2. • Outline impact of the Patient Care and Affordable Care
Act on Telemedicine (TM)
• Identify barriers to telemedicine (TM) implementation
• Discuss impact on stakeholders
• Overview of TM evolution and origins in radiology
• Details of three studies designed to overcome barriers
• Synthesis and future outlook for TM
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3. • Enacted new provisions for advancing health
technology
• H. R. 3590-652 declared the Department of
Health and Human services accountable to:
1) Conduct improved research
2) Establish laws and policies
3) Implement TM services
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5. Economics principles tell
us a monetary value needs
to be established on the
TM visit in order to make
sound business decisions
regarding its highest and best
use (Zumpano, 2014).
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6. • Lack of detailed design
methods
• Failure to state the
economic approach
• Failure to consider all
direct and indirect costs
related to TM (Mistry, 2012).
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7. Establish a comprehensive plan for:
Readiness
Decision making
Assessment…
…of TM services.
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8. • 20-year lag in medical advancement
• Exorbitant costs for health care
• Long waiting room lines
• Rural patients travel long distances to
see a doctor
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10. • Transition from analog to digital image capture in
late 1990’s and early 2000’s
• Digitally obtained images printed on laser film in
early 2000’s
• Picture archiving, communication, and storage
(PACS) systems arrived soon after digital imaging
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11. • Paradigm shift across the industry from
film/light box systems to digital
images/computer monitor systems in
late 2000’s
• Image sharing capabilities among
physicians, surgeons, caregivers,
and patients is now mainstream
method of radiology practice
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12. Three (3) separate models were identified, which captured
the spectrum of factors impacted by TM
• Maturity model (MM)
• Decision modeling (DM)
• Model for Assessment of Telemedicine (MAST)
All of these studies considered the direct and indirect costs
associated with TM, which was highly recommended in the
literature (Mistry, 2012; Wootton, 2012).
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13. • Matrix designed for use by the end users
• Maturity models (MMs) allow for measurement, and
management of an organization’s maturity levels and
readiness to adopt TM
• Enables comprehensive and synergistic workflow
planning
• Develop uniformity from one user to the next and
from one implementation phase to the next
• Ensures the chosen solution will possess the
necessary capabilities for current needs as well as
upgrades in the future
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14. • eHealth readiness instrument
• Layered TM implementation model
• PACS maturity model
• TM process map
• National Health Service (NHS) maturity model
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15. Definition: The level of knowledge and experience end users, health care
organizations, and the entire industry possess for successful implementation of TM.
Table 1- Low and high level names for eHealth readiness assessment tools
(van Dyk et al., 2012)
Low Level HighLevel
Core readiness Development and assimilation
Technological readiness Accessibility, dependability, financials, etc.
Learning readiness Adequate resources to support technology training
Societal readiness
Inter- and intra- organizational relationships, roles, and
responsibilities
Policy readiness
Regulatory and executive matters (i. e. licensure, insurance,
payments, etc.)
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16. • Strength: Created an enhanced perspective of the
end users’ levels of knowledge and comfort with
the technology
• Weakness: Do not consider evidence-based
practices, or integrate processes for achieving
them
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17. Layered TM implementation model: The theory behind this framework is
a large project must be broken down into smaller tasks and learned one
by one. The order in which Broens et al. (2007) prioritized the
implementation is:
1) technology
2) favorable reception
3) finance and administration
4) laws and regulations
National Health Service (NHS) maturity model (NIMM): An IT
infrastructure maturity model which can be generalized to any
application
• Developed by the NHS Technology Office, several NHS IT
Organizations and Atos Healthcare
• van Dyk et al. (2012) used the NIMM as a benchmark for their MM
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18. PACS maturity model (PMM): A maturity model was also used in
the development of PACS infrastructure. Demonstrated
sustainability in teleradiology inspired the researchers to adapt
methodologies from the PMM (van Dyk et al., 2012).
TM process map: The researchers developed a 10-step process
map to illustrate the order of operations, including collecting
data; making a diagnosis; and analyzing patient outcomes. Each
step is critical to the overall success of TM practices (van Dyk et
al., 2012).
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19. The three dimensions were:
eReadiness categories, maturity
levels, and TM process steps (van
Dyk et al., 2012). In the MM,
eReadiness categories were the
dependent variables and TM
process steps were the
independent variables. Maturity
levels, ranging from one to five,
were measured on the z-axis.
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20. Problem statement: From an economic standpoint, it has
remained challenging to generalize the practice of TM from the
lab to the real world (Bergmo, 2012; Mistry, 2012; Wootton,
2012). This is because there are so many specialties of medicine
investigating TM; and each one has their own unique attributes.
Definition: Decision modeling is a computer-based technique
that uses a database of existing secondary literature to
simulate an infinite array of scenarios (Bergmo, 2012).
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21. • Aids in learning the relationships among different variables
• In combines with secondary literature, researchers are able to
increase validity with multiple regressions of existing studies
• Offers a systematic approach to investigating hypotheses in TM
implementation
• Simulations can be constructed to make predictions about items
of interest to health leaders
• Indiscriminate about the sources of data used during analysis
• Useful in service development and expansion to rural areas
• Able to duplicate outcomes from one arena to another
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22. • The European Commission (EC) strongly advocated for the use
of telemedicine in their health delivery system.
• Their goal was to develop and test an evidence-based model of
a TM system architecture designed to measure and manage TM
health outcomes (Kidholm et al., 2012).
• The EC hired Kidholm et al. (2012) to conduct two workshops
comprised of end users and stakeholders. They were charged
with using their findings from the workshops to develop an
implementation model.
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23. Results of workshop one: Although the groups agreed to the core model
objectives, they developed three main suggestions.
• Separate assessments at the local, regional, and national levels
• Identified additional considerations not captured by the core
model
• The degree of generalizability of results from research to general
practice
Results of workshop two:
• Lack of an objective statement
• Include outcome measures to illustrate patient benefits
• Consolidated the EC core model from nine domains to three
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24. As assigned, the researchers used these findings to develop the Model for Assessment
of Telemedicine (MAST). The model was comprised of three steps: 1) preceding
considerations, 2) multidisciplinary assessment, and 3) assessment of transferability.
Preceding Considerations
Mission statement
Description of reasonable
substitutions
Separate assessments for each
domain of authority
(i.e. local, state, federal, etc.)
Assessment of the maturity level of
the TM solution
Multidisciplinary
Assessment
Statement of medical issue and
TM application combination in
use
Safety precautions
Measure for addition of value
Survey patients for satisfaction
levels
Conduct economic analyses
Monitor organizational
financial performance
Societal, ethical, and legal
effects
Table 3- Step 2: Multidisciplinary assessment
Table 2- Step 1: Preceding considerations
assessment
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25. Transferability Assessment
Between countries
Different sized organizations
Universal to any medical
specialty
In summary, the MAST involved stakeholders at the discovery phase of
the research process, to improve upon the core model created by the
EC. Hebda and Czar (2009) emphasized the importance of involving
everyone from the executives to the end users in the TM project, to
increase the organization’s chances of realizing an appealing solution.
The model will also be more likely to gain buy-in across the industry
(Hebda & Czar, 2009).
Table 4- Step 3: Transferability assessment
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26. • PPACA (2010) mandated HIT solutions be implemented to
improve costs and quality of health services.
• The models examined here were more scientific, rigorous, and
objective (Wootton, 2012).
• Future research to study cost-effectiveness of TM versus
traditional health delivery (Wootton, 2012).
• Future research should investigate plausibility of QALYs in the
standardization of TM costs (Bergmo, 2012).
• Further regressions of the MM, DM, and MAST are needed to test
their ability to inform TM project guidelines.
• Understanding the relationships among the factors which
influence the success of TM will enable decision makers to
measure and manage data.
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