What about the Doctors?
The seeds of this article began when my CEO forwarded a Gartner case study from 2008with the question, “If a hospital could do 345,000 video visits up to 2007, why hasn’t telemedicine expanded more? Is the issue technological, cultural, managerial, or..?”
Fantastic question. The issue definitely isn’t technological–at least from a capabilities standpoint. It may be from a design standpoint…but more on that later. I’d argue that it is indeed cultural and managerial, although some of that culture and management reflects back on us, the telemedicine solution providers.
We are presented with a quandary: 1) Where telemedicine has been systematically implemented, it has radically improved patient care, lowered costs, improved doctor/staff morale, and even increased revenue…even in the face of lingering payor reimbursement questions currently being worked out by insurers and state legislatures, and yet… 2) Adoption by both individual healthcare providers and organizations has been, well, lackluster, and often outright resisted.
The gap is caused because our whole industry has been focused on the wrong pitch to the wrong people. That is, we’ve focused on pitching someone other than the end user about how wonderful the benefits are that don’t effect the end user directly. (The end users, by the way, are the doctors, nurses, clinicians, technicians, assistants, and patients.)
To support this, I will largely rely on an article titled Adoption of telemedicine: from pilot stage to routine delivery, appearing in BioMed Central in 2012. The authors effectively surveyed 74 footnotes worth of research into the possible reasons behind telemedicine’s lack of adoption and formulated a few well-educated hypotheses. In it, Zanaboni and Wootten determined, based on data collected in a study by LB Russell, that “the crucial determinant of the speed of adoption [of CT scans versus MRI scans] are the advantages for users.” In this same article, Zanaboni and Wootten went on to say, “Whitten and Mackert have pointed out that the provider is the most important initial gatekeeper for the deployment of telemedicine, and that project managers must keep providers’ needs (ease of use and incentives) in mind…”.
Regarding all this hullabaloo about cost reductions and revenues, Zanaboni and Wootten found that, “Although there is evidence of the cost-effectiveness of telemedicine in certain situations, its widespread adoption has not occurred. The main implication is that evidence of cost-effectiveness is a necessary but not sufficient condition for adoption.” [Emphasis mine] Conversely, “We believe that before health professionals will seriously consider the use of telemedicine, there must be some personal advantage to the user, in addition to the general advantages to society.” (I think this is true of all end users of any technology.) Cited as a common example of an area where telemedicine has had better adoption: “For example, health professionals at remote sites frequently view telemedicine as having a relative advantage, while those at hub sites often view it as offering no relative advantage and requiring changes to their existing practices and roles.”
Also regarding the users, multiple sources, including Zanaboni and Wootten, as seen above, cite the attitudes of users as key to adoption. For example, according to Kahn, et al., citing Mullen-Fortino, et al., “Another key barrier is the perception of telemedicine on the part of bedside practitioners, especially nurses who may be doubtful of the potential benefits and concerned about disruptions in daily workflow associated with remote monitoring.”
Lastly, in a Gartner case study on Texas telemedicine published in 2008, a key “lesson learned” was that, “Clinician adoption was a significant challenge. UTMB had to devote resources to train clinicians on how to use the telemedicine equipment, to convince them that telemedicine was a valid tool for clinical assessment, and to instruct them on when to use it and when to refer patients for a face-to-face encounter.” [Emphasis mine.]
I don’t think the key to better adoption could be clearer. Our industry has focused too much on cost benefits and administrative/IT buy-in, and not enough on educating, advocating for, and, well, marketing to the doctors, nurses, clinicians, technicians, assistants, and patients. They are the drivers of this change as the end users. (My apologies to any doctors, administrators, or others who may not wish to be marketed to.)
By the way, this is true even when you’ve already deployed telemedicine in your organization. If you were the key driver/decision maker in acquiring telemedicine, but not among the doctors using it, you may need to spend some time internally marketing the solution to the practitioners who will be using it to make sure they are on board! If you need help or want ideas on how to do that, please say so in the comments and I’ll see what we can do.
History is full of “perfect” products that never moved the market. In 1998, three years before the first iPod, a slew of digital music players entered the market. Remember seeing the Diamond RIO hanging from store racks? Maybe, maybe not. Back in 1979 was when the IXI prototype was created but never commercially produced. 3D TVs are another example of what looked like a slam dunk but wasn’t. (The TV industry is now hoping that 4K resolution can create the demand the 3D never did.) Car enthusiasts may mention everything from the Edsel to the DeLorean as examples. How about all the hybrid cars offered prior to the Prius? There were quite a few. In software, apps, and devices a “perfect” or “game changing” piece of tech dies an ignominious death every day.
Remember the Segway hype? Urban transportation was supposed to change overnight.
Unlike the industries above, it is highly important to reconcile the gap between how well telemedicine has performed and how little it has been implemented. The importance is summed up in four points: 1) making healthcare affordable to those who really need it; 2) making healthcare accessible no matter where those who need it are; 3) improving the morale of doctors and other providers, through decreased stress, improved outcomes, and increased productivity; and 4) relieving the shortage of doctors/providers across many specialties. An additional area, resulting from improved outcomes, is the possibility of reducing legal costs for malpractice, although in the short term that may not be seen as telemedicine may temporarily be seen as a new variable that can be blamed if something goes awry in patient care.
In almost any other industry, if a truly great product fails due to marketing or being ahead of its time or just failing to reach a tipping point of use due to whatever reason, there is little to no effect on the world as a whole. In healthcare, however, people may get sick. People’s conditions may worsen. Let’s be brutally honest here: people may even die. Then there’s the cost issue. There is a national burden of cost that increases when solutions are not found and implemented. How much worse when they ARE found, yet still not implemented?
This is not the fault of the individuals “on the ground.” Many doctors, hospital administrators, etc., have more pressing decisions to make on a daily basis. It’s hard to look to the long term decisions of this sort when there are so many fires to fight RIGHT NOW. And those same people, as well as state and federal legislators, want to make sure they have done their due diligence before making any decisions that may affect so many at such a potentially large scale. “I can’t make a decision about funding the bypass for a cardiac patient right now. I’m researching how to get video consultations into health records!” is not something any of us want to hear (especially the bypass patient).
The easier we make life for the doctors, they will push decision makers to implement this tech that is making things better for them. Part of that easier life is getting/keeping their patients—another set of end users—engaged and communicating with the doctors, meaning we have to make telemedicine easier for them as well.
What does this mean? Comfortable and comforting interfaces. Easy integration with EHR. Works from anywhere. And, possibly most importantly, making sure the doctors are fully aware of the existence of and uses for our various offerings, whatever they may be. I know we’re all doing everything we can to make doctors as effective as possible, but let’s also make them champions of what we’re doing.
This is where the cultural and managerial issues reflect back on the vendors: Knowing that we have to get decision makers on board, we have decided for efficiency’s sake only to educate decision makers. We SHOULD continue to approach, educate, and work with the decision makers, but we also need to approach, educate, and work with the key influencers…those who can speed up the decisions or kill a deployment if they don’t understand the advantages to them. If we’re mostly educating the IT and administration departments, who won’t be using this daily and therefore have little emotional motivation to implement these solutions, then we risk taking another several decades to turn telemedicine into just “medicine.” Let’s get the doctors using telemedicine. Let’s not focus only on cost reduction and revenue improvement, but on just plain using it.
Let’s come back to the iPod for an analogy of how we can do this. It was not a success because it was the least expensive digital music player. In fact, it had a premium price. It wasn’t a success because it worked better than the other devices. They worked, too. Yet that was all the other devices were built around: functionality. Other than not carrying CDs or tapes on us, what was the real advantage? The iPod was a success because it looked beautiful and inviting AND was easy to use (not just “useable”) AND it worked. (In my mind, I believe UI/UX design should jettison the term “user-friendly” and embrace “user-inviting.”) Then, it was marketed to those who’d use it, who in this case were also the purchasers. In our case, the users may not necessarily be the purchasers, but they ultimately decide whether something is working or not…and once the purchasers experience their positive results (decreased costs, increased revenues), then they, too, will embrace the change.
And if you are one of those doctors, administrators, etc., that has not yet given telemedicine a real fighting chance, please tell me below what you’d need to give it that shot?
 Edwards, Jonathan. “Case Study: A Texas Telemedicine Program Offers Lessons for Governments and Care Delivery Organizations Worldwide .” Gartner Industry Research: n. pag. Web.
 Zanaboni and Wootton: Adoption of telemedicine: from pilot stage to routine delivery. BMC Medical Informatics and Decision Making 2012 12:1.
 Russell LB: The diffusion of hospital technologies: some economic evidence. J Hum Resour 1977, 12(4):482-502.
 Kahn, Jeremy M., Brandon D. Cicero, David J. Wallace, and Theodore J. Iwashyna. “Adoption of ICU Telemedicine in the United States.” Critical Care Medicine 42(2): 362-368.
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