof telemedicine organizations? First, we cannot
underestimate the role of context for each program. Every program has
evolved based on its own unique attributes of personnel and resources. It is
important to acknowledge that trying to apply a simplistic model of
organizational communications (e.g. assuming that there is a generally
applicable "best" structure for telemedicine programs) falsely distorts the
nature of telemedicine, and of organizations. It overlooks the inherent
subjectivity of human interaction. Let the buyer beware of advisors who would
apply a cookie-cutter approach to telemedicine organization.
Finally,
we have found that it is very difficult to understand fully all the resources
involved in delivering telemedicine. Every one of the programs we surveyed was
highly dependent on personnel and resources from other departments. This is
akin to the situation with other areas of medicine, which are typically highly
interdependent and involve sophisticated cooperation between people,
departments, and disciplines. Perhaps this tells us most compellingly to focus
on the "medicine" rather than the "tele."
Pamela Whitten, Cand. Ph.D.
Director,
Telemedicine Services
Information Technology Services and Research
KUMC
8630 Halsey, Lenexa, KS 66215
913-588-2224;
pwhitten@kumc.edu |
