How to develop a sustainable telemedicine service? A Pediatric Telecardiology Service 20 years on - an exploratory study

Abstract

Background Telemedicine services are promoting more access to healthcare. Portugal was an early adopter of telemedicine to overcome both its geological barriers and the shortage of healthcare professionals. The Pediatric Cardiology Service (PCS) at Coimbra University Hospital Centre (CHUC) has been using telemedicine to increase access and coverage since 1998. Their Pediatric Telecardiology Service has been daily connecting CHUC with 13 other Portuguese national hospitals, and regularly connecting with Portuguese-speaking African countries, through a teleconsultation platform. Methods This study aims at exploring the Pediatric Telecardiology Service’s evolution, through a comprehensive assessment of the PCS’s development, evolution and impact in public health, to better understand the critical factors for implementation and sustainability of telemedicine, in the context of healthcare services digitalization. A case study was performed, with cost-benefit, critical factors and organizational culture assessment. Finally, the Kingdon’s framework helped to understand the implementation and scale-up process and the role of policy-making. Results With the total of 32,685 out-patient teleconsultations, growing steadily from 1998 to 2016, the Pediatric Telecardiology Service has reached national and international recognition, being a pioneer and an active promotor of telemedicine. This telemedicine service has saved significant resources, about 1.1 million euros for the health system (e.g. in administrative and logistic costs) and approximately 419 euros per patient (considering an average of 1777 patients per year). PCS presents a dominant “Clan” culture. The Momentum’s critical factors for telemedicine service implementation enabled us to understand how barriers were overcome (e.g. political forces). Willingness, perseverance and teamwork, allied with partnership with key stakeholders, were the foundation for professionals’ engagement and service networking development. Its positive results, new regulations and the increasing support from the hospital board, set up a window of opportunity to establish a sustainable telemedicine service. Conclusion The Pediatric Telecardiology Service enables real-time communication and the sharing of clinical information, overcoming many barriers (from geographical ones to shortage of healthcare professionals), improving access to specialized care both in Portugal and Africa. Motivation and teamwork, and perseverance, were key for the Pediatric Telecardiology Service to tackle the window of opportunity which created conditions for sustainability.

Experiences of Telemental Health Providers and Support Staff Serving Indigenous Patients of Northern Canada

“…All participants, providers and support staff, in this study feel like being part of a motivated team, one that is committed to their mandate in caring for mental health patients of Northern Quebec. In addition, a culture of rapid communication, facilitated by the physical layout of the TMH clinic, enhances the sense of teamwork and collaboration; which is identi ed as a differentiating factor between failure or success in TMH (40) and supported by sustainable telemedicine services for other patient populations, such as Portuguese a pediatric telecardiology service, which is one of the oldest telemedicine services worldwide (41). Indeed, developing a sustainable TMH program requires more than just hardware and software, as centralized support staff who provide administrative, logistic and technical support are undeniably key to the success of a telehealth service (42,43).…”

“…Despite efforts in the integration of EMRs, "hold time" due to sending documents and receiving proceedings between telehealth consultations is considered as wasted time and counts for 52% in a pediatric telecardiology service (41). Without doubt, implementing a new documentation platform, such as the one used in the TMH clinic, requires the necessary adjustment of the staff and initial program issues will resolve over time; however, it is important that selected platforms are compatible with existing EMRs; allowing for a secure and seamless transition of patient information and optimizing clinical work ows.…”

Telehealth for Pediatric Cardiology Practitioners in the Time of COVID-19

“…Telehealth may also represent a paradigm shift in reaching patients with barriers to in-person appointments. Decreased travel costs and savings of travel time may help those living distant from their pediatric cardiologist or with lack of transportation [11]. Telehealth may also allow a glimpse into the home environment of patients, providing insights into their lives that may never have been known otherwise [42].…”

“…This includes its value in fetal echocardiography and fetal cardiac monitoring, neonatal consultation for the sick newborn with suspected congenial heart disease, the care of pediatric patients presenting for follow-up care or to the local emergency department with acquired heart disease, and providing expertise in the management of the adult congenital patient [4][5][6][7][8][9]. Multiple publications have detailed the ability of telehealth to extend subspecialty availability and expertise to rural or community practices without an on-site pediatric cardiologist [10][11][12][13]. A study of telehealth in a Portuguese pediatric cardiology practice noted improved access to patients living in rural areas and the ability of global outreach to cardiologists working in low and middleincome countries [11].…”

Telemedicine Network in Pediatric Cardiology: The Case of Tuscany Region in Italy

“…This approach was effective to increase efficiency and quality of care, to improve echo examination quality, to prevent unnecessary transport of babies without critical heart disease, to enhance sonographer skill level, to yield financial savings, to decrease length of hospitalization, and to raise patient and physician satisfaction. More and more institutions are implementing tele-echocardiography [2,[10][11][12][13][14][15][16][17][18].…”