Political Factors

The political and cultural situation of health care delivery systems is dependent on the religious, sociological, philosophical and natural science’s view of a population, as well as on the type of state and economy. It has to be taken into account that behind the terms patient, medicine and ‘health care delivery system’ there are people, who follow their tasks and interests. Between all of them there is an interaction corresponding with the respective system [Köhler, 1997, p. 11]. To understand the political and cultural situation, which may have an influence on telepathology introduction, it makes sense to have a look at the key players of telepathology system introduction and their main interests.

10.1.1 System Suppliers

From the point of view of the private sector there are only two ways to increase sales in a commodity market. Either one increases the size of the total market by expanding the demand for bandwidth, or market shares have to be increased by marketing and product differentiation. Telemedicine applications promise to serve both. No surprise that much of the current enthusiasm for telemedicine applications is being generated not just by pioneer physicians, but mainly by suppliers of information highway services and by other commer-cial developers. They are interested to offer and to extensively market their products and services for telemedicine to ensure that an investment pays for itself or even gains profit [Perednia, 1995/(3)].

Considering telephone and cable television companies, many of them have invested vastly in optical fibre cable networks, which they now want to be used. They realize that tele-medicine applications are based on the network transfer of a huge amount of data. There-fore they are increasingly funding pilot telemedicine projects to assess their commercial viability (horizontal integration in the value added chain) [Puskin, 1995/(1), p. 64; Swett, 1995, p. 594]. As an example, in the German telepathology project HISTKOM, as well as in the Swiss SAMEBAS project, the telecommunications providers were the driving force.

Searching for new markets, also manufacturers of video conferencing, imaging, computers, medical, and multimedia equipment have likewise been attracted to the telemedicine mar-ket. The same takes place with microscope suppliers, for example, Olympus, Zeiss, Leica, and Nicon, which are all offering solutions for telepathology (see chapter 9.3).

However, designing a system is not simple. Users’ needs have to be assessed, system speci-fications have to be written, prototypes have to be tested and still there is no assurance that the system will be used in clinical practice [Weinstein, 1997/(3), p. 1]. Those, interested in

developing telemedicine systems struggle a lot. They often have to note that policy-makers and regulators have still not shaped tariffs, payment policies, and laws that respond to technological change and its applications for health care. Therefore not rarely the pioneer suppliers of telemedicine systems went bankrupt, because the lack of these factors did not allow to find customers and to create a market (e.g. Resintel at the project in Dijon/F – see chapter 9.1.3.5). Another reason that developed systems failed, is that the actual available systems do often not meet the needs of physicians and are not capable of being integrated into the ‘everyday’ practice. That is why critics recommend that all the people concerned should participate in the design and development processes of telemedicine applications, including potential users, the federal government, congress, states, telephone companies, health care providers, and other public and private institutions [Puskin, 1995/(2), p. 64; William, 1995].

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10.1.2 Health Care Providers

During the last years the situation of health care providers was embossed by increasing competition for a shrinking economic pie [Braly, 1995/(1)]. This situation is driven by the policy of health care reforms and insurance behaviors, which resulted in falling insurance capital investment rates, discounted provider payments, and deeply slashed government health expenditures. Consequently the economic pressure of health care providers increased.

The health care providers responded. First of all they started to think more ‘economically’.

Many controlling activities were introduced. For example providers shortened treatment processes and thereby lengths of hospital stay. They avoided unnecessary diagnostic and surgical procedures, or reduced inpatient utilization by shifting patients as soon as possible to ambulatory units [Fack-Asmuth, 1996, p. 385 ff.]. Second, facing a situation of strong competition, many providers started to think like entrepreneurs and interacted strategi-cally. They either followed a price-based strategy with faster cash flow, reduced cost, pro??cess optimization, and improved resource utilization, or they followed the nice or differentiation strategy and invested in very high specialized quality medicine [Austin 1995; Whipple, 1993; Hufnagl, 1999, p. 93]. Such providers not rarely seek telemedicine links to prestigious academic institutions as part of their quality assurance program [Swett, 1995, p. 594]. In addition ‘patient satisfaction’ was declared as overall aim [Thill, 1996, p. 232; Murphy, 1993], combined with extensive ‘quality assurance’ activities and

marketing campaigns [Rode, 1997, p. 20]. Third, they created business alliances, multi-unit hospital chains and corporate medicine by either co-operating with competitors, or by just mergers and acquisitions [Taylor, 1994; Weinstein, 1987, p. 647]. Health care

networks were created, sometimes even ‘virtual delivery systems’ [Coile, 1995].

One of the most important pier of these developments and key to success are information systems. Providers realized that information system plans therefore have to be tied closely to the overall strategic plans of their organization [Solomon, 1995; Landis, 1991, pp. 23-26; Newman, 1990; Lumsdon, 1992]. A kind of ‘marriage of information technology’ and care delivery arose [Braly, 1995/(1)]. Within this structural changes, telemedicine applica-tions were recognized as powerful tools of the future, which therefore were integrated to the overall information architecture [Slipy, 1995].

Due to the situation of increased competition, mandated access to care, and increased pro-vider risk with regard to patient outcomes, the interest of propro-viders in telemedicine tech-nologies increased continuously. On a long term, with telemedicine support providers hope to become more competitive in winning health care contracts, to reduce the economic and medical risks associated with caring for patients in rural areas, and to provide relatively low-cost specialty services to areas where full-time staffing is impractical or uneconomical.

However, as long as equipment is expensive and rates of capacity utilization are low, exis-ting telemedicine systems rarely showed efficiency. This is especially obvious at dynamic-robotic telepathology systems. That is why most provider who are following the strategy of cost reduction, went in a position of ‘wait and see’. An exception is the ‘Veterans Integra-ted Service Network’. The decision makers of the Veterans Hospitals in USA see in tele-medicine a possibility to share resources. Therefore they have invested in teletele-medicine applications, even though the actual trials are mostly not cost efficient. Considering the behavior of physicians, especially specialized physicians recognized telemedicine as a figure to efficiently deliver their highly specialized services. With this they hope to

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increase there position in the state’s ‘shared care’ policy [Blobel, 1998, p. 72, Wyman, 1995]. Such kind of physicians often were found to be the pioneers of telepathology.

Altogether most providers recognize in telemedicine applications tools which could im-prove both - access to certain types of specialty care and the overall quality of the care pro-vided [Perednia, 1995/(3)]. From the position ‘to wait and see’ they slowly change to a curious behavior.

10.1.3 Insurance Companies and HMOs

Insurance companies can be seen as the representatives of patients. In the USA 100 million Americans are enrolled in HMOs (Health Maintenance Organization) or preferred provider organizations. 33 million people are enrolled by Medicare and Medicaid, the governmental health programs for older and poor US citizens [Coile, 1995]. No surprise that insurances with such high member rates and health market penetration have a huge influence on health care politics and thereby on the development of new technologies like telepathology appli-cations.

There are two main interests of insurance companies. Firstly to keep health care cost low in order to avoid an increase of membership premiums, and second to guarantee high quality of medical treatment. However, due to the higher life expectancy of members, and the growth of new expensive technologies and treatment procedures (e.g. operation on the heart, expensive implants and medicine), together with new medical equipment (e.g. CT, lithotripter) the cost recovery of the health care systems became a problem all over the world.

In the USA the problems of under-served rural areas pushed the development of telemedi-cine applications a lot. That is why the reaction of the US-insurers is from high interest, since it may be adaptable to other countries’ situation. At first insurers shaved an attitude of reserve. But after some telemedicine applications proved to be cost-efficient and appro-priate, for example ‘teleradiology’ services, billing-codes were introduced hesitantly. Some HMOs and managed care organizations started to experiment with their own systems to improve access to specialists. For example, they started trials where radiologists are no longer summon to hospitals at night, but where CT scans and MRIs were transmitted to their homes instead. Others, like Kaiser-Permanent system or the HMO in Albuquerque, are piloting dozens of telemedicine projects by themselves. The objective is, to expand services to other rural parts of America, where primary care physicians can teleconsult the participating specialists [Ziegler, 1994].

Considering the behavior of insurers all over the world, by contrast to the US-insurers, most of them prefer to remain in some kind of waiting position. They fear increased health cost if these new tele-technologies are introduced. As an exception, some insurers support research activities with grants. Up to now most insurers did not set up regulations for con-tinuous billing of telepathology services and do not give clear statements, if and when they will do so. This cautious reaction may create a barrier for telepathology introduction and is therefore investigated at this study (see chapters 18.3.1, 19.1.2.9) To overcome this resis-tance, Turcan recommends the strategy of heavily involving insurers in network discussion to persuade convince from telemedicine applications.

”I have yet to hear any commercial insurer refusing to reimburse a medical consult when they’ve been involved in the network and process design.” [Turcan, president of Telemedical Systems Inte-gration, an Atlanta based health care consulting firm specializing in telemedicine, in Wyman, 1994].

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10.1.4 Governments

While insurers and suppliers are more or less starting to realize the value of telemedicine, much of the money used to develop systems still comes from the federal governments [Ziegler, 1994]. Many governments regard it as their task to guarantee health care support for their people. That is why for example in Switzerland or Germany hospitals are often owned by the state or communities.

Congresses act to reform health care delivery and create various reform packages. These packages try to consider and answer the health market needs, to improve the disease man-agement, and to coordinate the health care delivery process as a whole [Braly, 1995/(1);

Rienhoff, 1998, p. 9]. In addition, organizations like the WHO (World Health Organiza-tion) generate frames to support the development of an integrated international health care delivery system. Since the WHO recognized that telemedicine application may be a good tool, it asked their member states to develop national programs which may improve the introduction of telematic solutions in health care [Rienhoff, 1998, p. 7]. With the introduc-tion of such systems the WHO hopes to improve the overall quality of internaintroduc-tional health care, especially the one of third would countries.

To discover the potential of telemedicine, several governments set up market analyses. For example in Germany, in 1996 the Government passed the study ‘Info 2000’ - Germany’s development towards an information society (Deutschlands Weg in die Informationsgesell-schaft⁵⁵). Further in 1997 the Roland Berger & Partner GmbH⁵⁶ in Munich was instructed to examine the situation of telemedicine in Germany [Matthies, 1998, p. 98]. Both reports search for solution to overcome the exploding information flood. It was hoped that the de-mand for high quality care and cost reduction in medicine can be answered by telematics.

As a result of these studies, several plans of actions were developed and the work group

‘telematics in health care’ was built at the ministry of health care [Dietzel, 1997/(1), p. 2;

Dietzel, 1997(2), p. 171]. In parallel, several state governments in Germany introduced model programs. The Bavarian Government for example introduced ‘Bayern Online’, the Government of Sachsen introduced the program ‘Telemedicine Sachsen’, and the Govern-ment in Berlin supports the ‘high-speed network of Berlin’, which connects the University Clinic Charité of the Humboldt-University of Berlin with other medical institutions. The Charité is also considerably involved in telepathology trials [Wedekind, 1998, pp. 59-63;

Brummer, 1996, p. 15; Thiel, 1996, p. 17].

In the past, state policy makers in the USA often failed to consider needs and solutions across the range of state activities. This resulted not only in missed opportunities for ca-pacity and cost sharing, but also led to cost redundancies and incompatibilities. However, governments started to concern a lot to provide accessible, low-cost health care to all Americans [Perednia, 1995/(3)]. That is why they became highly interested in the provision of political, technical and economical frames for a managed care approach to health service delivery and telemedicine introduction. Since analyses showed that one problem of tele-medicine introduction is inadequate information infrastructure and uncoordinated infra-structure planning, state decision makers put a lot of effort in the standardization and

55 http://www.kp.dlr.de/BMWi/gip/programme/info2000.

56 Roland Berger Study: ”Telematik im Gesundheitswesen - Perspektiven der Telemedizin in Deutschland”. Study for the German Government, Department of Education and Science, and for the Department of Health Care Policies.

http://www.hcp-protokoll.de/arbeit.html

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dination of technical environments. Frames were developed, which especially consider the integration of information technology planning and development processes across state agencies and within communities. Within these approaches the US-governments recognize the national effort to develop the electronic information highway, which is needed as a back-bone for telemedical services. Moreover, since former states’ telecommunications legislation often failed to consider the integration of health care concerns, too, legal aspects were adapted to the new situation [Flaherty, 1995/(2)]. In parallel, several national ‘Shared-Care’ and ‘Managed-‘Shared-Care’ concepts were developed. Doing so, a special focus of federal governments became the deployment of advanced medical telematics in rural communities to increase the viability of their education and health care systems [Smith, 1997]. Examples for US interstate telemedicine demonstrations are the WAMI network in Alaska, Idaho, Montana and Washington, or the High Plains Rural Health Network in Colorado, Kansas and Nebraska. Since recent years several other state funded telemedicine networks arose.

Finally governors, their cabinet officials and budget directors regarded the integrated planning process of telemedicine not just as a part of periodic high-level initiatives but also in the course of the regular budget process [Flaherty, 1995/(2)]. A similar situation can also be recognized, for example, in Norway, Sweden or Japan, where the governments started to push telepathology developments.

In summary, governments showed even more interest than insurers to support and examine telemedicine approaches, since they are aware that the ‘health of their people’ is an impor-tant value, and they feel responsible to protect this value. That is why they maintain health care delivery systems and are keen on a high level health care for all their citizens. Tele-medicine seems to be a tool for them to serve this objective.

10.1.5 Professional Organization of Pathologists

At most countries similar groups of people or organizations are united in an association of interest, often referred as lobby. Depending on the size of the group, such unions often have a huge impact on the policy and developments in their environment.

Pathologists are mostly united to such associations, which care about their interests. In Germany for example it is the ‘Deutsche Gesellschaft für Pathologie’ (association which cares about pathological scientific issues), the ‘Berufsverband Deutscher Pathologen e.V.’

(professional organization of pathologists, which concerns about political, economical or structural issues), and the ‘Bundesärztekammer’ (professional organization of doctors).

These associations make the policy from the point of view of pathologists, take care of the quality of pathology procedures, set up documentation standards, initiate directions for the future, or give statements about critical points in pathology, e.g. legal statements, organ-izational recommendations, or statements about the estimation of new technologies such as telepathology.

To give an example about the reaction and influence of such unions, on April 12th of 1996 the directors of the German professional organization of pathologists published a statement about intraoperative frozen section examinations (see appendix I, letter 2). Their judgement was very negative and rejected frozen section examinations executed by telepathology.

Firstly they denied macroscopically examinations being executed by a less experienced client. They argued that macroscopy demands many years of experience and huge compe-tence and therefore can’t be delegated to the client. Secondly they warned their colleagues about the legal consequences related to the increased risk if tasks are no more directly under control of the examining pathologist. Such statements are almost like a written law

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and therefore are followed by most pathologists. Nevertheless, some pioneer pathologists in Germany started to use telepathology systems, mostly static systems for second opinion consultations. Since their experience was positive, in 1999 they made a statement⁵⁷ to their professional organization of pathologists with the request to revise the negative statement of 1996. As a reaction in June 2000, the professional organizations in Germany set up a work-group to investigate telepathology applications. Pathologists now await the statement of the professional organization full of suspense, since it will strongly influence the tele-pathology distribution in Germany. It is to assume that, similar to Germany, also in other countries the influence of professional organizations will have a huge impact on the national telepathology developments. Therefore the participants of this study were requested to judge this impact for the success of telepathology.

Other important interest groups in pathology are the International Academy of Pathology (IAP), and the International Academy of Cytology (IAC), together with the Scientific Association of Pathology. These organizations set up the directions in pathology education and training, and decide which new procedures, treatment practices and therapy forms will be used by pathologists in the future. They are also responsible for the training of young physicians to become specialized pathologists. That is why it is to assume that their judge-ment about the different telepathology services will also have an impact on pathologists’

telepathology acceptance.

10.1.6 Support of Decision Makers and of the Top-Management

At a research study of Williams, who requested telemedicine project leaders about their experience, one director of a successful telemedicine project attributed the secret for suc-cess to the commitment from management and from the top of the sponsoring organization to adapt telemedicine. Another project leader reported that the managers of his healthcare organization almost killed his project before it even started. A third director described how organizational support for telemedicine was not a forgone conclusion, even after equipment had been purchased [Williams, 1995; Moore, 1995, p. 3]. Also Puskin discovered effective leadership as a cornerstone of any telemedicine system. He found out that if there are champions, there is a much greater likelihood of a project being successful. The promotion of leaders with an influence on decisions, who are within a community’s power structure and who can dictate action and commit resources, both human and financial, is needed.

At a research study of Williams, who requested telemedicine project leaders about their experience, one director of a successful telemedicine project attributed the secret for suc-cess to the commitment from management and from the top of the sponsoring organization to adapt telemedicine. Another project leader reported that the managers of his healthcare organization almost killed his project before it even started. A third director described how organizational support for telemedicine was not a forgone conclusion, even after equipment had been purchased [Williams, 1995; Moore, 1995, p. 3]. Also Puskin discovered effective leadership as a cornerstone of any telemedicine system. He found out that if there are champions, there is a much greater likelihood of a project being successful. The promotion of leaders with an influence on decisions, who are within a community’s power structure and who can dictate action and commit resources, both human and financial, is needed.