The novel coronavirus disease, COVID-19, was first detected in China in December 2019 and, since then, it has spread worldwide; almost all healthcare systems throughout the world have been severely affected by such a heavy burden. In Europe, Italy was the first country hit by this disease and one of the most suffering. In late February 2020, the Italian Government imposed a lockdown to the citizens in order to ensure social distancing, which is considered one of the most effective – albeit demanding – preventive measures to halt the virus propagation. A great part of the Italian healthcare staff was particularly under pressure for the management of COVID-19 patients, and especially for the dramatic high number of those hospitalised in intensive care units; nonetheless, local healthcare trusts also had to keep providing assistance to citizens despite social distancing. In this scenario, the Healthcare Trust of the Autonomous Province of Trento – Azienda Provinciale per i Servizi Sanitari (APSS) – identified as a main priority the setup of a solution for the remote provisioning of healthcare services to allow reducing the risk of contracting the virus and to comply with mobility restrictions. For this purpose, a remote service to connect the healthcare staff and the patients was implemented adopting a systematic tele visit approach. Tele visit has been defined by the Italian Ministry of Health as the ‘health-related act of remote interaction between doctor and patientFootnote 1’, and by the World Health Organization (WHO) as ‘the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries’ (WHO 2009).
This paper focuses on the implementation of a tele visit service in the Autonomous Province of Trento, Italy. Before the COVID-19 emergency, such a system was not available in the Province: it was only planned as a future development to improve the healthcare provisioning service for better serving the citizens located far from the main healthcare facilities in Trento. The pandemic stressed the need for implementing such a service quickly to overcome the limitations imposed by the emergency in the whole territory. Therefore, tele visit was chosen precisely because it has been already explored in other regions worldwide where remote assistance is necessary and has been well documented in literature and acknowledged by public administrations and healthcare institutions. The main challenge faced by the Province of Trento in relation to the tele visit was its rapid and effective implementation, and this has been the main driver for the research question object of this work. This paper analyses how tele visit could be integrated into the healthcare system from an organisational and technological point of view in a short period of time and which aspects should be considered in order to scale it up into a structural service of the Trentino healthcare system in the longer term. In addition, the paper highlights the various barriers encountered for the implementation of the proposed solution (organisational, technical, ethical and legal) that can be taken into consideration as a precedent for the immediate and long-term implementation of similar systems in other geographical contexts.
The paper is organised as follows. First, it frames the context of digital healthcare services provisioning in the Province of Trento through TrentinoSalute4.0 (TS4.0) Competence Centre. Then, it describes the methodological framework adopted for TreC_Televisita: this includes the analysis of the elements necessary for developing and integrating the service by eliciting the organisational and technical requirements as well as the regulatory ones, an analysis of the outcomes obtained after the preliminary user evaluations conducted in a living lab environment, and of the possible barriers for the structural inclusion of the service in the healthcare system beyond the COVID-19 contingency period. Finally, the results of the TreC_Televisita projects are analysed, and the related conclusions are drawn.
Background and overall context of TreC_Televisita
TreC_Televisita has been realised through the support of the TS4.0 Competence Centre on Digital Health of the Autonomous Province of Trento. TS4.0 was formally established with an Act of the Local Government n. 2412 on 20 December 2016: the partnership governance includes the Autonomous Province of Trento (PAT) through the Department of Health and Social Policies in the role of decision-maker, the local Healthcare Trust (APSS) in the role of the health service provider and the Bruno Kessler Foundation (FBK) as the research institute responsible for technological innovation, as shown in Fig. 1. TS4.0 also involves citizens, health professionals and sector companies according to a quadruple helix model (Mayora-Ibarra et al. 2019). Also, in May 2020, TS4.0 has officially become a Joint Research Unit for strengthening cooperation among the institutions. This kind of virtuous partnership has been considered a good practice enhancing sustainability in healthcare provisioning (Botti and Monda 2020).
As the key local actor in digital health for Trentino Province, TS4.0 had the mandate to support the development and adoption of digital solutions to quickly respond to the needs that emerged during the COVID-19 lockdown. TS4.0 fast reaction was possible thanks to the long-term strategic cooperation on digital health among the three main stakeholders that have worked side by side since 2017, leading to a swift and robust decision-making process. In fact, this relationship has led to the increase of the digitalised services offered to the citizens in the Trentino Province, including both those strictly integrated with the healthcare system, which feature a medical dashboard and an app for the patients such as TreC_Diabetes (Dragoni et al. 2019) TreC_Cardio (Maines et al. 2020), and those offered to the citizens for health promotion (e.g. Salute +, an app based on gamification promoting healthy lifestyles).
All the digital services provided by TS4.0 are sustained by the ‘TreC’ (the Trentino Citizens Clinical Record) platform, which is the personal health record (PHR) of all Trentino citizens (Eccher et al. 2020). TreC has been developed as a modular platform whose extensible architecture allows sub-systems to be integrated for the provision of additional and specific functionalities (Osmani et al. 2017). Therefore, TreC has become the pillar for the long-term strategy of healthcare digitalisation – a ‘one-stop-shop’ for the Trentino healthcare system – as, beyond its function as PHR, it also provides a place for testing new technologies. Moreover, TreC can include third party apps and microservices, and is compliant from the legal and ethical viewpoints (e.g. GDPR). During the COVID-19 emergency, TS4.0 was able to ensure the development of new apps to respond quickly to the emergency, that is, TreCovidFootnote 2 (Gios et al. 2021) and TreC_Televisita. The existence of one healthcare provider for the whole Trentino territory has the advantage of having a unique PHR where all patients’ data are gathered. In addition, because the whole digital healthcare system in Trentino is built into TreC, it is currently used by a large number of the Trentino population (over 110,000 users) which facilitate the scaling-up of new digital services and applications, such as TreC_Televisita.
The production of digital solutions for positively facing the COVID-19 situation in Trentino over the TreC platform was done in two steps. The first solution implemented during the COVID-19 emergency was the TreCOVID-19 app, released on 16 March 2020. The app had a double role: on the one hand, it supported the citizens in better understanding the initial rules during the lockdown with reliable and official information for facing the pandemic. On the other hand, it provided a home monitoring infrastructure for diagnosed and suspicious COVID-19 patients to collect their physiological and behavioural parameters related to the disease and transmit them to the doctors for supporting treatment decision-making. The second step was the implementation of the TreC_Televisita solution, conceived from the alignment of patients and healthcare professionals needs on the one side, and healthcare and policy management requisites on the other. From the patients and practitioners’ side, the request for the implementation of tele visits did not emerge during the COVID-19 emergency but started a few years ago: in the Trentino Province, the two main healthcare districts (located in Trento and Rovereto) are not easily accessible to citizens living in the faraway valleys, where a trip to the main cities can take up to one and a half hour driving or more than a two-hour journey with public transport. For example, the need for tele visits clearly emerged from the interviews conducted during an early pilot activity conducted back in 2018 for remote monitoring of pregestational diabetes patients (Piras and Miele 2019).Footnote 3 Since March 2020, the COVID-19 emergency has triggered the healthcare management and policy-makers to decide to implement tele visits as a way to mitigate, on the one hand, the issue of accessing healthcare services due to mobility limitations and, on the other, as a means to reach distant communities, such as the numerous valley communities of Trentino. The need for tele visits became officially a political priority through a formal action of the Autonomous Province of Trento, namely the deliberation of the Provincial Council n°456 from 9 April 2020, called ‘Provisions on Telemedicine and other provisions to deal with the emergency from COVID-19’. With this resolution,Footnote 4 the Provincial Council has updated the nomenclator of outpatient specialist assistance services, of diagnostic imaging and laboratory specialists by integrating it with telemedicine services (services provided remotely). In this way, the Autonomous Province of Trento was the first of the Italian Regions/Provinces to provide telemedicine in the era of COVID-19 as an alternative to the traditional healthcare approach. From the healthcare–provisioning side, in March 2020, i.e. after the mobility restrictions were imposed, the need to substitute a service traditionally performed on-site, i.e. patient–clinicians face-to-face visits, led to the decision of TS4.0 management of developing TreC_Televisita solution.
The TreC_Televisita project has its basis on a multidisciplinary approach that is intrinsic to the TS4.0 partnership by integrating clinical, technological and policy-related expertise, with a focus on implementation research. The methodology implemented in TS4.0 stands on evolving research developments with medium technology readiness levels (TRL 5–7) into validated systems and services with TRL8 and 9 with the goal of ameliorating public health outcomes, scalability and sustainability of solutions for improving citizens’ health, as suggested by Theobald (Theobald et al. 2018). An inherent characteristic of TS4.0 implementation research methodology is that the approach chosen is not based on various context elements such as the vertical (disease-specific) or horizontal (cross-cutting) focus: rather, it shifts the attention towards the links between research and practice, and the different actors and competences involved. The implementation research approach utilised by TS4.0 considers a real-world setting, often without the specificities and restrictions of a clinical trial and allows a real-time adjustment of the solutions in an iterative and dynamic process (Theobald et al. 2018; Peters et al. 2013). This methodological approach was adopted for TreC_Televisita as it has demonstrated to be effective for the definition of the other services already integrated into TreC, e.g. TreC_Diabetes (Eccher et al. 2020).
Therefore, despite the unexpectedness of the situation in the spring of 2020, the realisation of TreC_Televisita was the natural – albeit accelerated – prosecution of the work of TS4.0 in the provisioning of eHealth services for the Trentino citizens and its development followed the same approach. Such methodological approach has been implemented with three different steps:
Identification of App requirements – The first step of the methodology for the app realisation is the gathering of the organisational and technological requirements, meaning those elements necessary for the integration within the healthcare process and clinical procedures and for embedding the service into the existing TreC platform (Piras et al. 2010). For the organisational requirements, the whole patient management process was considered, starting when the patient is taken in charge by the doctor, until the monitoring after the (tele) visit. Considering the time-constraints for delivering the solution, we have first analysed the requirements gathered for telemonitoring past solutions (e.g. TreC_Diabetes), adapted them to tele visits and, as a final step, these were validated with healthcare professionals and modified when needed.
Compliance with regulatory issues – The second phase focused on the structural issues related to its implementation because the TreC_Televisita overall solution needed first to comply with the framework of the Trentino Healthcare provisioning system in terms of payment methods, data protection and validity assessment. Data protection issues followed a privacy-by-design approach developed together with the healthcare staff to define, for instance, the information sheets. Validity assessment and payment methods were dealt with at a management level within the policy entity and the healthcare trust.
User evaluation in a living lab environment – For TreC_Televisita, four case studies were identified with the aim to test feasibility related to various users’ aspects such as usability and perceived usefulness. A mixed-method approach was adopted to investigate the organisational impact, the patient–provider relationship, and the solution usability: the final objective was to gather a generalisable understanding drawing on theoretically selected cases. For the evaluation of usability, initially a heuristic evaluation by user-interface researchers was conducted and successively a cognitive walkthrough exercise assigning specific tasks during a simulated tele visit to healthy volunteers.
Owing to the contextual factors already described in the first part of the paper (i.e. the centralisation of the healthcare infrastructure in Trento, its Alpine morphology and the related complex transportation network), which makes Trentino a particularly suitable environment for the exploitation and scalability of the TreC_Televisita service, the methodology has been enriched with a fourth step. This fourth step follows the implementation research approach defined by Peters (Peters et al. 2013), which underlines that the investment of money that focuses on the health innovation per se rather than its exploitation, too often leads to a failure when it comes to the shift from small-scale piloting to large-scale implementation. Therefore, an additional component was considered, namely:
Future sustainability – the analysis for the longer-term applicability of the TreC_Televisita service has been considered since its conception for addressing both: the immediate needs originated by the pandemic, and the identification of the barriers for the long-term sustainability of the solution together with the strategy for overcoming them. The state-of-the-art frameworks concerning the identification of barriers to telemedicine implementation were analysed: the framework that better matched the Trentino context was used as the starting point for the definition of the potential solutions and lessons learnt.
The methodology applied, as well as the analysis of the results and the lessons learnt, could serve as a starting point for other healthcare systems towards the definition of tele visits: in particular, the app requirements for both the organisational and the technological infrastructure as well as the necessary elements for the compliance with ethical and legal issues could be scaled up to other contexts, especially in the European Union. In addition, the long-term sustainability section provides a framework that is adaptable to different context and can be the basis for a feasibility study for the long-lasting implementation of new services into healthcare systems.
Identification of app requirements for the integration in the Trentino healthcare process
As explained above, the first step of the methodology is the identification of the requirements for the development of the app: TreC_Televisita is a digital solution integrated into the healthcare provisioning system of Trentino Province; thus, it should be part of a patient’s path when taken in charge by the doctor. For this purpose, a series of procedural changes needed for the correct implementation of the tele visit were identified. These procedural changes included not only the tele visit itself but also pre and post actions to be performed by the patient after the prescription of this intervention. In the first phase, the preliminary visits held remotely during the COVID-19 emergency were conducted for eliciting overall organisational requirements of the solution by implementing existing technologies based on phone calls and the Google ‘Meet’ App. A successive version implemented a mobile app for patients and a front-end web dashboard for the healthcare staff supporting clinical professionals for prescribing the Trec_Televisita app, scheduling tele visits, and checking patient’s data; the functionalities of the patients’ app included inserting files, images, chatting, viewing scheduled appointments, video calling, etc.
Since the lockdown period, different healthcare domains have adopted various instances of the TreC_Televisita service in Trentino besides those managing COVID-19 patients. Amongst the first ones, diabetologists and cardiologists requested its use for overcoming some of the collateral problems raised by the pandemic (Maines et al. 2020). Additionally, ophthalmologists, paediatricians and occupational doctors voluntarily requested the provisioning of tele visits for their patients in an experimental way. From mid-April until the end of July 2020, a total of 12,000 tele visits were performed for the above-mentioned diseases’ domains. It is important to mention that while the tele visit service is conceived as a standard conceptualisation for all diseases, each domain visit requires ad-hoc customisation to adapt the remote consultation services and specific requirements. In this regard, the features implemented for each clinical speciality are different, as TreC_Televisita is a solution adaptable to the needs of each domain. For example, ophthalmologists explicitly requested the possibility for their patients to upload specific information to the portal (e.g. images, pdfs) before the consultation, as a prerequisite for conducting a tele visit. In this way, TreC_Televisita manages to follow the different necessary customisations according to the disease-specific procedures and requirements following the general outline described in Figs. 2. Figure 2 shows how the tele visit prescription may be optionally activated between step 4 and 5 of the telemonitoring process.
Figure 2 displays the path a patient will follow when they enter the healthcare system and is supported by digital health technologies for a specific condition: as an example, the path followed by a diabetes patient is described. First, the general practitioner (GP) prescribes the patient a visit in the diabetology centre, where the patient is taken in charge by the diabetologist (step 1): after a careful examination of the symptoms, habits, etc., the diabetologist prescribes an app – i.e. TreC_Diabetes, and a personalised care plan (step 2). During the weeks after the visit, the patient’s adherence to the treatment is monitored (step 3) supported by the TreC Diabetes virtual coaching platform (Maimone et al. 2018). On the medical dashboard, the diabetologist can view the patient’s data on a regular basis and modify the treatment following a step-based approach in order to increase the patient’s adherence (step 4). When needed, the doctor can prescribe the patient a tele visit and other exams to perform before the visit and upload the results (pdf, images, etc.) on the tele visit system: these tests will be examined by the doctor during the tele visit in order to have an even more complete clinical picture of the patient. Afterwards, the doctor might assign additional tasks (e.g. diet, drug prescription) to the patient. The results of the tele visit and other monitoring tasks will generate specific referrals. The generation of these referrals will be further achieved in successive versions of TreC_Televisita by automatically updating them from TreC PHR. From this step, the healthcare continuum cycle reconnects with step 3, where the doctor monitors the patient’s compliance.
While the previous flow of events is the same for most of the digital treatments of the TreC ecosystem, the tele visit component is only included if a patient or their clinician requests it. Moreover, in the case of COVID-19 management during the lockdown, the tele visit component operated independently from the 5-step-flow as it is prescribed directly to patients at risk.
Regarding reimbursement and payment management of tele visit service during the pandemic, the Province of Trento decided to apply a solution that could simplify the wider access to this kind of service to the population. In non-pandemic scenarios, the prescribed visit is associated with a code corresponding either to a payment or the partial or full exemption. The Trentino healthcare system had never faced the issue of payment associated to tele visits; however, payment and reimbursement have been a sensitive issue for many years in the tele visit context. In fact, this has been constantly evolving since the early 1990s when in some countries, such as the United States, telemedicine provision was excluded from the Medicare programme as it explicitly required ‘processes ordinarily involving physician–patient contact be delivered in person’. This changed in 1999 when Medicare increased both the number of telehealth services covered and payment rates for these services (Gilman et al. Gilman and Stensland 2013). Payment parity was not ensured for the same service code, representing a hurdle for exploiting the full potential of tele visits, until COVID-19 (Shachar et al. 2020); however, in order to ensure widespread implementation of tele visits, it would be necessary to maintain this equity even after the pandemic. In this regard, during the pandemic and until the end of the state of emergency, the Autonomous Province of Trento declared that the services of telemedicine (including tele visits) would be provided in the scheme of exemption from sharing health care expenses (so-called ticket) for all patients registered with the national health service, specifying that this exemption, (identified with the ‘TEL’ code), applies regardless of the assessment of the COVID-19 contagion.
Identification of app requirements: TreC_Televisita technical integration
TreC_Televisita provides an environment for testing and implementing innovative data-driven telemedicine services. Originally, it was conceived to mitigate COVID-19 emergency and later-on to extend its functions for post-lockdown services to other disease domains. The TreC_Televisita system incorporates various services through the TreC middleware that interconnects a series of sensors and devices from multiple data sources (such as EHRs, apps) in order to allow the combination of their data flows either for immediate decision-making of clinical professionals on treatment management or for other processing purposes, i.e. for virtual coaching services relying on previously developed systems (Fig. 3) (Maimone et al. 2018; Dragoni et al. 2018). Moreover, other basic services such as authentication and access control are already provided by the TreC ecosystem. Other specific functionalities such as the telemonitoring hub and dedicated messaging system are also provided through the TreC middleware interconnecting the TreC_Televisita app with the medical dashboard. In this way, the tele visit system allows the prescription and intervention of a clinician through the medical dashboard functionality for any further required direct patient–clinician contact.
In order to define all steps related to handling the remote visits, TreC_Televisita utilises the disease management workflow and knowledge from the respective approved protocols and good practices for handling each disease. The TreC_Televisita technological infrastructure is constantly monitored to ensure its proper functioning and its protection from possible cyber-attacks.
The compliance of TreC_Televisita with regulatory issues
Notwithstanding the boost of tele visits performed globally during the COVID-19 emergency, some formal issues connected with their implementation remain unsolved, especially in a long-term perspective; these will need to be determined by Governments more structurally in the longer term in order to ensure the structural integration of tele visit in the healthcare provisioning system (Romanick-Schmiedl et al. Romanick-Schmiedl and Raghu 2020). In the meantime, because of the urgent need for coping with the emergency situation in many regions, basic aspects related to the use of technology within the healthcare sector (e.g. privacy) were deregulated. The following paragraphs analyse the second step of the methodology corresponding to the identification of the issues that the Trentino healthcare system had to comply with for the implementation of the TreC_Televisita solution: these are personal data protection and validity assessment.
The management of personal data has always been a crucial issue when implementing eHealth solutions (Robles et al. 2020), also within the Trentino healthcare system. In the EU, all the services related to telemedicine, scientific research,Footnote 5 the use of apps for social distancing measures, warning and contact tracingFootnote 6 needed to comply with the current legislation, e.g. the General Data Protection Regulation (Regulation (EU) 2016/679) – GDPR. In particular, according to article 9, the processing of health-related and genetic data is prohibited, but it is allowedFootnote 7 when (art. 9.2.g) ‘processing is necessary for reasons of substantial public interest’ and when (9.2.j) ‘processing is necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes’. Moreover, the article states that ‘processing shall be proportionate to the aim pursued, respect the essence of the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and the interests of the data subjectFootnote 8’. For the implementation of TreC_Televisita, the aspects related to personal data management in the Trentino Province were considered by design thanks to the inputs from a multi-professional group of experts. Ad hoc documents (including information sheets for citizens/patients) have been developed in line with the privacy regulation’s principles, whilst from a structural viewpoint, tele visits’ tools and systems were embedded in the PHR platform, which has been developed in line with the General Data Protection Regulation standards.
Considering the lack of time available for a clinical trial phase for the validation of the TreC_Televisita service, another important issue to consider related to the implementation of tele visits is the validity assessment, meaning the quality and the effectiveness of the service compared to the traditional face-to-face practice. Literature has underscored that traditional visit and tele visit can be comparable: for example, for neurological care (Bloem et al. 2020) videoconferencing was even deemed more efficient, while home activity-based training for survivors of stroke was equally effective. However, the randomised trials aimed at assessing tele visit quality mostly focused on chronic patients with stable conditions and some studies have shown the concerns of clinicians related to clinical quality as well as accountability and, thus, insurance issues (Greenhalgh et al. 2020; Wherton et al. 2020). In Italy, the clinicians association (FNOMCEO) has criticisedFootnote 9 the proposalFootnote 10 of the Health Commission of the Italian Regions and Autonomous Provinces related to the implementation of tele visit during the pandemic: article 87 of the Clinicians’ Deontological Code explicitly mentions that tele visit cannot substitute the direct doctor–patient relationship but can be used for remote monitoring, and article 24 states that a certification of the patient’s health status is the consequence of a direct patient’s evaluation. While the previous considerations apply widely in Italy, the experience in Trentino Province in this regard can be considered unique. Significant and concerted efforts have been promoted by the local Health Trust (APSS) to develop and to standardise a set of procedures to ensure proper implementation and management of tele visits during the epidemic acute phase, covering a large number of clinical activities from first consultations to follow up visits. After the infection’s peak, the core procedures have been strategically adapted to cover follow up sessions and tele consultations. The entire process has been promoted, coordinated and monitored by multidisciplinary groups of experts, to guarantee smooth implementation and response to the fast-changing epidemiological situation.
TreC_Televisita evaluation in a living lab environment
In the previous sections, we have illustrated the institutional framing of TreC_Televisita as a part of the services offered by the local Healthcare Trust and some technical specifications of the platform. While these aspects are highly relevant, it is important to verify that they do not only reflect the perceived needs of the institutions but also those of the healthcare providers and patients, the end-users of the platform. In line with previous experiences with remote monitoring based on the TreC Platform (Piras and Miele 2017; Piras and Zanutto 2014; Passardi et al. 2017) we have piloted and evaluated TreC televisita in a living lab environment to address organizational and acceptability issues.
For the sake of this article, which intends to provide the full picture of the institutional framing, the technical design and piloting implementation of TreC_Televisita, we shall limit the description of the methodology and results of the case study analysis which requires a paper in its own right. From its conception, the TreC_Televisita project had the ambitious goal to define a standard for a larger set of clinical practices to cope with the problem of social-distancing while providing a solution for clinicians to follow their patients: this solution can also be exploited for tele visits with COVID-19 patients who are, at the moment, monitored with the TreCOVID-19 app. To this end, the chosen approach was to proceed with four case studies whose selection was theoretically informed according to two axes: routine visits vs. acute care visits, structured vs. open-ended visits. The two axes allow identifying four broad categories of reasons for encounter that can be applied, by analogy, to many different consultations: routine visits structured around a specific health issue, routine control visits, visits triggered by an acute need that requires monitoring over time, and visits needed to evaluate an unspecified acute need. Table 1 below presents the selected cases studies.
The theoretically informed choice of cases has a twofold objective. On the one hand, it allows identifying opportunities and challenges that may apply to similar patient–provider relationships. For instance, the case study of paediatricians may be used to gather a preliminary understanding of challenges and barriers to adoption in context where reasons for encounter are triggered by an acute need and vary from patient to patient, such as general practitioners and emergency medical services. On the other hand, through the generalisability of the results, it serves the purpose of conducting a quick evaluation of a technical solution which is required to be designed, implemented and scaled rapidly to provide a timely response to the pandemic.
The case studies employed a mixed-method approach utilising both qualitative and quantitative analytical techniques to investigate three main dimensions: organisational impact, modification of patient-provider relationship, acceptability and usability of the technical solution. The organisational impact was investigated involving all healthcare providers in two online focus groups, the first to establish a baseline before the onset of the project and a final one to discuss the results of the use of the platform. The modification of the patient–provider relationship was explored with specific questions in the focus group with providers and through dedicated telephone interviews with patients to have a narrative account of their experience and discuss in more detail the future of teleconsultation. The acceptability of the platform was assessed by asking all patients to complete a survey about their socio-demographic profile, the usability of TreC_Televisita (assessed through the System Usability Scale (Lewis 2018), the appreciation of relevant dimensions of the visit, and comments regarding the possibility to extend such form of communication beyond the coronavirus pandemic period.
The analysis of the initial focus groups with providers sheds some light on the perceived opportunities and barriers of TreC_Televisita. Healthcare providers have shown appreciation for the opportunity to test (and possibly adopt) an ‘official’ technology. While they appreciated the possibility to keep in contact with patients during the hardest months of the pandemic offered by SMS, instant messaging platforms (i.e. WhatsApp), email, Google Meet or the like, they hailed a system whose use was explicitly endorsed by the local healthcare trust. Moreover, such a system is perceived as instrumental to identify one preferred channel of communication with patients. Moreover, clinicians regarded with particular interest the control granted by the platform which, unlike other systems, offers the possibility to manage the flow of communication with patients allowing for a smoother integration of teleconsultation in their usual workflow.
In order to further scale up the solution to more patients and clinical domains, a strategy should be defined to overcome the potential barriers that may arise, as defined below.
Ensuring the long-term sustainability of TreC_Televisita
Even before the number of people infected by COVID-19 started to dwindle and limitation restrictions were waived, TreC_Televisita was becoming a structural part of the services offered within TreC; therefore, the fourth step of the methodology relates to the identification of barriers that might undermine the future sustainability of the tool. This issue should be thoroughly considered in order to avoid what in literature is defined as ‘pilotitis’, i.e. ‘the growing concern that most of the telemedicine innovations never make the threshold from pilot project stage to full implementation and translation into quality care practice’ (Harst et al. 2019). Thus, ensuring the scalability and the long-term implementation of eHealth solutions requires an upstream definition of what the barriers are and the risks that such solutions might face as well as the strategies for their mitigation.
This section aims at identifying the main potential barriers for implementation of the TreC_Televisita solution in the long term. In the short term, TreC_Televisita aimed at its definition and implementation in the Trentino context to mitigate the effects of the COVID-19 pandemic; in the future, the solution will be applied to a broader context, be it more clinical domains or larger geographical focus in a sustainable way. In fact, a wider domain of application of tele visit services originated in Trentino Province foresees the potential engagement of other Italian public administrations through the practice of ‘re-use’ of services.Footnote 11 In this regard, according to the implementation research guidelines (Peters et al. 2013), contextual differences are key factors leading to failure when transferring a service from one country to another. Hence, even though TreC_Televisita is not yet in the scalability phase, it was decided to conduct a revision of state-of-the-art frameworks on barriers to telemedicine implementation to analyse the applicability of potential solutions and lessons learnt to the Trentino context.
Therefore, while the authors acknowledge the numerous works related to the definition of the main barriers hampering the implementation of telemedicine solutions in different geographic contexts and with different clinical targets (e.g. Medhanyie et al. 2015 in Ethiopia for the implementation of telemedicine for maternal healthcare; Ag Ahmed et al. 2017 changed perspective by defining success factors for maternal health in Sub-Saharan Africa; Jang-Jaccard et al. 2014 in rural Australia; or Waterson et al. 2012 who described the barriers in the UK for solutions for frail elderly, just to mention a few), it was decided to consider only the literature review that proposes a barrier framework targeting telemedicine solutions without specific clinical or geographical reference. First, we analysed Harst et al. (2019) recent survey as a review of previous reviews; however, all the works considered present a form of verticalization, either clinical or geographical, often both. After analysing the list of Harst’s references, van Dyk’s review of telehealth services (2014) was thoroughly evaluated, especially where the author highlights the relationship between Tanriverdi and Iacono’s (1998) and Khoja’s (Khoja et al. 2007) works: his result, displayed in Table 2 below, is a framework where Tanriverdi and Iacono’s barriers are defined at micro as well as macro level and that matches the potential barriers identified for the implementation of telemedicine in Trentino.
van Dyk’s barrier framework is the one that better matches the Trentino healthcare context and thus was chosen for the analysis of the barriers related to the large-scale adoption of TreC_Televisita. The framework defines four macro categories that include the main aspects for its development (technical and economical) and first adoption (behavioural and organisational): the subdivision provides a definition in relation to the actors involved (end-users, policy, society as a whole) and to the practical elements necessary for its implementation. Moreover, for the subject of this paper, such a framework was extended with other criteria, namely the legal and ethical aspects involved in providing tele visit services, to better include all the dimensions of TreC_Televisita and to be more adaptable to the Trentino healthcare system context. Table 3 below describes the barriers that TreC_Televisita will/might need to overcome (or has already overcome) for its large-scale implementation. A set of different goals have been identified by the Healthcare Trust administration, considering the different stages of the epidemic. A short-term goal was to reach 30% of tele visits in the first part of the epidemic peak (on the total of clinical visits performed for that period), a target of 50% was set as a standard percentage considering follow up visits, and a long-term target of 60% was identified, including also tele visits performed by the community clinics at local districts level.
Even though the implementation of a tele visit service poses major barriers and challenges that require a great effort from the decision makers, significant opportunities arise as well. First of all, during the COVID-19 emergency TreC_Televisita has enabled clinicians and patients to respect the social distancing measures, decreasing the risk of contagion while performing healthcare services; at the same time, tele visit allowed eliminating geographical barriers among patients and healthcare professionals. In addition, the scale-up of TreC_Televisita might allow a reduction of costs in the long term. As a matter of fact, the European Union has encouraged the development of telemedicine throughout the years, with guidelines, communication, action plans, as well as financial investments. In 2008, the European Commission adopted the ‘Communication on telemedicine for the benefit of patients, healthcare systems and societyFootnote 12’, defining three goals: (i) to build confidence in and acceptance of telemedicine, (ii) clarify legal aspects and (iii) solve technical issues and ease market development. The COVID-19 emergency was a strong trigger that led healthcare providers and policy-makers towards this direction: the reasons why decision makers did not commit to the implementation of tele visits before might be connected to the difficulties in assessing the efficacy of telehealth. In fact, this depends on multiple factors (e.g. demographics, quality and modality of the service provided) and, therefore, the scientific community is still evaluating its pros and cons. In this perspective, after a few years of implementation at operating speed, TreC_Televisita might be a forerunning experience that will allow a proper assessment of clinical, social, organisational and economic factors, eventually leading to an increasing number of tele visit services to become structural in other healthcare systems.