This research has examined the issue of teleconsultation project sustainability from the perspective of participating healthcare providers. However, their continued participation and project sustainability are not ends in and of themselves; rather, they are useful only if they improve healthcare delivery at remote sites. Implementing the design steps identified in this research (learning and convenience) has the potential to do so in a number of additional ways than just by providing limited increased access to HSC specialists.
The increased expertise of RSHCPs enabled them to handle more complex problems locally without the need to refer patients to HSC specialists. This made them better able to handle patients requiring follow-up care in general, and, in particular, the many challenges patients with chronic conditions face. This had the potential to reduce the cost of care because such patients are more likely to be compliant and thus cheaper to treat if keeping such appointments is easy and convenient. HSC specialists and RSHCPs time constraints concerns were further addressed because the ability of RSHCPs to handle more complex problems on their own resulted in fewer teleconsultation sessions.
Further, when teleconsultation sessions did occur, the evidence suggests that access to HSC specialists was increased in that they could see more patients in a given amount of time than they could see face-to-face at their clinics. For example, HSC Y Burn Specialist estimated he tended to see nine to ten patients per hour via telemedicine compared to five or six in a face-to-face setting. One reason for this was process-based, where the teleconsultation sessions required changes that shifted the workload away from HSC specialists. For example, in teleconsultation sessions, it was the patient who had to in effect change rooms, unlike face-to-face sessions where it was the specialist who had to move from patient to patient. An additional reason was that RSHCPs, by seeing patients on a regular basis and often being their primary care provider, were more familiar with the patients than whoever prepped them at the HSC clinic. Combined with their increased expertise, RSHCPs could better predict the relevant background information HSC specialists might or might not require, and this enabled RSHCPs to proactively provide such information without being asked.
In effect, RSHCPs were often required to take on a number of additional roles and responsibilities not necessary in a face-to-face setting. This highlighted the importance of trust in the relationships between HSC specialists and RSHCPs. HSC specialists had to trust the competency of RSHCPs, and RSHCPs had to be willing to take on new roles and trust that HSC specialists would be accepting of such new roles and input. Further, by combining HSC specialists’ expertise with RSHCPs’ local knowledge of the patient, teleconsultation projects had the potential to provide higher quality integrated care. For example, Project HCV had collected preliminary data showing that the outcomes for patients treated for hepatitis C via the teleconsultation project were as good if not better than the results of patients being treated at HSC Z only.
Teleconsultations sessions utilized as a means by which to exchange information were particularly useful when the information required was complex and needed to move the process from one stage to the next when addressing patient healthcare issues. The findings indicated that the most useful telecommunication consultations occurred when both sides of the teleconsultation project were learning from the exchange. This raised the level of consultation and enabled growth of all parties involved.
The findings indicated that the importance and effectiveness of designing for learning held regardless of whether participants were physicians or other healthcare professionals. Project ECDD‘s HSC participants were primarily non-physician specialists, yet their attitudes and beliefs about the philosophy of the teleconsultation projects and the importance of learning were consistent with those expressed by HSC physicians involved in other projects. Although only three of the teleconsultation projects (Project HCV’s Z1 and Z3 and Y4’s Oncology) involved physicians at remote sites, there appeared to be little or no difference between these and other RSHCPs in terms of the critical role continuous, collaborative learning played in their decision to continue to participate in teleconsultation projects. Rural areas also tend to have significant challenges in both attracting and retaining healthcare providers [47–49], and the learning aspect of teleconsultation projects can help overcome the sense of professional isolation that often contributes to RSHCPs leaving.
The findings also indicated that, when comparing individual teleconsultation projects, there was no evidence to suggest that severe time constraints were an even greater problem for those projects that were discontinued by the healthcare participants themselves (as opposed to the telemedicine network); rather, the healthcare providers involved did not perceive the teleconsultation projects as being of sufficient value to continue to participate in relative to the time commitment required.
Although outside the scope of this article, it should be noted that, contrary to what was probably the most common reason given in the literature [4, 6, 14], limited reimbursement was not perceived as a major barrier to telemedicine project sustainability. For the HSCs, there were a number of possible explanations for this. First, the amount of time that individual participating HSC specialists allocated to non-specialty teleconsultation projects was quite limited and averaged approximately one session per month. Second, in the case of the specialty teleconsultation projects involving conditions with long-term treatment regimens or follow-up, HSCs often were reimbursed on a global fee basis—making teleconsultation session reimbursement a moot point. Third, many of the teleconsultation sessions involved indigent care, where HSC specialists were not going to be reimbursed whether the patient was seen via telemedicine or in the clinic. Moreover, the HSCs studied had not developed the administrative processes necessary to file reimbursement claims for eligible teleconsultation sessions. Finally, many of the teleconsultation project sessions were not eligible for remote site reimbursement because the patient was not present during the teleconsultation sessions themselves.
Contributions to research and practice
This research makes significant contributions to research and practice by making researchers, policy makers, and participating organizations aware of what influences healthcare providers’ continued participation in teleconsultation projects, and by providing implementable and affordable design steps to address these influencing factors. It also provides an alternative perspective on designing, implementing, and evaluating teleconsultation projects to facilitate their sustainability.
The findings indicated that the challenges of provider time constraints and remote participant professional isolation can be effectively and efficiently addressed by designing the teleconsultation projects for convenience and to facilitate learning. Mechanisms by which RSHCPs were empowered through the leveraging of HSC specialists expertise when so little time was actually dedicated to teleconsultation sessions themselves were identified. This research also further explains why teleconsultations appear to be especially relevant to effectively managing chronic conditions and those with long treatment regimens by facilitating and thus increasing the likelihood of patient compliance over the long term.
This research is consistent with and helps explain why teleconsultation projects sustained over time were collaborative in nature and included the active participation of all the healthcare providers involved. This study deepens our understanding of why interpersonal trust is a necessary precondition for telemedicine projects to have a positive impact on remote site healthcare delivery . Active, continuous learning is a collaborative process that requires not only interpersonal trust of the other parties but trust that the technology is reliable and suitable for the demands learning places on it, and trust that the processes that facilitate the teleconsultation sessions themselves are necessary and properly carried out.
This research also provides a counter argument to the popularly-held belief that technology requirements for effective teleconsultation must be quite advanced because they must replicate the face-to-face experience [1, 4, 38, 50]. Instead, it supports and helps explain why other studies have found that technology challenges related to teleconsultation projects deal with the technology being too complex and having more functionality than needed, and, in some cases, not having the relatively basic functionality healthcare provider participants wanted [38, 51].
This research is not without its limitations. First, even though drawing on data collected at two different points in time, this study was not actually multiperiod because much of the data included cases that were not active at the time of the first study. However, it can be argued that in some ways this further strengthens the findings presented because inferences were able to be drawn from data about projects that were relatively inactive or not sustained, and these inferences could be compared against the characteristics of those teleconsultation projects that were sustained over time. It is argued the timing of the two data collection periods were appropriate and enabled the collection of the necessary data. While there are many reasons for this, a key reason was that most telemedicine projects at the time of the first data collection period started as pilot studies or proof of concept, while those from the second data collection period occurred after the efficacy and efficiency of telemedicine for many clinical activities had been established and the deployed teleconsultation projects were now being done as part of organizations’ ongoing operations.
Second, this research involved only teleconsultation projects located in the United States, which has its own characteristics in terms of healthcare providers, payers, and regulations which may not hold in other parts of the world. While these findings are consistent with and extend prior studies done in Australia, whose healthcare system differs significantly from that of the United States , this research needs to be replicated in additional countries with differing healthcare systems.
Third, while the sample size was limited, it is argued that the diversity in the types of healthcare activities practiced, the professional qualifications of healthcare providers involved, and population size, location, and remoteness of the sites themselves makes this an appropriate sample. The results between those teleconsultation projects located in areas designated metropolitan and those in nonmetropolitan areas exhibited no meaningful difference. The majority of remote sites in this study were located in nonmetropolitan areas were in effect rural, and rural areas tend to face healthcare challenges that are similar to or in some cases more pronounced than urban areas because rural populations tend to be poorer, older, and have higher rates of certain chronic diseases [4, 27, 52].
In addition to addressing the limitations discussed above, future research needs to examine the effect of widespread deployment of electronic health records (EHRs) shared by both remote sites and HSCs. At the time of the second data collection period, only Primary Care Project Y5 had integrated the use of EHRs into its teleconsultation sessions (HSC Y had integrated the state’s Department of Corrections’ EHR into their correctional facility telemedicine projects). None of the other projects had done so. Most had not even integrated the ability to receive laboratory reports in a format other than paper or facsimile. As a result, RSHCPs believed administrative burdens related to their continued participation in teleconsultation projects presented additional time constraints. Future research is needed to determine the extent to which integrated EHRs can help address the increased administrative overhead RSHCPs often face as a result of their continued participation. It is also needed to better understand whether teleconsultation projects with integrated EHRs can further improve the quality of care by enabling patients to receive more integrated care. This could be especially important as healthcare moves from episodic to preventative care.
Future research is needed to address whether or not healthcare providers require certain characteristics, and whether those characteristics can be determined by professional qualifications or are individually-based. Teleconsultation project participants require a certain level of qualifications to take advantage of the learning aspects, but the results from this study suggest it is individual characteristics and not professional qualifications that matter more. Future research is needed to determine whether it is the ability and willingness of the participants, given a certain level of training not specific to physicians, to learn and assume new roles that is more important to their continued participation than is the formal professional qualifications RSHCPs hold. Furthermore, given the status differentials between the project participants, a better understanding of the social processes and power dynamics involved in teleconsultation projects might also be needed.