Telehealth Technical Assistance Manual by the Cooperative Telehealth Steering Committee
Seven Steps of Telehealth Planning for Program Success
A document to assist in the planning of telehealth and telemedicine projects for UC
Health and associates.
Adopted from the original document by Samuel G. Burgiss, Ph.D.
Evaluate Needs
Develop Care Services Plan
Develop Business Plan
Plan Technology
Train Personnel
Test Care and Technology Plans
Evaluate Outcomes
Step 1: Evaluate Needs
Evaluation of needs is the most critical step in telehealth planning. Decisions made in this
step will affect the entire program. As a planner in the organization, you will answer the
question Why do we need telehealth? You and your colleagues should begin by first
considering the patients that you serve.
Patients with chronic diseases such as diabetes and congestive heart disease are in need of
almost continuous care. Medical services need to be available in their community and
often in their home in order to keep their diseases under control, and to prevent
exacerbation and co-morbidity. Telehealth can bring specialty healthcare services to the
citizens of communities in need.
The next consideration in evaluating needs is the doctors, nurses, and other healthcare
providers. Consider the following questions: If a physician, nurse, or other medical
provider is providing care to a patient using telehealth, what does that clinician or nurse
need to make the delivery of care effective and efficient? What information and
communication does a referring physician need? Do the clinicians travel between
facilities? What if one day travel to a partner hospital could be eliminated by using
telemedicine technologies such as simple videoconferencing?
Providers in some organizations use telehealth technology to participate in grand rounds
at medical schools and to present their cases for collaboration with faculty members.
Participation in distance learning can reduce clinician isolation and increase satisfaction.
The final consideration of need is for the organization. Your organization must be
financially viable in order to continue providing services to your patients. Telehealth
should not be a detriment to the financial status of the organization. It should be planned
so that its return on investment to the organization will be realized.
THE POINT: Identify the problem that may be solved using telehealth.
Telehealth Technical Assistance Manual by the Cooperative Telehealth Steering Committee
Step 2: Develop a Care Services Plan
In developing the Care Services Plan, you should consider the needs identified in the
previous step, determine which services will be offered, and how they will be delivered
using telehealth. In this step you must consider the source of medical services through
telehealth (who are your clinical assets), how those services will be delivered, the
location of the providers, the location of the patients, and the guidelines and protocols for
delivering these services. This step also includes consideration of telehealth technology
features used in delivering the services, such as the quality of audio and video
transmission, special instruments to view the patient, or the equipment to measure certain
physiologic parameters such as ultrasound imaging.
In this step, references to technology should be in terms of general features and
specifications, and not in terms of specific vendors or equipment models. For example,
you might state that your patients have a high incidence of congestive heart disease which
indicates the need to measure blood pressure, pulse rate, and body weight in their homes.
This will need to be followed by developing protocols that include the referral of the
patient by the primary care provider, the scheduling of the telehealth examination (if real
time such as videoconferencing), communication with the staff at the remote site, and the
examination between the patient and the physician.
All of the steps in the process should be in a written protocol that supports the patient, the
referring provider, the remote clinic staff, and the local staff. These protocols should be
written into your planning document and revised as the planning progresses. If you make
a commitment to implement the program, these planning protocols can be revised to
become approved clinical protocols. Following this process will make these protocols
more mature (less likely to have errors) and will help you with planning the other steps.
Developing and maintaining relationships with other health services facilities near your
organization are critical to most telehealth programs. Typically, telehealth involves
bringing in services from outside your organization. Some hospitals are in alliances that
include hospitals in nearby regions. Alliances could also include primary care
associations, assisted living facilities, skilled nursing homes, and home care agencies.
Such relationships can bring valuable assets to your organization for telehealth and other
programs in the form of referrals.
Developing relationships with the major employers in your region can be critical to
serving the needs of their employees and to the success of your program. You can
promote telehealth to employers by explaining how employees will spend less time away
from work for medical services. Your organization could establish a clinic in the
employers facility and use telehealth in the delivery of services. In addition, the
employer may be able to influence reimbursement for services delivered by telehealth.
THE POINT: Itemize what can be done given the current environment.
Step 3: Develop a Business Plan and Risk Analysis
Telehealth Technical Assistance Manual by the Cooperative Telehealth Steering Committee
Developing a business plan is a critical step that is often omitted but is necessary to
predicting sustainability of the program. Based on the previous two steps, you should
identify all possible increases and decreases in cost, increases in revenue and risk
assessment that will be impacted by the telehealth program.
An obvious additional cost is the technology. Though you might consider that the
technology should be considered before the business plan, evaluating the business plan
should be considered before technology so that you list all internal impacts on the
business before obtaining more specific costs from the technology vendors. In this
calculation you would consider what existing technology is already in place and how that
can be leveraged.
Using the sequence of evaluating needs, developing the care services plan, and
developing the business plan will enable you to explore the technology that meets your
needs rather than buying equipment and then trying to make it fit your situation.
Certainly with additional passes through the planning steps and modification of these
steps, improved information will be obtained and the business plan can be revised.
Reductions in cost and increases in revenue are often more difficult to identify. As an
example, providing continuing education to your staff at your site could result in a
reduction of cost and an increase in revenue.
An example of cost reduction can be achieved by decreasing the travel of staff members
between clinics in multi-clinic organizations to save transportation and labor costs.
Reimbursement from CMS and commercial payers is complex. Based on the outcomes of
Steps 1 and 2, identify the specific CPT codes likely generated and check with the CMS
and candidate payers as to reimbursement for those services. Often, a modifier is added at
the end of a code to designate it as a telemedicine encounter such as GT or U1-UD. Use
caution however, to bill for these services usually requires certain guidelines to be met
such as patient and provider must be in the same state or only synchronous systems such
as videoconferencing be used. Once you have identified the eligible CPT codes, outline
the requirements and educate the staff.
Telehealth can do something that is not often realized It can bring you a physical
patient. For example, if you have expertise at your facility such as a cath lab, consulting
with a remote site may yield the decision to transfer that patient to your facility for
critical care and ancillary services.
If home monitoring of chronic diseases is used, you might predict that patients would
continue in your care rather than going to other facilities and estimate the resulting
increases in revenue.
A marketing plan should be included in the business plan. It is a part of this step since
marketing typically has a cost and since the success of the marketing plan will impact
Telehealth Technical Assistance Manual by the Cooperative Telehealth Steering Committee
utilization and revenues. This plan should include communication to leaders of the
community, patients, healthcare providers, and other healthcare organizations.
An organization could take the position that if grant funding will buy equipment, the
organization will support the operations by maintaining and using the equipment. This is
not actually long-term sustainability which requires that the return on the investment be
able to replace equipment when needed (e.g. after five years of use). In other words, true
sustainability would mean keeping the program supported for 10 years or more. Thus, the
calculated projections of expenses and revenue in the business plan should be for at least
five years with the cost of the equipment amortized over three or five years.
And finally, despite the Federal Government pushing for reform and healthcare
technology, risks remain. Clinical interventions/processes need to be evaluated from a
risk-return perspective. It is important to re-visit existing malpractice policies to ensure
care delivered over the wire is covered.
THE POINT: Analyze costs, revenues and risks to create sustainable business
models.
Step 4: Plan Technology
Sometimes organizations plan the technology before any of the other steps listed in this
process, and occasionally the other steps are neglected. This can increase the probability
that the program will fail and the equipment will be in a closet within a few years.
A thorough and objective technology plan based on realistic needs, a care services plan,
and a business plan (the first three steps) can increase the probability of long-term
sustainability of a telehealth program. The technology planning process should begin
with a review of the priorities you listed in Step 1 Evaluating Needs. This includes the
functions needed by the patient, the functions needed by the healthcare provider, and the
functions (e.g. cost, return on investment) needed by the organization. The members of
the organization should gain sufficient knowledge about telehealth technology to
determine the features and specifications of equipment to meet their needs for clinical
services and the business plan. Physicians, nurses, medical providers, clinicians, and
technologists should be involved in this activity.
After gaining knowledge about telehealth technology, the next step is to develop a
specification for the equipment that is needed to provide the functions and results as
planned in Steps 1 through 3. This specification should include the patient operation (if
applicable), provider operation, report generation, features, quality of performance, and
service. An experienced person who has developed telehealth programs and who will
collaborate with the group is a valuable resource.
After a specification is written, vendors can be invited for demonstrations and
performance testing of their products. Some organizations require that a sample of the
product be loaned to them for a period of time (e.g. two to four weeks) so that personnel
can gain experience with the equipment as it would be used in the program in order to
Telehealth Technical Assistance Manual by the Cooperative Telehealth Steering Committee
obtain the best product. For example, a nurse in the organization might use home
monitoring equipment with a family member acting as the patient. Data can be
transmitted and the nurse can observe the data in the patients record. Operation by both
the patient and the nurse can be evaluated.
THE POINT: The needs of the program drive the technology.
Step 5: Train Personnel
A plan should be developed for training personnel to prepare them for the arrival of the
technology and for its use with patients and providers. Organizations often do the obvious
operational training of nurses and patients (or remote clinicians) who use the equipment
while other staff members are left out of the training plan. For example, referring
providers need to receive training concerning the function of the telehealth services and
potential benefits to them and their patients.
Administrators need to be trained concerning the services that will be offered to the
patients and the benefit to the community. Other clinicians such as health educators,
social workers and mental health providers can learn to use the equipment in order to
provide consultation, education, and patient care services across distances within multi-
clinic systems.
THE POINT: Training must be comprehensive and include peripheral parties.
Step 6: Test Care and Technology Plans
The process of writing the plan and reviewing it by people with different skills improves
its quality so that the probability of errors and omissions are reduced. It also needs to be
tested in the implementation phase. The care and technology plans should be tested by
performing a pilot program with a limited number of patients and staff members. For
example, the pilot can provide services in cardiology to one or two clinics rather than the
complete plan of several specialties to several clinics.
During a pilot program, much will be learned from patients, nurses, referring providers,
specialty providers, and other staff members as the pilot is being implemented. This
knowledge could be used to revise the clinical protocols, the business plan, and other
parts of the telehealth plan. In most organizations, it is much better to learn lessons with a
few patients and staff members than it is with large numbers.
THE POINT: Roll out the program initially with pilots.
Step 7: Evaluate Outcomes
It is very helpful to think of three target beneficiaries in the planning process, and to
identify three related sets of outcomes: outcomes important to patients, providers and the
organization. In actuality, the needs and well-being of all three are interdependent and
mutually supportive of the healthcare safety net. Evaluation of outcomes is critical when
performing clinical research. It is also valuable for any organization that is implementing
a telehealth program.
Telehealth Technical Assistance Manual by the Cooperative Telehealth Steering Committee
The program and the technology will be new to the organization and it needs to determine
if the expected results are obtained. Goals and performance standards can be written
based on the needs and care services plan (Steps 1 and 2). Data collection can be planned
to measure the performance. Outcome data will be important in evaluating the results,
adjusting the operation of the program, and planning the future of the program. The time
to start the telehealth planning process is now.
THE POINT: To measure success, collect the necessary data to support the
investment.
Examples of projects:
Our doctors complain because they have to travel to West Chester twice a week and their
RVUs drop dramatically on those days.
Existing consult services such as the UC Stroke Team can be enhanced by implementing
videoconferencing to remote sites. This can bolster contract services and facilitate patient
transfers for procedures such as catheterization.
Tele-ultrasound is already being used here. A specialist can remain in one location while
connecting to various sites in the region to review ultrasounds and interact with the
patient.
