How can telehealth help in the provision of …

1 POLICY BRIEF 13 HEALTH SYSTEMS AND POLICY ANALYSISHow can telehealth help inthe provision of integratedcare?Karl A. Stroetmann, lutz KubitschkeSimon Robinson, Veli StroetmannKevin Cullen, David McDaid World Health Organization 2010 and World HealthOrganization, on behalf of the European Observatoryon Health Systems and Policies 2010 Address requests about publications of the WHOR egional Office for Europe to:PublicationsWHO Regional Office for EuropeScherfigsvej 8DK-2100 Copenhagen , DenmarkAlternatively, complete an online request form fordocumentation, health information, or for permissionto quote or translate, on the Regional Office web site( ).All rights reserved. The Regional Office for Europe ofthe World Health Organization welcomes requests forpermission to reproduce or translate its publications,in part or in designations employed and the presentation ofthe material in this publication do not imply theexpression of any opinion whatsoever on the part ofthe World Health Organization concerning the legalstatus of any country, territory, city or area or of itsauthorities, or concerning the delimitation of itsfrontiers or boundaries.

2 Dotted lines on mapsrepresent approximate border lines for which theremay not yet be full mention of specific companies or of certainmanufacturers products does not imply that they areendorsed or recommended by the World HealthOrganization in preference to others of a similarnature that are not mentioned. Errors and omissionsexcepted, the names of proprietary products aredistinguished by initial capital reasonable precautions have been taken by theWorld Health Organization to verify the informationcontained in this publication. However, the publishedmaterial is being distributed without warranty of anykind, either express or implied. The responsibility forthe interpretation and use of the material lies with thereader. In no event shall the World HealthOrganization be liable for damages arising from itsuse. The views expressed by authors, editors, or expertgroups do not necessarily represent the decisions orthe stated policy of the World Health policy brief is one of anew series to meet the needsof policy-makers and healthsystem managers.

3 The aim is to develop keymessages to supportevidence-informed policy-making, and the editors willcontinue to strengthen theseries by working withauthors to improve theconsideration given to policyoptions and :TELEMEDICINECOMPUTER COMMUNICATIONNETWORKS utilizationDELIVERY OF HEALTH CARE, integrated trendsHEALTH POLICYCOST BENEFIT ANALYSISE ditorsWHO Regional Office forEurope and EuropeanObservatory on HealthSystems and PoliciesEditorGovin PermanandAssociate EditorsEnis Bar s Josep FiguerasJohn LavisDavid McDaidElias MossialosManaging EditorsJonathan NorthKate Willows FrantzenThe authors and editors aregrateful to the reviewerswho commented on thispublication and contributedtheir can telehealth help in the provision ofintegrated care?ContentsPageKey messagesExecutive summaryPolicy briefHealth policy context and current use1of telehealthWhat do we know about the benefits8and effectiveness of telehealth ?Policy options to help foster use of12telehealth as a support to integratedcare systems Identifying alternative ways of 18bringing about changeSummary and outlook 23 References24 AuthorsKarl A.

4 Stroetmann, lutz Kubitschke, SimonRobinson and Veli Stroetmann empiricaCommunication and Technology Research, Bonn,GermanyKevin Cullen Work Research Centre, Dublin,IrelandDavid McDaidLSE Health & Social Care andEuropean Observatory on Health Systems andPolicies, London School of Economics andPolitical Science, London, United KingdomISSN 1997-8073 Key messages Demographic change, rising incidence of chronic disease and unmet needsfor more personalised care are trends that demand a new, integratedapproach to health and social care. Professionals must work across sectorsas a team with common goals and resources to deliver a coordinatedresponse to each individual's care requirements. Advanced informationand communications technology (ICT) provides a major new opportunityto realise care integration, superseding today's chain of disjoint responsesto discrete threats to health. telehealth , the provision of care at a distance, is a key component in futureintegrated care.

5 Today's segregated telehealth applications still requirelinking into more comprehensive eHealth strategies, in which clinicalpathways and service delivery processes are fully coordinated and patientdata safely shared. An increasingly solid evidence base is emergingindicating that telehealth can be used effectively to respond to thegrowing call for improved care, in particular for those with chronicconditions. Mainstreaming remains a challenge; market forces alone arelikely to remain insufficient. Making the case for investment in telehealth applications requires bettermarshalling of existing evidence, not only to show that telehealth works,but also to show where in what organisational context it will from large-scale pilots and the few mainstream implementationsrequires careful synthesis, taking particular account not only of clinicaldimensions but also of indicators relating to successful deployment innormal care: change management, human resources, organisationalinterfaces, financing requirements, technology integration and ethics foreveryday practice.

6 Financial flows in health systems must be critically assessed for their abilityto act as incentives or disincentives for telehealth provision ,acknowledging that the business case for telehealth is often verydifferent for different players. Medico-legal and regulatory regimes canalso pose critical barriers to the exploitation of telehealth . The variousregimes should be compared to identify best practice and opportunities forregulatory and legislative reform, so as to facilitate better integrated carethrough the use of telehealth . The use of telehealth , as a tool to help support better integrated care, canbe helped through initiatives that bring policy responsibilities together. Thiscould include setting up financial and organisational vehicles (jointbudgets, joint ventures) to support partnership across can telehealth help in the provision of integrated care? To bring about change, mechanisms should be put in place to fosterdialogue, thereby instilling a sense of partnership in reform and reducingresistance to change.

7 Process innovation driven by clear health policypriorities should precede telehealth design technology on its own cannotbe expected to deliver. Change management must fully engage allinvolved participants. Full attention to ethical issues should be mandatoryand the usability and interoperability of today's ICT systems can, andshould be, much briefExecutive summaryThe quest for more integrated care is not itself new, but new opportunities foreffective realisation have emerged quite recently. In particular, the appropriateapplication of advanced ICT can make a major contribution towards achievingthis goal. telehealth , the provision of care at a distance, is certain to be a key componentin future ICT infrastructure for integrated care. It has already raised high hopesamong policy makers with reagrd to its potential for delivering solutions forgrowing capacity problems. For integrated care, today's segregated telehealthapplications still require linking into more comprehensive eHealth strategies, inwhich clinical pathways and service delivery processes are fully coordinated andpatient data safely few instances of routine application have yet emerged in Europe orelsewhere in contrast with an enormous breadth of research activities anincreasingly solid evidence base is emerging indicating that telehealth can beused effectively to help support better integrated care, in particular for thosewith long-term chronic optionsGenerating and using evidence of the benefits and cost effectiveness oftelehealthMaking the case for investment in telehealth applications, as one aspect of theICT infrastructure, requires better marshalling of existing evidence, not only toshow that telehealth works, but also to show where in what organisationalcontext it will work.

8 Evidence from large-scale pilots and from suchmainstream implementations as there are requires careful synthesis, takingparticular account not only of clinical dimensions but also of indicators relatingto successful deployment in normal care: change management, humanresources, organisational interfaces, financing requirements, technologyintegration and ethics for everyday comprehensive approach to its socioeconomic impact is of particularimportance in further telehealth evaluation; the human and infrastructure costsaccruing to health, as well as to social care systems and other services, shouldbe taken into account. Modelling can be used to assess the long-term benefitsand costs, and help identify the level of effectiveness a telehealth investmenthas to achieve to be considered worthwhile. How can telehealth help in the provision of integrated care?Analysing governance frameworks and institutional arrangements tofacilitate the implementation of efficient telehealth solutionsFinancial flows in health and welfare systems must be critically assessed as towhether they act as an incentive or disincentive for telehealth provision : the business case for telehealth is often very different for different players in thehealth care system and beyond.

9 Medico-legal and regulatory regimes can pose critical barriers to exploitation oftelehealth. In many jurisdictions, the regulatory framework is not well adaptedto the specific characteristics of these new services. The various regimes shouldbe compared to identify best practice and opportunities for regulatory andlegislative reform, widening achievement in optimal societal outcomes with thesupport of telehealth . Establishing mechanisms to support better collaboration across sectors The majority of mainstreamed services are still firmly located in either the healthor social care sectors. One policy imperative to support the use of telehealth asa tool to help facilitate better integrated care is to bring these policyresponsibilities closer together. This could include setting up financial andorganisational vehicles (joint budgets, joint ventures) to support partnershipacross alternative ways of bringing about changeEstablish mechanisms for awareness raising, dialogue and exchange ofinformation between stakeholdersProfessional cultures and resistance to change, as well as lack of organisationalcapacity and willingness to innovate, are key barriers that need to beaddressed.

10 One approach that can help reduce resistance to change and breakdown barriers between different stakeholder groups is to set up mechanismsthat allow for genuine iterative dialogue on potential innovation and reform. If stakeholders are involved in discussion on reform, they are more likely to havea sense of ownership over the outcomes of this process, which in turn can helpto facilitate the adoption and acceptance of new structures, includingtelehealth solutions. Pursue process-led innovationPolicy development and its transformation into strategy must, in order tosucceed, start with a strong focus on improving, streamlining and integratingservice delivery processes. Many existing processes are inconsistent, convolutedand not coordinated sufficiently to continue to deliver when a telehealthPolicy briefsolution is introduced in an attempt to support a process. Delivery processesneed to be examined, particularly where they cross different organisational andmanagement boundaries.