Evaluation

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Quality Improvement and Evaluation in Telemedicine

Defining Value

The value of healthcare has been often defined as the ratio of quality over cost (figure 1).  While value is typically measured from the patients' perspective, asking what value means to other components of the healthcare delivery system is critical.  Not applying the value equation to the system as a whole runs the risk of implementing a telemedicine program based on false, and potentially expensive, assumptions and fails to engage the support of key administrative and clinical stakeholders.  Therefore, a comprehensive value equation should consider the people, processes, tools (figure 1) of the entire care delivery system (figure 2).  Telemedicine, as a healthcare delivery strategy, can help optimize this value by addressing many aspects of quality and cost. 

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Figure 1:

 

Figure 2:​


 

Thinking about Quality (numerator of the value equation):  It is useful to define telemedicine outcomes anchored on the Institute of Medicine six quality dimensions.

  • Effectiveness is the degree with which evidence-based practice is done for the appropriate patient, without underuse or overuse.   For example, will telemedicine help improve the provider's adherence to an asthma care pathway and the patient's compliance with the care plan? 
  • Efficiency refers to the degree that avoidable waste is achieved.  For example, does telemedicine reduce travel time for patients and providers?  Conversely, does seeing a patient through a virtual encounter versus an in person encounter raise the chances for error and harm?
  • Equitable refers to care that does not vary with personal characteristics such as gender, socioeconomic status, ethnicity, and geography.  The technological requirements of telemedicine can be problematic for patients without such means.  While this situation does not mean that one should abandon all telemedicine activities, it is important to find ways to help underserved populations overcome the technology barrier.
  • Patient centeredness refers to how telemedicine can promote the patient's values, needs, and preferences.  For example, are telemedicine visits more accommodating to the schedules of providers and patient's family lives (i.e. avoid missing work and school days)?  Can patients see their providers in the comfort of their own environment and homes?
  • Timeliness refers to access to care.  Do virtual clinics allow patients to see providers sooner (when health condition(s) dictate the need)? 
  • Safety is always important – can telemedicine provide patients with the safest care, despite any potentials shortcomings (i.e. reduced ability to exam a patient)?  For example, one must weigh the added benefit of not having to transport an immunocompromised, ventilated patient in an ambulance to the hospital for a clinic visit versus doing a remote visit without the benefit of the provider able to do an in-person exam. 

Thinking about Cost (The denominator of the value equation):  When considered by themselves, resource utilization and monetary cost reduces the value of a system.  One approach is to assess preventable cost as non-value added and "waste" in time, unnecessary transportation, motion, process, inappropriate use of staff and equipment (using over qualified staff, over engineered equipment to do a task), overproduction/unused resources and defects.  Keep in mind that although some cost can be non-value added to the patient, they are necessary for the system to function (i.e. long wait times at airport security).  Additional examples of necessary non-value added costs are educating staff on new procedures and changing the work environment to accommodate telemedicine workstations.  The goal is to eliminate unnecessary waste in the system while also working towards improving the system so that necessary waste is no longer needed.  How can telemedicine reduce any of the above waste in the system? 

  • LEAN Six Sigma is a methodology used in healthcare to improve performance by systematically removing waste.  How can the use of telemedicine reduce each of these "MUDA" for difference parts of the health delivery system.  A "swimlane diagram" of the current health delivery process is often helpful to identify specific areas where telemedicine can help eliminate non-value added cost and improve quality.  In the example below (figure 3), doing a telemedicine coaching session shortly after discharge helps patient be more compliant with doing the proper exercises, thus avoiding clinical complications, unnecessary and expensive resource utilizations.

Figure 3:

 

Improvement Methods (PDSA and QI)

Defining the problem will help explain why it would be important to succeed. Two approaches can help identify the program goals:

  • SMART AIM: Specific, Measureable, Attainable, Relevant, and Time-bounded.  Establishing a SMARTT aim early in the implementation process can be helpful in articulating the ultimate goal of the project and defining the boundaries of the project.  For example, "Reduce the number of clinical complications post arthoscopic knee surgery that is due to exercise non-compliant by 10% within 12 months"
  • PICOT: Patient group, intervention, comparison group, outcome, time can be helpful in summarizing the goals of the program.​

The following three key questions (adapted from the Institute for Healthcare Improvement) can be helpful when deciding when to pilot, do more tests, or implement an intervention: 

  • How ready is the organization ready for change? Reluctant versus Eager?
  • How much​ do you believe that the intervention will result in the desired outcome? Doubtful versus Absolute Certainty?
  • ​How much will the intervention cost (resources, monetary, etc)? High or Low? 

​Figure 4:
 

A goal for testing is to identify the limitations of the intervention (i.e. where the intervention fails).  For example, are post-operative follow-ups limited to certain case types? Are they cost effective only if the patient has to travel more than 3 hours?  Can the visit be done given the limited bandwidth of cellular connection, or must it be done over Wi-Fi?   

Change management is a critical aspect of telemedicine implementation.  Knoster et al presents a framework for managing change in a system (figure 4), which lists 5 key ingredients needed for successful change: Vision, Skills, Incentives, resources, Action plan. 

  • Without vision, there is misalignment of purpose amongst stakeholders, staff, providers, and patients and confusion ensues.  Confused, participants are less likely to appreciate the value of the telemedicine.
  • Not having individuals with the necessary "how to skills" to execute the plan (i.e. technicians, screeners, providers, administrators) produces anxiety, especially when unqualified individuals (with the best intentions and hard work) are assigned tasks that they are uncomfortable doing. 
  • Lack of incentives (intrinsically or extrinsically driven) can lead to resistance to change.  Not always having to do with accolades and rewards, intrinsic incentive can come from belief in a well-articulated vision, job satisfaction, or a self-motivated desire to improve the system. 
  • Resource is, perhaps, one of the most important components for successful change.  Without proper resourcing, the performance of the system can be suboptimal and eventually, frustrate providers and patients.  It is often a difficult, not necessary balance, between resource allocation and the cost associated with it.  From the "list of wants", identifying which resources are mission-critical can be helpful.
  • Action plan is the roadmap for the change.  Without it, participants will feel "as though they are getting nowhere."  Typically, each action is defined by what is being done? Action plans should include identifying the responsible person or group, timeline, resources available and/or needed, success indicator, evaluation, potential barriers, and communication plan.        

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