A study of a rural community s readiness for telehealth

Original article... " A study of a rural community s readiness for telehealth Penny Jennett*, Andora Jackson*, Theresa Healy {, Kendall Ho {, Arminee Kazanjian, Robert Woollard**, Susan Haydt {{ and Joanna Bates** *Health Telematics Unit, University of Calgary; { School of Environmental Planning, University of Northern British Columbia; { Continuing Medical Education, University of British Columbia; Centre for Health Services and Policy Research, University of British Columbia; **Faculty of Medicine, University of British Columbia; {{ Department of Sociology, University of Calgary, Canada Summary A qualitative approach was used to explore the readiness of a rural community for the implementation of telehealth services. There were four domains of interest: patient, practitioner, public and organization. Sixteen semistructured telephone interviews (three to five in each domain) were carried out with key informants and recorded on audio-tape. Two community awareness sessions were held, which were followed by five audio-taped focus groups (with five to eight people in each) in the practitioner, patient and public domains. In addition, two in-depth interviews were conducted with community physicians. Analysis of the data suggested that there were four types of community readiness: core, engagement, structural and nonreadiness. The level of readiness varied across domains. There were six main themes: core readiness; structural readiness; projection of benefits; assessment of risk; awareness and education; and intra-group and intergroup dynamics. The results of the study can be used to investigate the readiness of rural and remote communities for telehealth, which should improve the chance of successful implementation. Introduction The successful introduction of telehealth services has the potential to solve a number of pressing problems facing the Canadian health-care system, including clear inequities in health status, quality of care and access. (For the purposes of this study, telehealth is defined as the use of advanced telecommunications technologies to exchange health information and to provide health-care services across geographical, temporal, social and cultural barriers 1.) These are challenges often faced by rural and remote Canadians 2. A key justification for telehealth is the Canada Health Act the cornerstone of the publicly funded Canadian health system, which promises comprehensive, Accepted 27 March 2003 Correspondence: Dr Penny Jennett, Faculty of Medicine, Health Telematics Unit, University of Calgary, G204 Health Sciences Centre, 3330 Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada (Fax: +1 403 270 8025; Email: jennett@ucalgary.ca) universal and accessible care for all citizens regardless of gender, race or place of residence 3. The successful introduction of telehealth requires the examination of complex social, political, organizational and infrastructure factors. Theories suggest that multiple factors determine whether an innovation is successful or not, although the interactions and relationships among these factors and the adoption of an innovation are not clear 3. One such factor is readiness, which is a preliminary requirement for the successful implementation of telehealth 4. Readiness can be defined as the degree to which a community is prepared to participate and succeed in telehealth 4, and is the cognitive precursor to behavioural resistance to, or support for, change 5 10. Large-scale information technology (IT) projects are associated with failure rates of 30% or more 11 13. A better understanding of readiness may help to reduce this rate. The failure of telehealth systems (which generally represent a substantial IT investment) can result in a substantial waste of time, money and effort 14,15. Journal of Telemedicine and Telecare 2003; 9: 259 263

The present study was designed to examine the readiness of a single rural community for the implementation of telehealth services, as the first step in creating a readiness framework that could be used in further exploration of this concept. We used a qualitative approach to explore the meaning of readiness for telehealth 16. Methods The literature suggests that there are four domains that are relevant to telehealth readiness: patient, practitioner, organization and public 3. Telehealth, as an element of clinical health-care, involves the patient and practitioner domains, as well as elements of the organizational domain. Telehealth at the level of the community for health promotion and prevention programming involves the public domain 3. A Canadian town that met the definition of a rural community used by Statistics Canada 3 was selected to act as an exemplar community. Data on telehealth readiness were collected from expert key informants, clinicians and from the lay community. A convenience sample was recruited. All key informants were experienced professionals who were active in telehealth. The interviewers were experts within their specified domains and had extensive experience in conducting interviews and focus groups. The data reflected both retrospective (key informants) and prospective (community participants) views of readiness. Permission for the study was granted by the appropriate ethics committees and consent was obtained from the participants. Sixteen semistructured, audio-taped telephone interviews (three to five in each domain) were carried out with key informants. Two community awareness sessions were organized, which were followed by five audio-taped focus groups (with five to eight people in each) in the practitioner, patient and public domains. In addition, two in-depth interviews were conducted with community physicians. The data were organized using both programme and implementation theory 17. Programme theory is abstract in its focus. It addresses the effect of intangible factors, such as people s reactions to programme activities, cultural factors, and interactions between and within communities. Implementation theory focuses on identifying the concrete steps that programme designers take to implement a programme successfully. Once organized, the data were coded and analysed using a multi-step approach. Theory and data were treated as dialectic, that is, the programme s theories of change were kept in mind while reading and organizing the data, but analysis remained open to other processes, patterns and ideas 3. As new themes arose, transcripts were read and coded by one analyst several times in order to answer the following questions: (1) What factors do key informants believe contribute to a successful service? (2) How do these relate to readiness? (3) How do various communities react to the prospect of telehealth? (4) What do these tell us about readiness from the perspective of various communities? Results The data suggested that there were four types of readiness: core readiness, engagement, structural engagement, and non-readiness. Core readiness Key informants strongly expressed a combination of genuine need for telehealth services (usually based on conditions caused by isolation) and a felt or expressed dissatisfaction with current conditions. These community members were willing to adopt new practices (like telehealth) to create change. This core readiness was evident in all domains. Engagement Less obvious in the data was a process in which people actively engaged with the idea of telehealth, weighing its perceived advantages and disadvantages. This process was most obvious in the focus group data, where people were aware of their needs as members of a rural community, but were unaware of the potential of telehealth applications. These people did not immediately and unquestioningly accept telehealth as a solution. Rather, they asked questions about what telehealth could do, and expressed their hopes, fears and concerns about adopting such a system. This process of actively questioning telehealth also appeared in the key informant interviews, in the form of resistance to, or hesitation about, using telehealth. Structural readiness A considerable quantity of data focused on building efficient structures (e.g. people, training and technical) to support the successful implementation of telehealth. People s perceptions of the structure of telehealth and how it could work (or not work) were often related to 260 Journal of Telemedicine and Telecare Volume 9 Number 5 2003

their willingness to adopt it, which suggests a relationship between engagement and structural types of readiness. Some data specifically focused on building efficient structures, such as suitable network connections, to support implementation. Non-readiness Instances of non-readiness, characterized by a lack of need for change, or a failure to recognize such a need, were apparent in the data, across all domains. Common factors within types of readiness Six prominent themes, or factors, were identified (Table 1). These were: core readiness, structural readiness, projection of benefits, assessment of risk, awareness and education, and intra-group and inter-group dynamics. Core readiness Core readiness seemed relatively stable and consistent across all of the communities. Where telehealth services had been successful, there was always a recognized need for the service, along with an expressed dissatisfaction with existing services or circumstances. Further, the isolation of the rural or remote area was shown repeatedly to be a factor in creating needs. Structural readiness Appropriate infrastructure was required for successful telehealth services. This infrastructure included adequate human resources, training, policies, funding and appropriate equipment that functioned properly or was easily repaired. Since users fears and reservations were often linked to telehealth structures, levels of readiness among the practitioner, patient and public communities were higher if they perceived the structures surrounding telehealth to be adequate. Finally, it was suggested by respondents that allowing flexible and multiple uses of telehealth equipment would allow for greater responsiveness to meeting community needs, and would increase the chances of the successful use of telehealth services. Projection of bene ts An appreciation of the benefits that telehealth could bring to rural and remote areas was present in all the domains. Respondents from all communities were able to visualize ways in which telehealth would relieve some of the strains that isolation placed on their health-care system. All hoped that telehealth would reduce the need to travel, improve access to services and information, support the quality of services, as well as enhance the professional education of practitioners in rural and remote areas. Assessment of risk In addition to the sense of benefit in adopting telehealth, there was an assessment of risk on the part of each domain. For practitioners, the risks of telehealth ranged from demands on working time and professional liability to deciding whether to trust the information available to them through Web-based applications. For patients, the risks related to privacy and the obtaining of reliable information. The data from the public perspective reflected a fear that telehealth services would replace the existing healthcare system, along with face-to-face contact with practitioners. Furthermore, there was the perceived risk of excluding poorer or less educated segments of the population from health services. For organizations, telehealth presented a financial risk, especially in the short term. Educating the communities of interest in remote settings about the strengths and limitations of this alternative way of providing care and information will be important. Awareness and education Awareness and education were significant themes in the data, and potentially represent a broader, structural-level solution to some of the problems raised. Overall, respondents stated that a genuine understanding of telehealth (understanding the various applications, their potential benefits and limitations) was linked to a readiness to adopt. (In any case, not having this understanding makes people wary about adopting it.) Awareness and education may be spread via information campaigns or through example, with champions or innovators playing a major role in the latter. The public and patient data-sets referred mainly to the role that information campaigns could play, while the practitioner and organizational datasets referred mainly to the role of champions in diffusing information through example (demonstration, visible successful use). Learning through example was believed to be far more potent in its effect of producing readiness than the provision of information only. Planners of future information campaigns might consider demonstrations as part of a campaign. Intra-group and inter-group dynamics Group interaction was a theme that occurred repeatedly throughout the data. Both intra- and inter- Journal of Telemedicine and Telecare Volume 9 Number 5 2003 261

Table 1 Factors within three types of readiness a, by study domain Type of readiness Public Patient Practitioner Organization Core readiness Dissatisfaction with the current state of health-care Dissatisfaction with typical doctor patient interaction; desire for a more comfortable setting for obtaining health information Desire for change Isolation; poor access Sense of isolation, lack of access Recognition of unmet need Desire for change; willingness actively to help themselves or their condition Extreme dissatisfaction with the status quo First-hand understanding or experience of negative effects of isolation Driving need to address a public or patient problem (as opposed to a practitioner-specific one) Recognition of unaddressed needs Dissatisfaction with the organizational status quo Engagement Wanting to know what telehealth is; having a clear definition of telehealth Recognizing (or estimating) the benefits of telehealth Having a sensitive health condition; desire for privacy regarding health practice Knowledge about what exactly telehealth is Knowledge about the benefits (or anticipated benefits) Fear of damaging equipment Gender Privacy concerns Availability and reliability of content that fits rural or remote culture Address concerns about telehealth as a replacement for existing services Sense of ownership Innovators; champions Sense of curiosity Peer influence Evidence of utility Inter-group cooperation (between practitioners and the other domains) Intra-group cooperation (between working practitioners) Communication Openness; respect for others Willingness to make initial extra investment in time Champions Availability of risk takers, pioneers Education and awareness for innovators Reduction of nay-sayers/resisters Ability/willingness of senior administration to consider benefits outside standard business case/costeffectiveness schemes Willingness to consider long timelines for implementation Movement from short-term funding; short-term accountability deadlines Cost benefit analysis Established mechanisms of knowledge transfer between staff Structural readiness Education Availability of formal and informal information networks Availability of testimonials from people Awareness campaigns Champions, especially local ones Community consultation sessions; sense of ownership Healthy inter-organizational dynamics in promotion activity Education about telehealth Awareness of telehealth; overcoming sense of vulnerability in videoconference Ability or training to use equipment Practitioner-mediated liaison for telehealth programmes Addressing scheduling concerns; overextended workloads 24-hour access to equipment Established reimbursement plans Reliability of equipment; good technical support; backup plans Confirmation of reliable and available clinical consultants Reliable content (clinical and continuing medical education) Liability Identification of equipment difficulties; bugs Well conducted needs assessment Community consultation process; ownership Allowance for creative use of equipment by practitioners and patients Accessible, comprehensive technical support, locally available and on-call Effective scheduling; integration into the routine Proper facilities (lighting, size, heating); adequate equipment Accessible, sustained staff training (including training at medical school to encourage routine perception) Provision of a telehealth coordinator Written policy on reimbursement, liability, cross-jurisdiction use, privacy Sufficient ongoing funding (local, provincial, federal) a The fourth type of readiness was non-readiness. This was characterized by lack of need for change, or a failure to recognize such need. This type was apparent across all domains, but factors within non-readiness were not explored. group dynamics were found to play a role in readiness. Intra-group dynamics were examined in detail in the organizational and practitioner data-sets, where innovators were shown to play an important role in diffusing innovations like telehealth. A healthy respect for the various levels of readiness in the practitioner community was believed to be important in allowing a gradual spread of telehealth with the least resistance. Inter-group dynamics were examined to some extent in all domains, but were most obvious in the public and organizational data-sets. Communication across the communities of interest (in the form of consultation and effective listening) and cooperation between these communities were emphasized as factors that contribute to readiness to adopt telehealth. Discussion Previous studies have identified readiness as a preliminary requirement for success in the adoption of 262 Journal of Telemedicine and Telecare Volume 9 Number 5 2003

telehealth 4 10. Based on the literature, we examined four domains of interest, in a single rural community. The present study identified an initial classification scheme for telehealth readiness for rural and remote communities. There were four types of readiness: core readiness, engagement, structural readiness and nonreadiness. Key informants stated that readiness in telehealth was related to needs and a willingness to try telehealth as a solution. Although readiness varied across the four domains (public, patient, practitioner, organization), there were six themes and related comments that were repeated. For example, within existing systems of health-care, strong, flexible and responsive telehealth structures are required. Education and awareness campaigns, including demonstrations, also promote readiness by enhancing a sense of curiosity and willingness, and by spreading the understanding of the benefits and limitations of telehealth. Indeed, from the perspective of Prochaska and DiClemente 9, anything that moves a community or individual from pre-contemplation to contemplation (e.g. awareness sessions) will increase readiness and accelerate the process of change. The results of the present study create a framework which can be used when investigating the readiness of rural and remote communities for telehealth. Acknowledgements: We are grateful to all the key informants, community members and volunteers who supported and participated in this project. We acknowledge the valuable work of the other project research assistants Gilat Linn, Christina McLennan, and Monica Pauls. This project was funded by the Canadian Network for the Advancement of Research, Industry and Education (CANARIE) and Health Canada s Of ce of Health and the Information Highway (OHIH). References 1 Reid, J. A Telemedicine Primer: Understanding the Issues. Billings, MT: Innovative Medical Communications, 1996 2 Health Canada. Towards a Healthy Future: Second Report on the Health of Canadians. Federal, Provincial and Territorial Advisory Committee on Population Health, 1999. See http://www.hc-sc. gc.ca/hppb/phdd/report/subin.html. Last checked 11 March 2003 3 The Alliance for Building Capacity. Framework for Rural and Remote Readiness in Telehealth. Project report for CANARIE, June 2002. See http://www.fp.ucalgary.ca/telehealth/projects-canarie- Final%20Report,%20June%202002.htm. Last checked 26 March 2003 4 Information Technologies Group, Center for International Development at Harvard University. Readiness for the Networked World: A Guide for Developing Countries, 2002. See http:// www.readinessguide.org/. Last checked 11 March 2003 5 Armenakis AA, Harris SG, Mossholder KW. Creating readiness for organizational change. Human Relations 1993;46:681 703 6 Lewin K. Frontiers in group dynamics. Human Relations 1947;1:5 41 7 Lewin K. Field Theory in Social Science. New York: Harper and Row, 1951 8 Coch L, French J. Overcoming resistance to change. Human Relations 1948;1:512 32 9 Prochaska JO, DiClemente CC. Transtheoretical therapy: toward a more integrative model of change. Psychotherapy: Theory, Research, and Practice 1982;19:276 88 10 Rogers EM. Diffusions of Innovations. 3rd edn. New York: Free Press, 1983 11 Dowling AF. Do hospital staff interfere with computer system implementation? Health Care Management Review 1980;5:23 32 12 Lyytinen K, Hirschheim R. Information system failure a survey and classification of empirical literature. Oxford Surveys in Information Technology 1987;4:257 309 13 More E. Information systems: people issues. Journal of Information Science, Principle and Practice 1990;16:311 20 14 Southon FC, Sauer C, Grant CN. Information technology in complex health services: organizational impediments to successful technology transfer and diffusion. Journal of the American Medical Informatics Association 1997;4:112 24 15 Doolittle GC. Telemedicine in Kansas: the successes and the challenges. Journal of Telemedicine and Telecare 2001;7 (suppl. 2):43 6 16 Taggart WHJ. Enablement and the Community. A Policy Approach for the Future. Ottawa, ON: Canada Mortgage and Housing Association, 1997 17 Weiss C. Evaluation: Methods for Studying Programs and Policies. 2nd edn. Upper Saddle River, NJ: Prentice Hall, 1998 Journal of Telemedicine and Telecare Volume 9 Number 5 2003 263