Management Factors of Telepathology

10.3.1 Integration of Telepathology in Strategy Settings

”Information systems are going to play an increasingly important role in the success of health care organization of the future.” ... That is why ... ”...someone in the organization must be linking infor-mation systems’ capabilities with the strategic direction of the organization.” [Larry Grandia, Vice President of Information Systems at Intermountain Health Care, Salt Lake City, Utah/US., in Hard, 1993]

Health care provider are facing a situation of strong competition and cost pressure. To answer this situation, they introduced business strategies and aligned goals for their infor-mation systems with those of their strategic plans to meet the future challenges towards a

‘Health Strategy Centers’, as Andersen Consulting is calling it [Hard, 1993; Hard 1992;

DeBow 1994]. There are several widely accepted strategic frameworks described in the literature and adapted to the situation of health care providers, such as Ansoff’s strategic management model, the four strategic orientations of Miles and Snow, or Porter’s com-petitive analysis model [Austin, 1995]. No matter, which strategy is followed, e.g. in Porter’s model cost leadership strategy based on aggressive approaches to cost reduction and efficiency, differentiation, where health services are offered that are different from those of competitors, or niche strategy, where providers attempt to focus on a particular market segment or on a specific geographic location, information systems can and should play a broad role in the support of strategic planning and strategy development. Sometimes they even will create strategic advantages and new services by themselves. That is why telepathology systems should be an integrated component in health care providers’ overall strategy, and be embedded into a well structured information management [Judge, 1993;

Puskin, 1995/(1), p. 64; Weinstein, 1989, p. 41].

Scenarios How Telepathology Can Support Strategy

In the context of telepathology, strategic advantages may be gained in continuous quality improvement, in improvements of productivity and efficiency, or in supporting physician

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relationships and the creation of health care delivery networks. Lets give some scenarios for illustration.

Cost leadership: The owner of three hospitals, one medical center (A) and two smaller clinics (B/C), want to reduce cost. He employs three pathologists at the medical center, one at clinic B, and clinic C is served by center A, either by specimen transport or a pathologist from A is travelling to C. With telepathology, pathological examinations at clinic B and C are now served by A. Consequently staff and transportation cost are reduced at C and B. In addition, to ensure that investment pays for itself, productivity at A is increased by serving two other clinics in the region with telepathology services. Further, the pathologists coop-erate with another telepathology consultant, so that holiday and weekend services can be shared.

Differentiation: Hospital A only employs one general pathologist as it is usual for its size.

Therefore, if this pathologist cannot give his diagnosis without any doubt, he is sending the specimen to the medical center, which is more than 100 miles away. Thus the patient has to wait for his result and perhaps a second operation is necessary. Now this hospital uses telepathology, so that expert pathologists can be consulted and knowledge databases can be accessed via Internet. This may make this hospital more attractive to patients than the com-petitor’s one, although they are eventually more expensive.

”We’re trying to do something that nobody else has done so we can get a big strategic advantage and everybody else will spend their time catching up.” [Dewey, Manager of Clinical Information Services at Kaiser-Mid-Atlantic, in Taylor, 1994]

Niche Strategy: A pathologist at A decides to create a specialized telepathology service center. He employs highly specialized pathologists, invests in the newest equipment, and links his institution with other pathology experts and to knowledge databases. In parallel, he starts with aggressive marketing activities, offers bulletin boards and online education lessons. Following this strategy, the Armed Forces Institute of Pathology is now famous all over the world for its pathological consultation quality.

Business Plans

After the strategy direction is set up, the strategy is transferred into business plans. These are high level, corporate-wide plans for all areas of the institution, describing the future production and capacity planning processes and the interrelationship between different functions. Also market shares and profitability are estimated in such a plan [Titone, 1994;

Grace, 1995; Williams, 1995, p. 16].

Unfortunately, although decision maker know about the importance of strategy develop-ment opinion polls showed that at many hospitals there is a lack of a strategic information system or business plans. As consequence, systems are often not integrated across separate facilities and their introduction often does not follow an overall strategy direction [Grace, 1995]. Perhaps this is one reason for the often isolated situation of telepathology systems (see judgement at chapters 19.1.2.9 and 19.1.2.11).

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10.3.2 Project Planning

10.3.2.1 Planning and Management

”You have to have a plan and you have to know what your goal is. Is it to improve access to health care, to reduce costs, to reduce professional isolation? It is so tempting to get confused, because you know, you can do all of that. But first you must know which one of these things is most important to you. Then, and only then, you can plan.” [Moore, 1995]

”There were two physicians who didn’t want to be on call every night, so they hooked their two small hospitals together. That is a simple solution to a simple problem. But with a more carefully developed plan they could have been linked to an entire network of specialty care.” [Moore, 1995]

Based on the business plans of the institution experience showed that the success of telepathology introduction depends on a thorough planning and management process (guidelines for introduction, see ITC, chapter 5.1.3, please). Managerial issues seem to play an important role in both, the effectiveness and utilization of all types of telemedicine services [Perednia, 1995/(3)]. Goals and priorities must be defined early and coordinated at all levels of the project. The planning process should involve all users. Doing so, users’

needs can be easily identified and systems will be perceived as useful as possible and of high value to potential users. Lessons learned from project evaluations showed that it is essential to well understand the users’ needs and perceptions, before equipment is pur-chased and programs are developed [Ricci, 1997, p. 205]. The planning of continued edu-cation, periodic meetings and seminars are further effective means of promoting

telepathology among health-care professionals and to increase acceptance [Sheng, 1997, p.

71; Puskin, 1995/(2), p. 126]. (Judgement of management factors see chapters 18.3.1 and 19.1.2.9).

Ongoing Evaluation Process

After all needs and goals are fully defined, data are collected and evaluated. Introduction plans are developed to avoid duplication efforts and misallocation of resources. The types of equipment and electronic services required is brought into the planning process.

Now ongoing evaluation is needed to determine whether investments made or approaches taken have been worth the effort, especially as telepathology technology continues to grow and change. Goals, technologies, and practice patterns that make sense today may not make sense tomorrow. Re-evaluation is necessary to ensure that the needs of users are being met in the future, too [Perednia, 1995/(3)]. Therefore it is recommended to use guidelines or frameworks for assessing the performance of the system with the given system goals.

Evaluation goals for telemedicine have been suggested by Puskin [Puskin, 1995/(3), pp. 393 ff.] and by the Institute of Medicine [Institute of Medicine, 1996]. Puskin distin-guished three general evaluation types: a) proof of concept, b) feasibility and value-orientated studies, and c) clinical trials. Several areas are regarded, in which the impact of telemedicine on health care has to be measured, including technical acceptability, integra-tion into the health care system, or acceptance factors.

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10.3.2.2 Strategy of Project Introduction

”You need to make sure that the initial few sites work well before bringing additional sites on-line.

This minimizes the number of variables you need to troubleshoot.” [Reid, Project Director of the Eastern Montana Telemedicine Project, in Anonymous, 1994]

System introducers mentioned the temptation to try to do too much at first, since the tech-nology makes so many things possible. That is why Puskin recommends, to build new telemedicine applications on the current telecommunications and to ‘start where you are at the moment’. In his experience even the simplest telemedicine systems provides a catalyst for communities to collaborate across a wide spectrum of users and services. This behavior automatically will create the market demand necessary for supporting more advanced tele-medicine services, he argues [Puskin, 1995/(1), p. 66]. Also Dzubur recommends for the beginning just to use an existing ordinary telephone network or ISDN connection, special-ized low cost equipment, and specialspecial-ized custom designed software [Dzubur, 1995, p.

269].

”My best advice is to have a plan that focuses on priorities. Start out small, and get functioning before your expand.” [Comment of a project leader in Moore, 1995]

10.3.3 Organization of Diagnostic Procedures

10.3.3.1 General Organization of Pathological Processes

Pathology procedures are either done for a specific single case (e.g. frozen sections or sec-ondary diagnoses, where a specific case is discussed with the correspondent expert), or for a set of multiple ‘en-bloc’ cases from different patients in a sequence without any break (e.g. for cytological smears). Telepathology is usually performed on single case diagnoses, since the appropriate equipment, line connections and organizational structures are not available for en-bloc cases, yet [Kayser, 1996, p. 476]. Considering telepathological proce-dures, the diagnostic behaviors of the involved pathologists have an impact to a smooth process. In addition, diagnostic performance and scheduling questions have to be solved to avoid long lasting breaks in diagnostic procedures.

Considering single cases, there are two different forms of telepathology organization - synchronous and asynchronous. Synchronous means that participating health care staff is discussing a patient’s case at the same time (real-time interaction); asynchronous in terms of telecommunications means that transmission is not dependent on the synchronization of timing or frequency between the two nodes. Synchronous meeting up to now is rather a rarity in health care practice, since it would take far to much coordination effort. Most group and treatment coordination are carried out in an asynchronous manner, via the medi-cal record, where most information is passed via textual, graphic or photographic materials [Allely, 1995, p. 208; Moynihan, 1995]. In telepathology, still imaging systems are

managed asynchronous, dynamic live systems are synchronous.

10.3.3.2 Experience with Organization of Telepathology Sessions

Many telemedicine clients already reported about difficulties in answering the question how and at what time is it possible to contact a colleague or specialized expert. Who is the expert who can give a rapid and accurate solution of some difficult or emergency problems

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in pathology? They also stated that scheduling is a problem, because interactive dynamic systems require the coordination of at least three schedules - at minimum two clinicians and a patient [Wyman, 1994; Martin, 1992, p. 420]. The problem of coordinated time schedule can go so far that rural site even prefer one medical center to another, as one project leader reported [Williams, 1995]. Also at a study in Sweden a limitation of the employed system was the difficulty to reach the right person to consult at the desired time (in 20 % the desired person was occupied) [Olsson, 1995, p. 240]. At another telepathology trial in Vermont, individual units could not rely on the connection every time. This led to the necessity of making test calls prior to schedule clinical interactions or meetings. This caused additional waiting time, adding to personnel costs and usage charges [Ricci, 1997, p. 202]. And not to forget, if a telepathology session last longer than it was set up, the following sessions will start with a delay, which again leads to an inefficient workflow.

Therefore synchronous telepathology sessions have to be carefully planned and the task of each person has to be carefully defined, since it is to assume that a smooth workflow could have an impact on the overall acceptance of telepathology.

One possibility to overcome the problem of coordination is, to introduce a coordination and control center for telepathology services. Instead of the diagnosis expert has to be selected by the user, a medical data center handles criteria to automatically propose and select a diagnosis center for the requesting client. Selecting criteria are for example spe-cialization, workload, up-time service, urgency, etc. [Allaert, 1999; Kayser, 1995/(1), p.

55]. Examples of such a center are the network of the French National Medical Association or the UICC Telepathology Consultation Center in Berlin.

10.3.4 Conclusion

The decision to establish telepathology services should support the strategic direction set-tings of an organization. The introduction of telepathology systems has to be carefully planned and managed. Within this planning process, the evaluation of the users’ needs and user involvement, as well as the support of decision makers is important to make tele-pathology introduction successful. Many experienced teletele-pathology decision makers recommend, first to start small and then to enhance equipment and services. As soon as a system is introduced, its performance should be permanently measured by guidelines and frameworks, based on the strategy and goal settings. One has to remember that telepathol-ogy technoltelepathol-ogy is permanently changing and that systems have to be adapted to actual and future situations. The usage of telepathology services will demand structural and organiza-tional changes. Especially at synchronous real-time sessions, the coordination of human and equipment resources has to be carefully planned. Since in telepathology, several per-sons are participating in a session, their tasks and responsibilities have to be clearly defined in advance.

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