Table 2.
Key Elements and Representative Quotes
| ELEMENT | QUOTE |
|---|---|
| Funding | |
| “… at the end of the day the funding ends. To me any real successful project should be sustainable well beyond initial funding and I see more projects stopping the time the funding ends than projects continuing at the time the funding ends. We are still really far from it.” (RCC 7-2:40) | |
| “Once some of those resources started to pull back, which was about a year into our telehealth program, then we started to experience, ‘Oh, God, they don't have a ride. Maybe we need to get bus tokens.’ Because when the money went, then some of those resources that helped it go real smooth for us were gone. So, we had some challenges with our clients that we forgot were there once the resources left” (RCC 5-3:172) | |
| Start-up: “Right now the cost to do it, to acquire the technology and the operations cost, is prohibitive…in the places we work at” (USA 5-4:172) | |
| Capital: “But I think another barrier is some community health centers are thinking even though they receive free equipment; they might associate making that equipment work properly with, ‘Okay, I have to spend some additional dollars that I don't necessarily have. Where am I going to get that money from to do this?’” (USA 6-1: 149) | |
| “And of course there is obsolescence built into technology. We just got through talking about having a fiber optic line; we just got through talking about resolution on the screen and the different kinds of screens. So every 5 years you probably will have another capital outlay to keep up with the progress of things…” (USA 7-1:166) | |
| Regulatory | |
| “The greatest challenge is, ‘Okay if I get into this and I provide the service, how do I get paid?’” (RCC 6-9:29) | |
| “For clinical services, we had trouble getting the doctors to buy into the clinical part of it. They believe in it but there is always a reimbursement issue that puts the brakes on the clinical side of it.” (RCC 7-3:60) | |
| Reimbursement: “Who gets paid and how much and for what? The specialist and everybody want to get paid so you have to figure out how to split the fees.” (RCC 6-4:35) | |
| “We don't really know what the cost structure is with all of this. Do I compensate a subspecialist in New York at the New York rate, or do I compensate that specialist at the Biloxi rate?” (USA 5-4:15) | |
| Licensure: “ there ought to be a process beyond a governor waiving the requirements…The governors agreeing to have a process…that would be the first to come to your aid, a process for telemedicine licensure that's renewable every 2–4 years, and across all specialties that are applicable to the use of telemedicine. I am also for a national MD license that would include the use of telemedicine in disaster areas.” (USA 7-1:43) | |
| Liability: “Luckily for the state of Mississippi, we are capped on medical malpractice. Some of the other states that we are looking at going to don't have that regulatory cap. Alabama for instance…” (RCC 6-3:52) | |
| “We had to also clear this with our malpractice coverage group, who had to make a decision about whether they would cover us and our telehealth services. (RCC 6-6:14) | |
| Workflow | |
| Internal policy: “We will start a process and then we say, ‘Well, what are you going to do?’ ‘Well, I can't do this, I don't have permission to do this,’ and that has been a big barrier as well, as this is new frontier for many of us. And we are just creating policy as we go.” (USA 6-1:73) | |
| Collaborations: “… waiting to figure out what all these other collaborative relationships are going to be” (USA 6-5:122) and “… trying to figure out what kind of memorandum of understanding or contracts we would have with the subspecialists to provide that service, we haven't even gotten to that point yet” (USA 6-5:124) | |
| Procedures: “And so we have insisted that [telehealth encounters] take place concurrently in clinical settings, so that I've got a backup doctor, a backup system on the other end with the patient. I insist on two things, that there be a phone available should my visual transmission cut out due to a thunderstorm…that has happened, and I am in the middle of a critical moment with my patient, I can pick up the phone and I can carry on that conversation” (USA 7-1:202) | |
| Scheduling: “It is just logistics. Making arrangements, the timing, the coordinating of the schedules with the patients, with the specialist and putting it all together.” (RCC 6-4:160) | |
| “… we have to have a really clear scheduling process…with technology. 10:01, 10:02, it matters. So, we have to have a clear scheduling process just as we do with any clinical activity.” (USA 5-4:112) | |
| “We had an issue with controlled medications…the fact that you need to have a handwritten prescription. So that means [sending prescriptions] by overnight service.” (RCC 6-1:52) | |
| Attitudes | |
| Administrator: “…getting some of the leadership to see the importance of using it. I'm not saying they don't think it's important, but it may not be at the top of their priority list.” (RCC 7-6:33) | |
| Provider: “Many people are frustrated when they can't get a signal or…not having enough bandwidth on the servers, if there is too much…interference or breakup that significantly limits people's willingness to use it for clinical purposes.” (RCC 6-8:21) | |
| Nurse: “The nursing staff at the hospitals can actually be a major player in deciding if the system is going to work or not. If they were not involved in the decision process and they weren't involved initially looking at the program to make sure they were comfortable with it, that can easily undermine the program.” (RCC 6-3:56, 57) | |
| Champion: “The biggest challenge is first finding a champion…at the spoke end, [who] really understands and believes in [telehealth] and then finding a champion at the subspecialty end where that individual believes in its effectiveness and is willing to try [telehealth] as a different model of care.” (RCC 6-2:22) | |
| Patient: “… we found out that what we were describing wasn't sufficient for the consumer to be comfortable, so we elaborated a little bit more, and we were a little bit more patient in the explaining of [telehealth] to the consumer, because they were coming in to receive some type of psychiatric treatment, and if [getting acquainted with the technology] took longer than 5 minutes,…we gave them as much time as they needed before they got comfortable.” (USA 6-7:191) | |
| Personnel | |
| “So [telehealth] kept falling to the bottom of our list, honestly. We were trying to take care of what was coming in our doors every day. We were never able to get caught up to think about [telehealth]” (USA 5-5:73) | |
| Staffing: “If we had a staff person who, for a few months that's all he or she was thinking about, was getting [telehealth] going, it would have gotten done.” (USA 5:5:133) | |
| “There are not enough providers who see [telehealth] as a way of providing care” (RCC 7-5:38) | |
| Nurses: “Now one of the glitches is, you've got to be sure you have, at a minimum, an LPN or an RN at the other sites to get the vital signs, the BMI, and all these other [clinical] issues” (USA 6-3:55) | |
| “There is also a nurse practitioner who facilitates the patient's connection to the mental health professional. They also need to be able to write prescriptions and coordinate medications or follow-up visits with the patient at the end of the session” (RCC 6-7:66) | |
| Training: “The cost for set-up and training [is borne] at the initial onset. So that first year or at least 6 months, you need people well trained in [telehealth].” (RCC 6-2:207) | |
| “…the turnover in personnel, where the patient is. So there is always an educational process, re-educational process. You train and you train and then a new person shows up so you are right back to training again. You give them material, there is always the time factor, ‘I don't have time to do it,’ ‘I don't have time to read it’” (RCC 7-3:164) | |
| Technology | |
| “… one of my complaints is that for a while…the equipment sat in its box in the foyer of the agency…because nobody really knew exactly what to do with it. So yes, some training would have been helpful” (RCC 6-10:56) | |
| “… the level of technical assistance that was being offered was really limited…there really needed to be a much more concerted, consistent, and persistent on the ground presence here in New Orleans…and I don't think that periodic drop-bys every 6 months or a year was sufficient to make that work” (USA 7-3:73) | |
| “Number 1 would be technical assistance. I had been on the phone for several days with an engineer who was supposed to be in charge of it, but he point blank told me he wasn't very familiar with it. And we went back and forth with it for a couple of days and things just kind of fell apart, so technical assistance is paramount” (USA 6-8) | |
| “… you've got some very upset and stressed person, and you are in a difficult environment, even if it's a normal fixed clinic, and you need help. Well, the truth of the matter is you need someone who is sophisticated and who technologically deals with this. Well, where are you going to get that person…for $80,000 a year or $60,000 a year, to sit down for the brief telehealth encounters you have in any given day?” (USA 5-4:80) | |
| “… when we do have a technical problem, we like to analyze it, why it happened, what created the problem, was it a failure in procedure, was it a failure in communication, and [we] try to build some kind of redundancy into the system where that failure won't happen again” (USA 6-7:139) | |
| Evaluation | |
| “I think at the end of the day, we have to first decide what success is…. Is success a patient getting better? Is success some sort of cost-effectiveness? Is success some kind of client or patient/provider uptake? I think those are all types of success.” (USA 5-4: 83) | |
| “I think that success is a measure. The measurement we use of course is one of patient satisfaction.” (RCC 7-5: 27) and “… the other success factor is that we…continue to keep a full schedule.” (RCC 7-5: 28) | |
| “… if there is a specific client that the technology is used with, and then other clients that the technology is not used with, maybe marking the progress of those clients and comparing the level of feedback and the level of growth and movement of the clients….” (RCC 6-10: 28) | |
Attribution of quotes is given by (transcript number paragraph: line).
BMI, body mass index; RCC, Regional Coordinating Center for Hurricane Response, USA, University of South Alabama.