Factors which assist the success of Telehealth projects

An international literature review 2012.

Literature Review Brief.

“The way in which health care is being delivered is rapidly changing. New technologies mean that more creative delivery methods are emerging and the birth of telehealth has heralded a different future for health care provision.” (Goodwin, 2011,p 1.) While this review will focus on telehealth, the umbrella under which it sits, will firstly be described. Two other delivery of care models, which sit alongside telehealth, will also be described.  

Discussion is still vigorous within the emerging technology community but the tentative answer seems to be that the term e-health is the umbrella term  for a range of services that are at the edge of healthcare and information technology. These services, which use a number of emerging technologies and systems, sit under this.


What is E-health?

Tan (2005)  defined E-health as:

 “The use of existing and emerging e-technologies to provide and support health care delivery that transcends physical, temporal,(time)  social, political, cultural and geographical boundaries” (Tan 2005, p 42) It is the use of emerging information and communication technologies by health professionals and consumers to improve or enable personal health care or health care delivery.  This type of delivery is being recognized internationally as enhancing quality, accessibility, accuracy, cost effectiveness, equity and efficiency of health care.











Fig 1. Three delivery of care models that sit under the e-health umbrella. (Irvine, 2012)


this is the use of mobile devices to deliver healthcare and healthy lifestyle  services e.g. texting patients to remind them of appointments or support for smoking cessation. Research in the use of M-Health  is increasing rapidly at the Clinical Trials Research Unit , University of  Auckland, led by Dr Robyn Whittaker. One such  trial is called Memo, which aims to reduce depression in young adults. It utilises multi- media mobile phone communication.

M-Health can also include mobile phone applications which can be downloaded to cell phones for such things as monitoring the amount of calories which may be in the food served when out for dinner or for tracking heart rate and  other bio-feedback information for fitness purposes.


is the use of equipment for patient self management in their domestic settings. The equipment used by the New Zealand Telehealth Research project, ASSET, consisted of high quality weight scales, blood pressure and heart rate monitor, oxygen saturation probe, blood sugar monitor and a hub to record and transfer data through a phone line to a website which a Nurse practitioner accessed daily and could make decisions regarding the need for communication with the client.


is the delivery of health related services and information via telecommunications technologies. “Telehealth is a means of enhancing an organisation’s ability to provide quality care in patients’ homes and delay the need for expensive hospital admissions or traditional nursing home care.” (Ghosh & Ahadome 2012.).

Literature shows that telehealth has the potential to encourage self management of care, reduce hospital admissions and strengthen the health partnership between the consumer and the health professional. However, because of the lack of information, relating to successful development, many international telehealth projects which have been set up over the years, have been unsuccessful. This has resulted in millions of health care dollars being wasted, frustrated health professionals and even poorer outcomes for the consumer. This international literature review investigates at some of the factors which are pivotal to the success of a telehealth project. (Elder, 2007, Consentino, 2009).


Case Study

A renal physician in Whangarei, Dr. Walaa Sewier, has provided an innovative service to dialysis patients within the Northland region. He has patients in Kaeo Hospital and patients in Kaitaia hospital. A video link service has been developed between Whangarei and the two hospitals, which he uses every Monday morning to conduct a grand round. A registered nurse and /or GP are with the patient at the hospital. All activities which are conducted with a face to face consultation are carried out.   Through this video link the consultant (Walaa) provides medication advice, professional education to the health professionals working with the patient and support to the patient. This service enables the patient to be seen more often, reduces cost and time of travel for both the consultant and the patient, and allows the patient to  remain in the area where support from family/whanau is readily available and the presence of  an informed health professional is constant.

This technology also allows the consultant to link with Auckland Hospital for further consultation with colleagues.

This literature review, is funded by WINTEC and conducted by Denise Irvine CEO. e3health ltd .It will identify factors from the literature which have been  pivotal to the success of telehealth projects. 

The government and therefore health providers are facing increasing challenges within the health sector because of the negative impact of  challenges on the health budget. These challenges are being caused by:

  • An ageing population with multiple long-term health conditions- such as diabetes, heart disease , and lung diseases caused by smoking and other pollutants
  • Rising expectations of consumers as to what they can expect from the health dollar regardless of age and health status
  • Google has added to a more health educated society, albeit one that has high expectations of the health system.
  • Difficulty in recruiting health professionals especially in rural areas means that there is a scarcity of health professionals trying to offer a wider variety of services to an ever expanding population
  • Widening disparities in health status and delivery in the wider community.

Government and health providers, need to make better use of existing resources within a constrained fiscal environment. Financial constraints do not allow the continuation of the same care model offered now. To meet the challenges above, the health care model must be more patient centric, including a greater involvement in management of our own health. Utilising emerging technologies to assist in this change is the only way forward to enable this change of health care model hence the exploration and utilisation of telehealth. This is confirmed by Dr Raza Toosy and Dr Saeed Chauddhary (2012) who have identified some key outcomes of telehealth.

  •  Reduction in hospital admissions by enabling patients to be monitored in their own homes.
  • Significant cost savings by preventing avoidable admissions to Accident and Emergency departments.
  • Improved patients’ quality of life by empowering them to have control over their condition and supporting independent living.
  • Reduced pressure on resources through more effective management and allocation of care services.  

These outcomes substantiate the claim that telehealth can assist in offering a more cost effective and efficient service but factors which impact on its success must be identified and managed. Below I  identify key components to assist in the successful implementation and continuation of telehealth projects.

Health Literacy

Health literacy is the ability to obtain, process and understand basic health information and services to make appropriate health decisions (Korero Marama 2010)

Low health literacy  means a patient is to a greater or lesser extent not able to achieve these skills. They may not be able to decode directions on prescriptions, follow written directions for health care activities, understand consent information or learn or understand the importance of health screening activities.  This may result in poor health outcomes and high use of healthcare services.


Results of poor literacy identified by the Korero Marama report (2010) in New Zealand identifies that people with poor health literacy:

  • are less likely to use preventative services
  • have less knowledge of their illness, treatment and medicines
  • are less likely to recognise the first signs of medical problems
  • are less likely to manage their long-term/chronic conditions
  • are less likely to communicate their concerns to health professionals
  • are more likely to be hospitalised due to chronic conditions
  • are more likely to use emergency services
  • are more vulnerable to workplace injury because they do not understand safety precaution messages.

 McCarthy (2012)states “that over the past two decades, the field of health literacy has emerged to document clear evidence, that a large number of adults in the United States have difficulty comprehending existing health material”. (McCarthy,2012, p 277)  McCarthy (2012) then explains that specific studies have repeatedly examined patient’s ability to understand health information conveyed through print, video or internet sources and discovered that limited literacy and numeracy skills to be a strong risk factor for comprehension failure.   (McCarthy 2012, Jones 2010, Kilonzo et all, 2011, Rudd 2012, Shieh et all, 2009)

Remshardt (2011) queries whether a nurse can be certain that consumers understand important health information such as those relating to prescriptions, diet and new skills needed in order to maintain health e.g insulin self injections.  have they understood the new skill taught e.g. giving an insulin injection? Have they actually understand why they must come back for a follow up appointment?. Do they understand the questions they need to ask? What level is their motivation to monitor their health and carry out the required treatment themselves? With telehealth there must be an even wider inquiry. Do they have access to, and a sufficient level of understanding related to  the equipment or do they need a support person available?  Education must be provided in order for the consumer to understand and use the technology. Wallis (2012) writes that nurses and health professionals may need to develop new skills and think about how they present information to a patient to ensure the language is understandable and they need to be more involved in helping people interpret data. She then continues, explaining that the ability to work with patients to manage their own health information and make sense of the data will need to become part of a clinician’s skill set.

In a study conducted by McCarthy and colleagues,(2012) it was found that many older adults have difficulty remembering verbal instructions given during clinical consultations, especially those with lower health literacy. To enable success with a telehealth project, which includes the older person who may possess low literacy skills, other forms of providing information must be sought, ensuring the older person understands. In a recent report, Health Workforce New Zealand (2012) stated that they have included enhancing the undergraduate and postgraduate understanding of health literacy issues within their Health priority areas.

Major stakeholders at the Decision Making table.

Strong buy- in from key stake holders is critical when trying to influence organisational change. Introducing technology into an organisation to deliver care is  a major change so every effort must be made to ensure all stakeholders i.e. all health professionals associated with the new technology, are involved at the decision making table so all perspectives can be examined and heard.(Weckman & Jansen, 2010, Lee, 2007). The project can move forward with a team approach developing a shared vision and sense of community (Ellis, 2005) for the introduction, design, planning, implementation and evaluation of the project (Weckman et al 2010)  


When the introduction of technology project is initially being discussed, Nurse Managers should be included. This prepares them to understand the requirements and resources needed and gain clarity about what is changing. (Eastman et al. 2012) However, as nurses represent the largest group of people who will use the technology, including them as well as the nurse  managers at the decision making table is vital (Singleton et al. 2009). It assists with the overall buy-in from staff if nurses see that their interests are appropriately represented and secondly ensures that the upfront planning of the IT implementation has input from the major stakeholders. e.g ensuring the  technology support nursing clinical workflows and exploring the implications for patient care. (Eastman & McCarthy, 2012,Singleton, 2009). Thus making sure that the right technology, is used for the right type of delivery, by the right health professional, for the right patient, in the right situation.  Unfortunately, frequently this inclusion does not occur.


Importance and value of planning.

Initially a SWOT analysis should be carried out to check the feasibility of the project. This analysis considers the Strengths, Weaknesses, Opportunities and Threats to the project allowing decisions to be made as to whether it is achievable. If the evidence suggests a positive environment, then planning should follow.

 “Strategic planning is an organisational process of defining its strategy or direction and making decisions on allocating its resources to pursue this strategy” (WikiPaedia) Currently a strategic plan is developed by an organisation for only a three to five year period as change is so rapid and anything longer would result in the organisation or project no longer meeting its targets.(Joseph et al, 2011).

One of the main parts of a strategic plan is the inclusion of a vision. A vision shows people where they want to go to and shows how getting there will contribute to achieving their objective. (Vanderwerf, 2004) “Successful telehealth projects consistently presented a clear vision of the project as well as a clear vision of how the telemedicine (telehealth) project contributes to the overall vision of the organisation”.

In a successful project, a strategy is also included. This is sometimes called a roadmap, which is a written piece of work which clearly identifies the direction to travel in order to achieve the end vision.

Once the vision and strategy of introducing telehealth into the organisation has been agreed upon, communicating the plan to all staff is essential. Often it will require change which will need managing. In the case of introducing telehealth, the requirement will be to communicate the value of this change to all staff who will be involved in this new type of service delivery.  Managing change or change management entails thoughtful planning, sensitive implementation and above all consultation with and involvement of the people most affected by the change.

Two points for successful change management are pivotal and described by Norris as      communicating the vision/change, reason for it and the future effect of it. Secondly

Having an identified champions to lead the change. (Norris, 2001)

Communication must involve as many people as possible. (Kotter 2002). “The Right thought plus the Right people in the Right environment at the Right time for the Right reason = the Right result (Maxwell 2011) These people can include management, opponents/competitors, consumers and health professionals. As well, it must also include all staff who will be affected by the change.  This can happen in staff meetings, casual “in corridor’” conversations, newsletters. It needs to occur both horizontally and vertically to ensure everyone one feels they are included in the change process and can contribute to it.  (Kotter, 2002)

In a paper which was presented in Denmark, Vanderwerf  (2004) stated that  “Successful programs need passionate supporters /champions at the sending sites. Find them, Train them. Support and nurture them. Keep them involved. They are critical to your success.” (Vanderwerf  2004)  Originally developed in 1999, J.M. Fisher’s (2012) “the Transition Curve” identifies clearly how individuals deal with personal change. To bring about change successfully a champion, who is passionate about the change and who understands the personal challenges which individuals go through when change is happening, needs to be one of the main persons included in the change process.

Fisher (2012) identifies the varying stages people go through in the process of transition.

Weckham et al (2010) identified that when users were reluctant to learn how to use technology ”one strategy for dealing with this was to create nurses who were “super users” or champions on each unit. These nurses were well prepared to teach and motivate nurses who were reluctant to learn new systems or feared doing so” (Weckham et al. 2010, Ellis 2005)

Also included in the planning should be a long term financial plan which can be presented to management. Financial considerations are critical. To ensure the success, there must be an adequate budget for start up and a continuing one to ensure sustainability

The plan must identify clear short and long term financial goals.

  • If it is a revenue model show clear revenue management
  • If it is a cost saving model show the benchmark and a method to clearly measure the cost savings
  • If it is a strategic model show a way to measure strategic contribution or result. (Vanderwerf  2004)

The financial plan for telehealth would probably include all of the above.

"Because of their constancy with the patient, nurses are in an excellent position to provide crucial feedback regarding the project but to do this effectively they need to have been with the project from inception and be aware what the end requirements are.” (Vanderwerf 2004)

Correct technology

The purpose of a telehealth program is not to deploy technology. It is to solve someone’s clinical problem. (Brown, 2002) If technology is used for its own sake the project will not work. There must be a complete plan developed which includes the use of telehealth, identifying which technology will be best used in this particular situation. Telehealth must never be just “an add-on”.  (Liebert, 2010, Legare et al, 2010).


Patient and staff education

 “The importance of IT training can’t be stressed enough because nurses and other health professionals need to acquire the requisite level of system skills, as well as an understanding of revised workflows and their clinical content.”  (Eastman 2012, p53). Eastman (2012)  suggests that running a dress rehearsal, that includes the whole  health team including scripted scenarios, is critical to success. Dress rehearsals like this provide valuable experience for nurses (and others) and should not be dismissed due to time and budget constraints.  Questions can be asked and answered, users (and patients can be included in this dress rehearsal) can get comfortable with using the technology and best practice can be explored. This dress rehearsal allows everything to come together giving nurses (and others) a chance to develop individual confidence and work as a team prior to implementation. (Eastman & McCarthy 2012). Within this training phase it is important to designate a particulate person for staff to call on when they run into difficulties. This person should be able to provide on-going support that continues after the project is initiated.

 Brebner et al (2003)confirms this.” The importance of appropriate training in the use of video conferencing for clinical purposes is often underestimated when telemedicine (telehealth) projects are established.”  (Brebner et al. 2003) Training to use all equipment when providing a telehealth service is vital. To deliver an exceptional service, the users need one to one training, written instruction which they can later refer to and weekly practice to ensure competence and confidence.  Vanderwerf (2004) has written “Training has a major impact on utilisation and can be a major factor in marketing and sustaining the program.” (Vanderwerf, 2004, Sevean et al.2008)

Evaluation of the Project

 The value of rigorous evaluations that employ well documented performance measurement techniques is increasingly being recognised, at least in concept, as a tool for building confidence in a telehealth service and successful management of these programs. The reviewers of telehealth projects in Scotland  commented, “evaluation involves assessing the extent to which the initiative has been successfully implemented and its effect on aspects of service quality ,cost or patient experience” (Audit Scotland, 2011, p 21). Evaluations form an important part of this process as they can provide an evidence base to inform decisions regarding the future development.  Evaluations should include social, cultural, organisational and policy aspects. (Sarhan,2009)  


Legal and Ethical issues in Telehealth


Providing a health service by telehealth is bound by the same legal and ethical requirements as a conventional service delivery. The following Acts must be adhered to:

Health Practitioner Competence Assurance  Act 2003  This Act provides a framework for the regulation of health practitioners in order to protect the public where there is risk of harm from professional practice.

The Health and Disability Commissioner’s Act 1994

Code of Health and Disability Services Consumers’ Rights 1996

Privacy Act 1993

Health Information Privacy Code 1994 (revised edition 2008)

For a health professional, competence is a legal requirement for using telehealth equipment . This is not only clinical knowledge and skills but also competence in the use of the technology which is being used. It is vital that education be provided to the health professionals using equipment to enable them to meet the legal requirements needed to deliver a safe service to their patient.


Beneficence is the ethical principle of justifying using technology to increase access to care and reduce costs.     An efficient service means a better service in terms of quality of care, mainly through increasing accessibility by minimising traditional barriers created by time and location. (Randall 1998).

Data Protection and Privacy

Control and protection of the health information provided by the patient sits under both the legal and ethical banners. Protection increases the trust and confidence in the health professional .”Individual practitioners should bear the ultimate responsibility for protecting the patient from emotional, spiritual, social and material harm”.( Sarhan, 2009). The newly established Health Information Governance Expert Advisory Group (2012) provides advice to the National Health IT board regarding the  protection of Electronic Health Data.



As presented in the introduction to this literature review, telehealth is here to play a pivotal role in the delivery of 21st century health care. It will assist proactive self - management of care by the consumer, it will balance the partnership between the consumer and the health professional and will play a major role in preventing or lessening hospital admissions. Identifying factors which assist is the success of telehealth projects is vital. The project team must know and understand the value of high consumer health literacy, inclusion of all health professionals at the decision making table from the inception of the project, careful and continuous planning, identifying and using the correct technology for each project, provision of education to both consumer and health professional, evaluation of each project, and ensuring that the care provided by telehealth is within the legal boundaries set. These are all vital factors to be considered to ensure the success of telehealth projects. 


I would like to thank WINTEC for the financial support which allowed this research to be undertaken. These findings were  presented at the Nursing Research Section conference 23nd – 25th November 2012. Nelson. New Zealand



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