"Tele-healthcare in the routinely healthcare setting -Determinant factors of success and failure from a single case study in Italy" Presentation @ XX National Conference of Italian Association of Health Econosmists

1. Sabina De Rosis, PhD Candidate
TELE-HEALTHCARE
IN THE ROUTINELY HEALTHCARE SETTING
DETERMINANT FACTORS OF SUCCESS AND FAILURE
FROM A SINGLE CASE STUDY IN ITALY
XX NATIONAL CONFERENCE
FOSTERING AND GOVERNING INNOVATION
IN HEALTHCARE BASED ON EVIDENCE
Università degli studi di Sassari
16 October 2015

2. What is exactly the Tele-Healthcare?
…it could be generally defined as the ability to provide interactive
healthcare services utilizing modern technology and
telecommunications.
Adapt from: Ministero della Salute (2014). TELEMEDICINA, Linee di indirizzo nazionali
Tele-medicine
provided
by specialists
Tele-healthcare
Tele-monitoring
CONTINUITY OF CARE 

3. Diagnosis
What is exactly the Tele-Healthcare?
Systems supporting formal healthcare institutions/processes (i.e. in a registered
healthcare setting under medically qualified professional care).
Public Health
System
Wellness and
Consumer Health
Home Care
Systems
EHRs/HIEs
Hospital
Provider
System
PayerSystems
Primary Care
System
Community
Care System
Wellness Prevention Treatment Monitoring

4. Tele-HealthCare as an Innovation
We refer to tele-healthcare interventions as innovative solutions.
Innovation meant as any object, idea, technology, or practice
that is NEW.
Rogers EM. Diffusion of Innovations. New York: The Free Press, 1995.

5. VARIABILITY
FRAGMENTATION
CONTEXT-SPECIFICITY

6. We are assisting to A PROLIFERATION OF TELE-
HEALTHCARE PROJECTS.
However,
• their use is actually LESS DIFFUSE than expected.
• their deployment in the real routinely healthcare
settings seems to be still relatively LOW.
A. D. Black, J. Car, C. Pagliari, C. Anandan, K. Cresswell, T. Bokun, et al., "The impact of
eHealth on the quality and safety of health care: a systematic overview," PLoS Med, vol. 8,
p. e1000387, 2011.
Dobrev, M. Haesner, T. Hüsing, W. Korte, and I. Meyer, "Benchmarking ICT use among
General Practitioners in Europe. Final Report for European Commission," Information
Society and Media Directorate General., Bonn2008
J. Walker and S. Whetton, "The diffusion of innovation: factors influencing the uptake of
telehealth," J Telemed Telecare, vol. 8 Suppl 3, pp. S3:73-5, 2002.
…
The Integration of Tele-healthcare
in the routinely healthcare setting

7. The Integration of Tele-healthcare
in the routinely healthcare setting
We have assisted to a growing and growing interest of scholars,
managers and policy makers on this issue, which can be
translated into a huge number of scientific pubblications on
the introduction of innovations in the healthcare systems (a few
on the specific field of tele-healthcare).

8. Papers mainly focus on the first phases of the innovation
introduction:
Greenhalgh,T, Robert, G, Macfarlane, et al. Diffusion of Innovations in Service Organizations:
Systematic Review and Recommendations. Milbank Q. 2004 Dec; 82(4): 581–629.
Introduction
(dissemination and
diffusion)
Adoption and
assimilation
Implementation
(integration in the routinely
practice, scaling-up and
deployment)
We focused on the IMPLEMENTATION, DEPLOYMENT AND
SCALING-UP phases.
Rogers EM. Diffusion of Innovations. New York: The Free Press, 1995.
The Integration of Tele-healthcare
in the routinely healthcare setting
The introduction of innovations in a health care system is
recognised per se a COMPLEX PROCESS in a COMPLEX
SYSTEM.

9. Tele-healthcare is both seen as
• a SOLUTION to healthcare system challenges, and
• a CHALLENGE for the healthcare system in terms of
establishment into the practice as routinely services.
Several factors may influence
the deployment of these
solutions in the “real life”.
There is wide debate on the
reasons why tele-healthcare has
stalled.
The Integration of Tele-healthcare
in the routinely healthcare setting

10. The topic
The Integration of Tele-healthcare in the routinely healthcare:
Determinant factors of success and failure from a single case
study in Italy.
• Why does tele-healthcare innovation present a slow
deployment and remain at (fragmented diffused)
experimental-phase?
• What are barriers and levers of successful deployment in the
voice of all the stakeholders?
• How to spread and sustain tele-healthcare innovations in
healthcare service delivery and organization?
The Research

11. Methodology
 Literature analysis
The theoretical background is based on existing frameworks of
determinant factors of technological and organizational innovation
in the healthcare sector.
 Case study
A single case study, design exploring several typologies of tele-
healthcare innovations in the continuity of care setting in the
Region of Tuscany (Italy).

12. Methodology – Literature Review
Diffusion of
Innovation
Model
Rogers 1962,
Rogers 1980, Cain
and Mittman 2002
Metaphor
of the
knowledge
barrier
Attewell 1992,
Tanriverdi and
Iacono 1999
Complexity
models
Van de Ven, Polley et al.
1999, Denis, Hébert et al.
2002, Greenhalgh, Robert
et al. 2004 et 2005
“Six
forces” of
innovation
Herzlinger
2006

13. Authors and models
Domains of determinant factors
Technology Individual Organisation Context
Diffusion of Innovation Model
(Rogers 1962, Rogers 1980, Cain
and Mittman 2002)
Innovation's
attributes
Characteristics of
adopters
Communication
channels
Social system
Re-invention Time and process
Metaphor of the knowledge
barrier (Attewell 1992, Tanriverdi
and Iacono 1999)
Technically
feasible,
medically valid,
reimbursable,
and institutionally
supported
applications
Technical
knowledge
Economic barrier
Organisational
barrier
Economic
barrier
Behavioural barrier
Behavioural
barrier
Knowledge
transfer’s practices
Methodology – Literature Review
(general framework)

14. Authors and models
Domains of determinant factors
Technology Individual Organisation Context
Complexity models (Van de Ven,
Polley et al. 1999, Denis, Hébert et
al. 2002, Greenhalgh, Robert et al.
2004 et 2005)
Technology
features
Individual aspects Organizational
structure and
system
Socio-political
situation
Strategies and
mandates
Incentives
Cross-
organizational
relationships
Industry and
society
infrastructures
Perceived benefits
and outcomes.
Innovation process
form
Communication
channels, learning
processes
Management
support
Task
characteristics
Path-dependence
of innovation
“Six forces” of innovation
(Herzlinger 2006)
Characteristics
of technology.
Actors of the
system (players
and customers)
Funding models Funding models
Accountability Policies
Methodology – Literature Review
(general framework)

15. Methodology – Case Study
In depth interviews in Tuscany Region
Data were collected through semi-structured in depth interviews.
A purposive sample was used, with snowballing approach, over
different stages to identify a multi-level and multi-stakeholder
sample.
We interviewed 32 informants
6
2
3
6 6
2
4
3
0
1
2
3
4
5
6
7
Clinicians
and clinical
academics
GPs Medical
Managers
Non-medical
Manager
Technicians Chief
executive
officers
Patients Innovative
firms

16. Determinant factors of Tele-healthcare - Results
• Determinant factors were nearly always reported as being
IMPEDING
• The most of barriers seems to be at ORGANIZATIONAL and
MANAGERIAL levels

17. Determinant factors of Tele-healthcare - Results

18. Determinant factors of Tele-healthcare - Results
DUM ROMAE CONSULITUR, SAGUNTUM EXPUGNATUR
Transl: While Rome decides, Sagunto is conquered
(medical manager)
A DECADE OF EXPERIMENTATIONS
(non-medical manager)

19. Determinant factors of Tele-healthcare –
Results compared with the theoretical background

20. Determinant factors of Tele-healthcare –
Results compared with the theoretical background
Domains of
determinant
factors Determinant factors
Present
in the
literature
Emerged
from our
results
Technology
Technically feasible. X
Trialable. X
Definition of tele-healthcare and difference in respect to ICT. X
Typology of target-population for which the solution is designed (i.e.
niches, restricted areas).
X
Different time-horizon between innovation and available observable
results (i.e. through trials), and decision processes.
X
Need of both generalizable evidence and “local” evidence. X
Objective advantages (economic benefits, social prestige,
convenience, or satisfaction)
X X
Fit with existing values and practices. X X
Simplicity and ease of use. X X
With observable results. X X
Re-invention (to fit the needs of individuals and groups). X X
Medically valid / evidence-based. X X
Reimbursable. X X
Institutionally supported. X X

21. The problem is not the technology
(chief executive officer)
The technology is ready
(medical manager)
We have all the technology we need
(non-medical manager)
Only some initial problems, then technology was not a problem
(aged patient)
Determinant factors of Tele-healthcare –
Results compared with the theoretical background

22. Domains of
determinant
factors Determinant factors
Present
in the
literature
Emerged
from our
results
Technology
Technically feasible. X
Trialable. X
Definition of tele-healthcare and difference in respect to ICT. X
Typology of target-population for which the solution is designed (i.e.
niches, restricted areas).
X
Different time-horizon between innovation and available observable
results (i.e. through trials), and decision processes.
X
Need of both generalizable evidence and “local” evidence. X
Objective advantages (economic benefits, social prestige,
convenience, or satisfaction)
X X
Fit with existing values and practices. X X
Simplicity and ease of use. X X
With observable results. X X
Re-invention (to fit the needs of individuals and groups). X X
Medically valid / evidence-based. X X
Reimbursable. X X
Institutionally supported. X X
Determinant factors of Tele-healthcare –
Results compared with the theoretical background

23. WHAT ARE WE TALKING ABOUT?
PROBLEMS OF DEFINITIONS
Determinant factors of Tele-healthcare –
Results compared with the theoretical background

24. FOR WHO IS IT?
PROBLEMS OF TARGET-POPULATION
“A diffused wrong conceptual link between tele-healthcare and
disadvantages places o niche populations”
“Tele-healthcare is useful if targeted to specific populations with
particular problems of mobility or with disadvantaged conditions.”
Determinant factors of Tele-healthcare –
Results compared with the theoretical background

25. FROM WHERE DOES IT COME?
PROBLEMS OF AVAILABLE EVIDENCE
Tele-healthcare makes sense today and needs evidence tomorrow.
(technician)
PROBLEMS OF FIT BETWEEN AVAILABLE EVIDENCE AND
LOCAL CONDITIONS
Yes, it works there*…but who can guarantee that it works here?
[*organisations/department or country where evidence was produced]
Determinant factors of Tele-healthcare –
Results compared with the theoretical background

26. Domains of
determinant
factors
Determinant factors
Present
in the
literature
Emerged
from our
results
Individual
Personal networks. X
Perception of and participation to innovation process. X
Characteristics of stakeholders. X X
Technical knowledge and skills. X X
Relative benefits and expectations (economic and none). X X
Psychological antecedents (i.e. behaviours, needs, motivations,
values)
X X
Attitudes towards assimilation process (i.e. readiness to change,
risk-adversity).
X X
Perception of and participation to decision-making process. X X
Determinant factors of Tele-healthcare –
Results compared with the theoretical background

27. WHO DOES PROMOTE THE INNOVATION?
THE ROLE OF THE CHAMPION
AND THE PERSONAL NETWORKS
Everything is left to local initiatives and to the single individual
(non-medical manager)
Determinant factors of Tele-healthcare –
Results compared with the theoretical background

28. WHO PARTICIPATE TO THE INNOVATION PROCESS?
REAL WILLING TO BE INVOLVED
Co-production meant as sharing of knowledge, know-how,
but also of needs, can be very useful
(clinician)
Determinant factors of Tele-healthcare –
Results compared with the theoretical background

29. Domains of
determinant
factors
Determinant factors
Present
in the
literature
Emerged
from our
results
Organisa-
tional
Accountability. X
Multi-disciplinary teams. X
Networks and collaboration among teams. X
HTA support for decision-making and innovation-making. X
Skills of managers (i.e. strategic, organizational, on innovation and
evaluation).
X
Structural and non-structural characteristics of the organization. X X
Sub-organizational levels characteristics and structure. X X
Task characteristics. X X
Budget, time and resources (economic and none). X X
Organizational behaviour and learning processes (i.e. culture,
norms, absorptive and adaptive capacity, readiness for innovation).
X X
Communication channels. X X
Knowledge transfer processes. X X
Management support. X X
Characteristics of innovation process (i.e. imitation, evidence-based) X X
Decision-making process (i.e. consensus, participation vs hierarchy
and power).
X X
Determinant factors of Tele-healthcare –
Results compared with the theoretical background

30. WHO ACCOUNTS FOR TELE?
RESPONSIBILITY ISSUES
Determinant factors of Tele-healthcare –
Results compared with the theoretical background

31. Domains of
determinant
factors
Determinant factors
Present
in the
literature
Emerged
from our
results
Organisa-
tional
Accountability. X
Multi-disciplinary teams. X
Networks and collaboration among teams. X
HTA support for decision-making and innovation-making. X
Skills of managers (i.e. strategic, organizational, on innovation and
evaluation).
X
Structural and non-structural characteristics of the organization. X X
Sub-organizational levels characteristics and structure. X X
Task characteristics. X X
Budget, time and resources (economic and none). X X
Organizational behaviour and learning processes (i.e. culture,
norms, absorptive and adaptive capacity, readiness for innovation).
X X
Communication channels. X X
Knowledge transfer processes. X X
Management support. X X
Characteristics of innovation process (i.e. imitation, evidence-based) X X
Decision-making process (i.e. consensus, participation vs hierarchy
and power).
X X
Determinant factors of Tele-healthcare –
Results compared with the theoretical background

32. A NEW FORM OF ORGANISATION?
MULTI-DISCIPLINARY NETWORKS AND TEAMWORKS
Determinant factors of Tele-healthcare –
Results compared with the theoretical background

33. A NEW MANAGEMENT?
MULTI-DISCIPLINARY SKILLS AND CAPABILITIES
We should analytically study each process and pay attention
to the daily practice of professionals
(non-medical manager)
The healthcare management should have competences for assessing
(medical manager)
Determinant factors of Tele-healthcare –
Results compared with the theoretical background

34. A NEW HTA?
HTA FOR NON-PHARMACEUTICAL TECHNOLOGIES
Not only Cochrane, but also evaluation along all the life-cycle in the
context of real implementation…
(medical manager)
Determinant factors of Tele-healthcare –
Results compared with the theoretical background

35. Domains of
determinant
factors
Determinant factors
Present
in the
literature
Emerged
from our
results
Outer
Context
Social system. X
External networks. X
Mandates, strategies and policies. X X
Incentives and funding. X X
Norms among organizations. X X
Environmental stability. X X
Determinant factors of Tele-healthcare –
Results compared with the theoretical background

36. WHAT CRISIS?
POLITICAL MORE THAN ECONOMIC STABILITY
Determinant factors of Tele-healthcare –
Results compared with the theoretical background

37. WHAT INTER-ORGANISATIONAL NORMS?
METAPHORE OF SAN GIMIGNANO
The pride of diversity rather than objective reasons of diversity
(medical manager)
Determinant factors of Tele-healthcare –
Results compared with the theoretical background

38. Managerial and Policy Implications
 A common ICT architecture and infrastructure for tele-healthcare,
a PLATFORM.
 INTEROPERABILITY standards.
 Development and management of COMMUNICATION channels,
COORDINATION tools and PARTICIPATION environments could
facilitate the internal visibility of tele-healthcare solutions.
 A DOUBLE PROCESS of innovation introduction and
implementation: bottom-up, and top-down.
 A clear national or regional PLAN, with indication of needs,
priorities, funds and reimbursement policies.

39. Managerial and Policy Implications
CENTRALISATION

40. Managerial and Policy Implications
 Organisation should present a PARTNERSHIP FORM.
 Re-organization and changes produced by innovation are obtained
through CONSENSUS, COMMUNICATION AND PARTICIPATION.
 Healthcare managers should more operate “on the ground”.
Processes in support of the continuity of care present peculiar
characteristics: huge variability, fragmentation, local-specificity,
horizontal organization
 Need to “CUSTOMIZE” innovative interventions in this specific
healthcare setting.

41. Managerial and Policy Implications
LOCAL APPROACH

42. Managerial and Policy Implications
 TRANSVERSAL ECO-SYSTEMS could create networks within and
among organizations, facilitate the knowledge sharing and use,
promote participation and co-creation in the innovation processes.
 INCREMENTAL vs DISRUPTIVE INNOVATIONS

43. Managerial and Policy Implications
GLOCAL AND MULTI-LEVEL APPROACH
balancing centralization and local autonomy

44. Managerial and Policy Implications
 The KNOWLEDGE
 EVIDENCE
 Organizational know-how
 Different competences to be represented in a multidisciplinary
team
 Solutions and experimentations “from inside”
 HTA results
 Second learning approach

45. Managerial and Policy Implications
 INVESTMENTS & DIS-INVESTMENTS
 Benefits for society or end-beneficiaries + ADVANTAGES FOR
PHYSICIANS, health workers, ...
 COMMITMENT (intention to support) & MEDICO-LEGAL
ASPECTS (action to support)
 New models of FINANCING, REFUND and REIMBURSEMENT

46. Sabina De Rosis | s.derosis@sssup.it
Sabina De Rosis, PhD Candidate
TELE-HEALTHCARE
IN THE ROUTINELY HEALTHCARE SETTING
DETERMINANT FACTORS OF SUCCESS AND FAILURE
FROM A SINGLE CASE STUDY IN ITALY
XX NATIONAL CONFERENCE
FOSTERING AND GOVERNING INNOVATION
IN HEALTHCARE BASED ON EVIDENCE
Università degli studi di Sassari
16 October 2015