The following example applies the cluster-based insights and interventions discussed above to a hypothetical scenario: the Government’s delivery of a national telestroke program. It is not intended to promote telestroke as a national priority; instead, it is meant to illustrate the end-to-end adoption strategy development process that could follow from the eHealth readiness research. Telestroke was selected as an example because it has already been successfully implemented in some sites in Australia and shows potential for both improving patient outcomes and reducing healthcare costs.
1. Describe the objectives and aspiration
First, clarify the objectives and overall aspiration in detail, along with metrics for measuring success. Understand and describe both the starting position and the intended end-state.
Purpose of program: connect emergency medicine specialists and physicians in rural and regional Australia with stroke specialists to rapidly evaluate and treat stroke patients in their local hospital
Objectives, aspirations and metrics from the perspective of each stakeholder are listed in Table 7 below.
Table 7: Example objectives, aspirations and metrics for each stakeholder
Objectives and aspirations
|Patients||Better quality of care because advanced lifesaving treatment could be started locally
Better quality of care because advanced lifesaving treatment could be started in time
Less post-stroke disability
|Neurological impairment and disability
Potential lost earnings
Long-term morbidity rates
|Healthcare professionals||Provide the patients with better quality care by bringing virtually services to their patients locally
Improve ability to take care of patients they otherwise could not handle (become able to perform lifesaving treatment)
Deliver care at an earlier stage of the disease development
|Proportion of eligible stroke patients treated with tissue plasminogen activator (tPA)
|Remote institution||The local medical staff at remote locations are enabled to take care of the patients locally in an improved manner
Deliver quality services locally at remote locations to the patients
Reduced costs (since the same equipment could be reused for more specialties)
|Time to treatment
Hospital length of stay
Percentage of patients going to rehabilitation and nursing homes
|Central institution||Provide the medical staff at remote locations with medical expertise allowing the local staff to give better patients treatment
Chronic care management improvement
More efficient use of the work force
Deliver quality services to the remote institutions
A regional neurosurgical service influences patient management and reduces the frequency of patient transfer
Are receiving the ‘right’ patients
|Proportion of eligible stroke patients treated with tissue plasminogen activator (tPA)
Number of remote patients treated
|Government||Acute care improvement
They can have access to services from other states to serve their own inhabitants when there is a lack of professionals in their own state
Proven long-term cost-benefit affectivity for the healthcare system
Better organised service
|Cost of hospital stay
Cost of outpatient clinic visits
Cost of drugs for treatment
2. Develop and prioritise use-cases
Describe the use-cases envisaged for the program. Prioritise these both on their impact – for example, for patients, healthcare professionals and the healthcare system – and their reach – e.g. how many patients or clinicians will be touched.
This example has been developed for telestroke, a telemedicine use-case that provides stroke care through the use of video telecommunications. Telestroke facilitates remote cerebrovascular specialty consults from virtually any location within minutes of attempted contact, adding greater expertise to the care of any individual patient.
Teleradiology is a critical component of a telestroke program, and is based on a Picture Archive Communication System (PACS). When standardised in a serviceable way, the system enables exchange of pictures not only inside an institution but also between institutions.
Basic patient demographics, vitals, and radiology are collected at the point of care and delivered securely for evaluation by stroke neurologists. Powerful reporting tools enable customised management plan creation based on diagnosis, including thrombolytic therapy and non-stroke cases.
3. Identify the critical participants and their roles
Within each use-case, identify the critical participants, the roles they would play, and the interactions with other healthcare practitioners or systems and with patients.
- Imaging specialist (radiographer): performs brain imaging review (CT scan) and local physicians and stroke specialist review on radiology PACS system. Imaging specialists need to liaise with the participating emergency physicians
- Rural specialists: assess and confirm diagnosis whilst videoconferencing with metropolitan stroke care specialist and collaborate with stroke specialist to determine best approach for care. A truly national telestroke program would engage with most of the country’s rural and regional emergency medicine specialists and physicians
- Neurologist/stroke specialist: confirms the diagnosis with local physicians and determines the best approach for care, and completes an electronic event summary, which is shared with emergency medicine specialists and physicians, patient, and other relevant care providers. The program would require a sufficient number of specialists to provide around-the-clock coverage, and could be implemented progressively. Complete adoption is not required for the program to run successfully. Over time, stroke specialists could potentially be sourced from other regions within Australia especially during the night hours that are more difficult to staff
- Hospital leadership: hospital administration, pharmacy and the hospital leadership teams are critical because they need to invest in the following items (if they do not already exist): videoconferencing equipment with remote zoom focus, a connection for videoconferencing through hospital firewalls, high-speed internet, CT or brain image transfer capability, and a computer. There also needs to be consideration of whether the rural hospital should have an additional budget for thrombolytics
- Other stakeholders include: product vendors, payers, health education and health workforce organisations (e.g. to determine roles and adjustments required), DoHA and State and Territory jurisdictions (e.g. to define regulatory framework under which care can be delivered, to determine approved technologies, and to coordinate changes in the end-to-end care pathway).
4. Highlight and prioritise clusters within specialties
Within these specialties, analyse the clusters that will need to be engaged, in terms of a) the role they will be expected to play in adoption; b) the timing of that role; c) their influence in overall adoption success; d) the degree to which their eHealth readiness needs to be shifted; and e) a targeted and compelling business case to support the desired shift.
Table 8: Target participants for telestroke program and their relevant clusters
Medical specialist clusters involved
|Radiographer||N/A (There is no need for the radiologist to be on site at the rural end, and it is sufficient for the neurologist and the physician to review the images prior to administering TPA. The radiologist can subsequently issue the report, but this is not critical for management to commence.)|
|Emergency medicine specialists and physicians||eHealth entrepreneur (13%); network adopters (51%), capable but unconvinced (16%) and apprehensive follower (18%)|
|Stroke specialist (internal medicine)||eHealth entrepreneur (35%); network adopters (16%)
(Targeting ~50% of potential stroke specialists should yield a reasonable number of participants)
- Short-term: The eHealth entrepreneurs and network adopters are the logical top priority, and between them they represent over 60 percent of all emergency medicine practitioners and over 50 percent of internal medicine practitioners
- Medium- to long-term: Capable but unconvinced and apprehensive followers can be targeted in concert. Both will need to understand the benefits, which should be fairly straightforward once the program is underway and demonstrating tangible improvements.
5. Identify the interventions that will be needed to shift attitudes and promote adoption
Before defining interventions, review the perceptions, barriers and influences of targeted clusters and specific needs of specialties.
Before identifying interventions, it is useful to compare the baseline with the desired end state to determine the specific needs for change. This can be done along the same dimensions of product, demand and ecosystem discussed above. This comparison is proposed in Table 8 for the telestroke example.
Table 9: Changes required to achieve program objectives
Desired end state
|Product||Current imaging and videoconferencing technology is suitable for administering program
Connectivity limitations may prevent some hospitals from sharing imaging and/or discharge letters electronically
|Reliable, easy-to-use videoconferencing tools supported by image/record sharing capabilities||Address connectivity/ interoperability concerns so that hospitals are able to seamlessly exchange information|
|Demand||Demand is low, due to lack of awareness and availability||Strong demand resulting from demonstrated improvements in patient outcomes and reduction in cost||Increase in awareness and interest levels and evidence-based support for the program|
|Ecosystem||Needs development – potential interest in telehealth but few strong drivers to influence change||A self-sustaining network of telestroke best-practice users and advocates||Identification and cultivation of early adopters supplemented by education and training programs
Incentives (financial or otherwise) to promote trial and use
Proposed interventionsShaping the product
Establish basic standards and certification criteria to achieve seamless information exchange.
- Ensure that guidelines for imaging and messaging transfer are clear, readily available, and include the basic requirements needed to support this program
- Verify that hospitals and private practitioners are using a certified system before granting them approval to practice and receive reimbursement for telestroke.
- Provide stroke specialists with convenient access to videoconferencing facilities, ideally integrated into their regular work environment so that they can easily alternate between live and remote patient sessions. Efficiency is critical – if the systems take too long to set up, access or use, specialists will turn to other priorities. Also, many internal medicine practitioners are patient-relationship oriented and will likely tire of performing consultations via videoconference only.
Shaping the demand
Establish a measurement and evaluation framework.
- Develop a system to measure, track and report the key output metrics defined in step 1 (e.g. time to treatment, proportion of eligible stroke patients treated with TPA) and to link short-term outputs with long-term outcomes (e.g. decreased mortality rates, increased quality-adjusted life years, cost savings)
- Test the metrics in conjunction with a pilot program launch.
- Offer footage from the videoconference sessions (with permission) to other relevant healthcare providers during training sessions so that they understand the benefits of sending patients to a centre that supports telestroke
- Use pilot program practitioners to act as change agents. These practitioners can help communicate benefits to their peers. They can also act as expert resources for any new practitioner who is having difficultly adapting to the new approach
- Engage organisations such as the Australian College of Rural and Remote Medicine (ACRRM) to act as advocates and provide education to enable this change
- Cultivate eHealth pioneers as change champions by targeting emergency medicine specialists and physicians who are already using telehealth. Invite a select group of practitioners to participate in pilot programs in order to generate interest and resolve any challenges. The combination of strong interest and solid skills will help the initial user group resolve any initial challenges without becoming daunted or overwhelmed by the technology or jeopardising patient care.
- Collect treatment statistics through the systems in place at each hospital and aggregate this data on a regular basis. Provide participating hospitals and stroke experts with access to de-identified data so that they can refine and improve diagnosis and treatment protocols
- Implement security measures to ensure that practitioner performance data remains private.
- Identify communities with high incidence rates and incorporate telestroke program into a broader stroke initiative that includes telemonitoring and other interventions.
Shaping the ecosystem
Cultivate eHealth pioneers as change champions.
- Identify medical specialists who are already using telestroke and invite them to help shape the initiative
- Ask the early adopters to present at medical conferences and share information on their experiences through relevant medical colleges (e.g. the College of Intensive Care Medicine of Australia and New Zealand and the Australasian College of Emergency Medicine).
- Ensure that support staff have the training and skills necessary to set up videoconferencing equipment and resolve basic issues through a nationwide training program.
- Share the value capture with stroke specialists. Over time, the early intervention enabled by this initiative can provide significant savings. Transferring some of these savings to the stroke specialists (e.g. in the form of further investment/budgets for their organisation) will ensure around-the-clock access to the highest quality of care.
- Track adoption and use over time and publish a quarterly report listing the hospitals that offer telestroke
- Similarly, track and maintain a list of stroke experts who are interested in linking with emergency departments as part of this program.
- Audit hospitals periodically to ensure adherence to guidelines for secure transfer of records and imaging files.
6. Integrate intervention levers to develop a coordinated strategy
Consider the intervention strategies appropriate to targeting each cluster, along with their relative merit for the intended objective, optimum sequence and timing. Combine and refine the potential interventions to develop a coordinated strategic plan, ensuring they are consistent with the objective, appropriately sequenced (both between clusters and between strategies) and can translate into a clear plan of action.
Based on the required changes and clusters involved, the following sequence of interventions are proposed to achieve program objectives. A further description of how each of these interventions could be applied more specifically to telestroke follows Table 9.
Table 9: Targeting and timing of intervention levers
(6 m to 1 yr)
|Shaping the product||Clusters targeted|
|Establish basic standards and certification criteria||1, 2, 3, 4|
|Make adoption easy and identify ways to minimise workflow disruption||1, 2||3, 4||4, 5|
|Shaping the demand||Clusters targeted|
|Establish a measurement and evaluation framework||1, 2||1, 2, 3||1, 2, 3, 4|
|Disseminate accurate information on product use and risks||1, 2, 3||4||4|
|Publically recognise and promote successful use cases||1, 2, 3||3|
|Provide assurance on the intended use of practitioner performance data||4||4, 5|
|Embed eHealth solution deployment in the context of a broader initiative||1, 3||4, 5|
|Shaping the demand||Clusters targeted|
|Cultivate eHealth pioneers as change champions||1||4|
|Design and offer training workshops targeting support staff||1, 3, 5||3, 5|
|Offer incentives for use||1, 4|
|Create transparency on adoption levels||4, 5||4, 5|
|Enforce system-wide measures to mitigate privacy risk||1, 2, 3||1, 2, 3, 4||1, 2, 3, 4|
7. Measure performance and refine
Establish a regular rhythm of performance measurement and review along the stated metrics. Consider progress on both how well you are doing at getting traction on adoption and use case enablement, but also whether you are achieving the targeted engagement role for each cluster and shifting core eHealth readiness attributes for these clusters (e.g. infrastructure, aptitude, and attitude). Refine the engagement approach as required.
In addition to tracking and reporting on the metrics listed in step 1 and refining as needed, the telestroke systems can be linked to a computerised database so that data can be collected and analysed regularly to compare all participating hospitals and medical centres. Outcomes data can then be used to improve the quality of the telestroke program and of stroke care in the future.