Diffusion of Telemedicine: Connecting Veterans to Healthcare

A fundamental transformation in the way healthcare is delivered is gaining traction in the United States. Ongoing concerns regarding access, quality, and cost of healthcare are driving consumer and provider interest in telemedicine. Recent research reveals how telemedicine can increase access to underserved populations and significantly lower cost to patients. The Veterans Health Administration (VHA) provides an effective model for the adoption and diffusion of telemedicine. VHA is the largest integrated healthcare system in the United States. Traditionally, veterans traveled to VHA hospitals or clinics for their healthcare needs. In 2013, more than 6 million veterans utilized this system for their healthcare services. Of the 8 million veterans, roughly 500,000 obtained healthcare via home monitors, videoconferencing, and other remote services (Terry, 2008). Adam Darkins, chief consultant for the Department of Veteran’s Affairs (VA), notes a 29% growth annually in telehealth services (2008).

According to Rogers (2003), an innovation is “an idea, practice, or object that is perceived to be new by an individual” (p. 12). The word “diffusion” is typically used in the study of innovations. Diffusion is the process by which a new technology is spread throughout a population over time. Four key aspects of Rogers’s definition of innovation are the innovation, communication channels, time, and a social system. Another term that is used in the literature when discussing innovation is adoption. Rogers defines the adoption process as, “the mental process through which an individual passes from first hearing about an innovation to final adoption” (p. 35).

“Telemedicine is not a different medicine, it a different interaction” said Jason Mitchell, director of the American Academy of Family Physician’s Center for Health IT (Laff, 2014). According to the American Telemedicine Association, “telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve a patient’s health status” (2014). Telemedicine is not a new innovation; it was first utilized in the 1950s. Until the 1970s, experimental grant-funded telemedicine programs could be seen in a range of settings, such as Native American reservations, psychiatric hospitals, prison systems, and medical schools (Field, 2002). None of these programs survived, due to their inability to prove the efficacy of telemedicine. However, recent growth and enthusiasm surrounding telemedicine is primarily attributed to increased access to telecommunications technology. The use of telemedicine at VA hospitals includes clinical video telehealth, home telehealth, and store-and-forward. The VA utilizes real-time base clinic base video telehealth at its 700 outpatient clinics. Many of these outpatient clinics do not have specialists on site, so patients are remotely connected to larger medical centers using video conferencing technology. This technology can be used to provide diagnosis, treatment, and perform check-ups for veterans in their community. Home telehealth can also be used to provide care to veterans with diabetes, chronic health failure, chronic obstructive disease, depression, or posttraumatic stress disorder. These services make it possible for veterans with chronic conditions to remain at home rather than in a nursing home or hospital. Donna Vogel, the director of case management of the VA Connecticut Healthcare system states, “We need to provide care in the least restrictive setting possible, and we want to take the care to the home and build a proactive patient care model” (Field, 2002, p. 30). Lastly, store-and-forward telehealth facilitates the acquisition, storing, and forwarding of clinical information to other VHA sites for consultation.

Organizations typically invest in innovations to change some aspect of their business. Innovations have the potential to change quality, create new markets, reduce cost, and improve processes (O’Sullivan, 2008). However, the failure rate of most innovations is 50% (Strebel, 1999). The causes of failure are varied. Expanding patient access to healthcare beyond institutional boundaries was the primary challenge to lowering disparities among veteran patients. Some veterans experience geographic challenges or severe disabilities, which presented obstacles to accessing healthcare facilities. More than 40% of veterans enrolled in the VA health program live in rural communities. Unfortunately, only 10% of physicians in the United States practice in rural regions, even though one fourth of the population lives in these areas (Barley, Reeves, O’Brien-Gonzales, & Westfall, 2001). The shortage of physicians in rural areas also presented significant challenges to achieving the VHA system’s mission of delivering exceptional healthcare that improves the health and wellbeing of veterans. Telemedicine is a means to mitigate the existing resource gap between rural and urban communities. VA hospitals and outpatient clinics can connect with their patients and eliminate existing barriers. Based on published data by Darkins et al. (2008), home telehealth has delivered significant reductions in patient resource utilization that would have otherwise been absorbed by the VHA healthcare system. The first year of the home telehealth program resulted in a 25% reduction in the number of inpatient days and hospital admissions by 19%. According to the telehealth VA report, in 2013 home telehealth reduced bed days of care by 59% and hospital admissions by 35%. Clinical video telehealth reduced bed days of care for mental healthcare by 35%. A survey of patients regarding home telehealth found that 84% of patients responded favorably; store and forward achieved a 95% favorability rating along with clinical video. Home telehealth produced a substantial cost savings of $1,999 annually per patient. Darkins states, “Telemedicine should not be used just for the sake of technology, it has to be based on fulfilling a need” (Lipowicz, 2010, n.p.). The VA has taken a lead role in adopting telemedicine strategies to better serve their veteran population.

While telemedicine delivers tremendous benefits to the healthcare industry, some challenges encumber its widespread diffusion. There are key concerns arising from legal, financial, and regulatory policies. A comprehensive review of VHA-supported research reveal some hindrances to the implementation of telemedicine are patient compliance to technology, maintaining current technology, and expert personnel trained on usage of telemedicine technology (Turner, 2003). For example, 15% of American adults do not use the Internet, which makes full implementation of telemedicine difficult (Zickuhr & Madden, 2013). Telemedicine requires an ongoing fiscal commitment, which may hinder some healthcare organizations from employing the technology. The Health Insurance Portability and Accountability Act presents another set of issues for users of telemedicine due to the involvement of multiple individuals and the exchange of protected health information over the Internet. Gupta (2008) states,

Teaching physicians and other healthcare practitioners to utilize new technology can be difficult, impeding the implementation of telemedicine (Turner, 2003). There are still ongoing fears among patients and practitioners that telemedicine technology will malfunction and cause a potential misdiagnosis. Moreover, coordination between different physicians and patients can prove to be quite challenging. Regrettably, telemedicine training is not offered in medical schools or health profession curriculums. Most physicians’ telemedicine training at the VHA is done virtually through the Office of Telehealth Services. A national training center was established in Florida to support home telehealth programs.

To address some of these barriers, the VHA has invested heavily in telemedicine and electronic medical records technology that meet data security standards, and it has sought partnerships with businesses that offer training to patients and healthcare providers. According to Darkins et al. (2008), “The computerized patient record is a fundamental prerequisite to establish a viable program at an enterprise level” (n.p.). The VHA has integrated electronic medical records at every VHA medical facility throughout the United States. Connections are made to patients and providers through secured networks between the VA hospitals and clinics. The VHA is developing a remote electronic medical records system to allow patient to access their medical records from home (Hatzakis, Haselkorn, Williams, Turner, & Nichols, 2003).

Telemedicine can be effective only if patient data are readily available to healthcare practitioners. An additional obstacle to the adoption of telemedicine is the differing state licensure requirements for healthcare providers and physicians in each state. These licensure statues are intended to regulate medical practice at the state level by assuring that practitioners are qualified to practice. However, the procedures for obtaining state licensure in each state are not uniform and can be extremely costly for telemedicine practitioners. Some states have begun to address this issue by providing limited telemedicine licenses. At this time, there is no consensus among the states to reduce the burden of multiple licensure requirements for telemedicine practitioners. The issue of multiple state licensure requirements deters many healthcare practitioners from practicing telemedicine. Licensure laws do limit VHA practitioners, who are allowed to practice across states (Hatzakis et al., 2003).

Despite the growing research confirming the effectiveness of telemedicine in reducing cost burden and increasing patient access, its diffusion remains slow. As Rogers (2003) noted, “Getting a new idea adopted, even when it has obvious advantages, is often very difficult” (p. 1). Many states have tried to implement telemedicine and failed to make it sustainable. One example of this is the state of Alaska, which poses significant geographic and climate barriers to healthcare delivery. Approximately 25% of Alaska’s population lives in communities of less than 1,000 people and no road access to hospitals. The telemedicine program implemented in Alaska was hampered by communication and transportation issues (Alaska Federal Healthcare Network, 2004). Another example involves the British Navy’s delay adopting an obvious treatment for scurvy. The cure for scurvy was discovered in 1601; however, it was not adopted until 264 years later (Rogers, 2003). In spite of overwhelming evidence, the adoption of practices to prevent and treat scurvy was painstakingly slow. Both of these examples highlight both slow diffusion and poor adoption of innovations.

Rogers defines diffusion as “the process in which an innovation is communicated thorough certain channels over time among members of a social system” (2003, p. 5). He enumerated five characteristics that determine the adoption rate of innovations:

1. Relative advantage—the degree to which a technology is perceived as being better than the idea it supersedes, reducing inefficient practices;

2. Compatibility—the degree to which a technology is perceived to be consistent with existing values, past experiences, and needs of potential adopters;

3. Complexity—the extent to which an innovation is perceived as difficulty to use;

4. Trialability—the degree to which an innovation may be experimented with before adoption;

5. Observability—the degree to which the result of an innovation is visible to others.

Rogers (2003) contended that innovations that are perceived to have more relative advantage, more compatibility, more trialability, and less complexity diffuse more rapidly. Most medical facilities make decisions to adopt new technology based on the impact on the patient and clinician, as well as the reimbursement and surrounding health care policies. Unlike other healthcare entities, the VHA is a closed health system, therefore rendering it immune to many of the complexities of cost reimbursement. The VHA is funded through a single payer system and operates on a fixed budget. Before integrating telemedicine program nationwide, the VHA implemented pilot programs to increase the adoption and diffusion of telemedicine. Goes and Park (1997) state, “hospitals that linked into multidisciplinary hospital systems, regularly exchanged resources with related hospitals, and aggressively built institutional affiliations were more likely to adopt innovative services and technologies” (p. 689). A clear example of this is the VHA’s system wide adoption of telemedicine technology to assist in reaching more patients.

The decision to adopt innovations takes time, primarily due to uncertainties surrounding new technology. The Innovation Decision Process moves from first obtaining knowledge of the innovation, to forming an attitude about the innovation, to deciding to adopt or reject the innovation, to implementing the new innovation, to confirmation of the decision made.

Another set of characteristics that help explain the rate of diffusion is the personalities of individuals. According to Rogers (2003), these five qualities determine between 49 and 87% of the variation in the adoption of new products. For successful innovation, the adoption distribution follows a bell curve that is divided into five categories. Innovators are the risk takers and the first to adopt innovations. Early adopters are known as opinion leaders. The opinion leaders are highly respected and have the ability to influence others. The late majority are risk averse and will only adopt the innovation after a majority of people have adopted it. Laggards are those who strongly resist the adoption of innovations. They don’t want to take any risk adopting a new innovation.

The VHA has been a leader for the use and diffusion of telemedicine to honor America’s veterans by providing exception health care that improves health and wellbeing. Discovering and leading innovations has its opportunities and risk. The ability to manage the innovation process is essential to the success of any organization. The VA has a successful strategic plan to “keep patients healthy” by addressing the disparity of its veterans, while making more efficient use of its resources. Telemedicine is central to this strategic plan by allowing healthcare providers to connect with patients and vital clinical information via secured video, health-monitoring devices, or store and forward. Significant gains can be seen in cost and clinical outcomes in the home telehealth. The barrier of distance between healthcare providers and patients is being shattered within the VHA system. Historically, the VHA has always provided quality of care comparable or better than their private sector counterparts. Much can be learned from examining the VA’s telemedicine structure.