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John Mitchell, BA (Hons), Dip Ed, M Ed Admin, AFAIM Benjamin Mitchell, BA (Psych.)

CH. 1: Description of Project and Manaement

One of the weakest aspects of most telemedicine programs is in setting up an organisational and management structure, as well as an ongoing user- and technical-support program. (Shwartz, 1994)

This chapter provides a description of the project and an overview of the approach taken to project management.

Plan, funding, aim

The plan for TQEH Renal Dialysis Telemedicine Project was initially prepared by Dr. Timothy Matthew and Dr. Alex Disney in December 1993 and extended by JMA in May 1994. The document (see Appendix 1) sets out the aim, background, applications, costings, projected savings, research framework, the project team and responsibilities, key dates and milestones. The project was undertaken by TQEH Renal Unit from May 1994-June 1995 and included the implementation of telemedicine sites (see diagram opposite) at Woodville, and at satellite centres at Wayville (10km from Woodville), North Adelaide (8km) and Port Augusta (300 km). Funding for the project was provided by the South Australian Health Commission (SAHC) in November 1993 and the project officially commenced in June 1994, with TQEH's Senior Staff Nephrologist, Dr. Alex Disney, as Project Director and John Mitchell & Associates as Project Managers and Researchers. (Appendix 2) The aim of the project was to assess the feasibility and cost effectiveness of telemedicine as a means of improving the quality of patient care, further educating dialysis staff and monitoring dialysis processes and equipment at sites remote from the main dialysis institution.

Telemedicine and dialysis services

Dialysis supports the majority of patients with chronic renal failure. The number of patients treated is growing at a rate of 10% per year. 75% of patients are supported on haemodialysis and in South Australia the majority of these are located in satellite centres. The trend here and overseas is increasing in this direction.

Problems which arise in delivering dialysis in these satellite units are numerous and include: maintenance of standards of care, initial training of staff, continuing education of staff and updating of procedural skills, managing acute problems in patients such as incidental illness, collapse, fistula problems and maintenance of professional relationships and discipline in a chronic care situation remote from senior management and assistance.

These problems are currently managed by high cost options which involve either staff spending more time gaining a high initial skill level with regular updating at the parent institution or skilled personnel travelling to the site (e.g. management, paramedical support, medical staff). Even with this level of support , compromise is frequent and in the case of country patients, referral of the patient back to Adelaide is often necessary.

The project began in 1994 with the expectation that telemedicine, involving the instantaneous transmission of live two-way video and audio, could provide a solution to a number of these challenges.

A user needs analysis in relation to the telemedicine project was undertaken in June 1994. The main issues identified in relation to the proposed telemedicine project were:

• the major uses of telemedicine within TQEH's Renal Unit's four dialysis centres were expected to be, in descending order: clinical diagnosis and patient support, staff development and administration
• clinical applications were expected to include consulting with patients and handling acute situations
• the major users were expected to be doctors at various levels, dialysis nursing staff, allied health professionals, machine technicians, nurse educators and patients
• benefits from the project would be the enhancement of staff morale and the continuation of the reputations of TQEH and the Renal Unit for innovation and excellence in health care.

It was recognised that there would be some resistance to the project, for a number of reasons, including the normal work pressure staff were under and their lack of experience with telemedicine and therefore their limited motivation to use the proposed facilities. Hence it was decided to introduce telemedicine facilities incrementally and to win staff and patient support gradually, as follows:

• two sites would be established in 1994 and two in 1995: TQEH Woodville and Wayville in September 1994, Port Augusta in February 1995 and North Adelaide in April 1995
• the initial two sites would be used as test beds for the technology and for the induction, training and management systems
• room modifications, including lighting and acoustics, would be tested at the first two sites, before funds were expended at the other sites
• additional equipment such as document cameras, probe cameras, headsets and videocassette recorders would be trialed before being purchased for the last two sites
• the mobility and flexibility of the rollabout units would be assessed at the first two.

The intention was to embed the process at two sites before extending it to Port Augusta and North Adelaide. The implementation process could then be accelerated at the new sites.

The following strategies were used to manage the concerns of the patients and staff, and to gradually win their support:

• activities to raise awareness were undertaken, acknowledging the concerns of the users
• the process was promoted through regular memos, newsletters, one-to-one and small group discussions
• information about project developments, such as the timing of installations and the provision of training and support, was regularly made available to the staff and patients
• the results of surveys were provided directly to the staff
• the staff were consulted when decisions were needed on issues that would affect them, such as the sitting of the equipment and the modification of the rooms
• a structured staff development program was developed, progressing from awareness raising activities, to induction, basic and advanced training
• accurate lists were kept of staff and patients who had been inducted and trained
• a series of demonstrations and special events were arranged
• equipment designed for ease of use was selected.

Literature on change management and technology adoption (e.g. Moore, 1991) cites the importance of identifying and supporting "champion users" and early adopters, to provide practical demonstrations of the benefits of using the new technology. Champions are the outstanding early users, who willingly use the technology, deliberately providing leadership and example to their colleagues. Following the lead of the champions are the early adopters: they are the risk takers who use the technology before it is settled in; they are excited by the power of the technology; and they are happy to experiment.

The Project Director, Dr. Disney, was the champion user in the first year of the project, quickly and enthusiastically using the equipment, for a range of purposes, throughout the project. His particular use of the desktop unit is reported on in detail in the chapter 7.

The Project Officer, nurse educator, Julie Meyer, appointed in October 1994, also used the system extensively, and introduced all staff and patients to the medium, using a structured training program. Part of her role was to identify and support early adopters of the technology.

Other early adopters included a number of the senior nursing staff who used the system from the early stages for regular meetings and a number of patients who were keen to use the facilities.

By early 1995, a second wave of users, often termed late adopters, emerged. The late adopters are happy to use the system after it has been trialed and found reliable. A number of these late adopters are profiled in Chapter 6, and included allied health staff, clerical and technical staff.

By early 1995, the ad hoc users started to be outnumbered by those staff who preferred to make regular, scheduled uses of the facilities. When this happened, it was obvious that the process was becoming part of the daily routine in the workplace.

In summary, the acceptance of the telemedicine technology by a range of staff took between three and nine months from the installation in September 1994: an excellent result, given that adoption of new technology is often much slower and, in this case of renal telemedicine, there were no precedents in Australia to follow.

One of the reasons for this acceptance of telemedicine was the care taken in specifying the technology required. Based on the user needs analysis, it was clear that:

• audio and video must allow easy group discussion
• audio and video quality must enable easy interaction
• patients and staff at each site must be able to clearly see and hear each other
• it must be easy for the videoconferencing unit and the document camera to be moved about
• it must be easy to plug in, turn on and start using the equipment.

Detailed equipment specifications were developed, based on these five points.

It was decided to operate the equipment at the low bandwidth of 128 kbps, in order to ascertain the quality and performance of the equipment at this very cost effective transmission rate.

The main videoconferencing technology selected for the project was manufactured by PictureTel, which was on the State Government list of preferred suppliers and was able to meet all the technical specifications. PictureTel agreed to provide a desktop unit to facilitate its evaluation over three months and additional discount on equipment upgrades.

Initial equipment purchased included:

• four PictureTel System 4000 rollabout units, with 29" monitor, full duplex audio, IDEC, camera preset positions, auto focusing camera with pan, tilt, zoom, and other features
• two Panasonic document cameras.

Equipment purchased later included

• headsets
• 3 probe cameras
• 1 videocassette recorder
• five desktop videoconferencing units.

While the PictureTel equipment came with a good reputation for ease of use and quality of audio, the units purchased were designed for boardrooms, not clinical settings, so modification of the equipment was required.

After the initial equipment was purchased, a technology integration firm, Network Nomis, was engaged to provide technical assistance and advice. This required an iterative process with the project management team regarding alternative solutions to the functional specifications developed for the equipment. Network Nomis was also required to become familiar with the special issues arising from the use of videoconferencing in the dialysis centre at TQEH.

These issues were set out for Network Nomis by the Project Management Team at the start of the project, as follows:

• the videoconferencing unit would be moved to a number of sites within TQEH dialysis centre, to any point in the main dialysis room and to nearby rooms.
• the mobility of the videoconferencing unit would be crucial, taking into account occupational health and safety issues, hence the unit's cables would need to be sufficiently long.
• the videoconferencing units normally would be placed so that a staff member at a remote site could easily see as many patients as possible with little camera movement
• an additional miniature probe camera might be stored in the videoconferencing unit, for close-ups of patients and equipment
• as the videoconferencing unit would be wheeled from one patient to the next, provision to attach the keypad to the front of the unit would be required
• an additional portable microphone, for patients and staff, might need to be attached to the videoconferencing unit
• lighting and audio conditions would need to be examined
• the use of headphones for privacy would need investigation
• transmission of data from one site to the videoconferencing screen at another site should be established
• the videoconferencing unit should be positioned close to an individual patient, to provide personal interaction with staff at the remote site.
• the videoconferencing unit will need to be positioned in appropriate rooms and used in conjunction with the document camera, as a teaching medium, for both group and individual instruction
• advice might be required on the benefits of miniature probe cameras, lapel microphones, a microphone attached to a stethoscope and other enhancements that would enable the staff to use videoconferencing for effective management of acute clinical problems.
• advice would be required on the technical issues arising from installation of an additional fixed surveillance camera with fixed lens on a pan and tilt head, to be used for panning back and forth across the dialysis area
• advice might be needed on multipoint connections.

Network Nomis was required to give special attention to cabling, power sources, occupational health and safety, audio and lighting and other engineering issues that might arise.

These fourteen points provide an indication of the challenge to the Project Management Team caused by attempting to convert boardroom videoconferencing equipment to the unique setting of a dialysis ward.

The project managers, John Mitchell & Associates (JMA), had considerable experience with managing the implementation of videoconferencing into organisations (Appendix 2), based on their educational, psychological and management frameworks. Factors the considered influenced the adoption of a videoconferencing system into an organisation included the following:

• unless the system is perceived as being easy to use, reliable and effective, the system will not be used
• unless users are properly inducted and given support and understanding over their concerns with the equipment, they will not progress past novice level of use
• unless users are provided with higher order training, adequate documentation and structures (such as timetables and local support), they will not progress to become regular users
• unless users can see specific applications that can make their job easier or enable them to provide improved quality of care and service to the client, they will not progress to become regular users
• users will use the system to the extent that it provides positive advantages for them in a personal and organisational context
• users are more likely to develop into frequent users if they have specific goals regarding their use of the system.

These beliefs were tested in surveys and interviews during the project and the results are reported on in chapters 4-7 of this report.

Induction and training sessions were undertaken in a number of stages using a variety of techniques, based on the beliefs listed above.

The initial Training Program for the Renal Unit comprised five stages:

1. Induction, covering the philosophy and objectives of the project; technology components; booking system; and resources.
2. Basic or Novice Training, covering switching the unit on, operating the keypad and conducting a basic session.
3. Training on the Document and Probe Cameras, covering display of documents, close-ups of patients and using the controls.
4. Advanced Operations Training, covering still graphics, presets, microphones and the videocassette recorder
5. Problem Solving Training Program, covering power failures, document and probe camera problems and microphones.

It was the responsibility of the Project Officer to induct and train the staff and patients, and to keep detailed records of those who had been inducted.

It was considered essential by the project managers that quality documentation should be developed and distributed to the staff and patients. The following were the main items developed:

• List of Ethical Practices
• Policy and Procedures Manual (draft)
• Operating Instructions
• Dialysis Telemedicine: Key Aspects for Patients
• Dialysis Telemedicine Project News

A number of items were added to the original system and a number of trials were conducted to improve it. The main developments were:

• trials with lapel microphones, infra-red and wired headsets, with selection of the latter
• trials with an electronic stethoscope, which was subsequently discarded
• addition of larger wheels to rollabout systems
• introduction of a stand with a flexible arm for the miniature probe camera
• investigation of videocassette recorders
• investigation into the addition of handles to the rollabout units
• investigation into the addition of a ledge for sitting the keypad on the rollabout.

The project was promoted both internally and externally, to enhance staff and patient motivation, to provide feedback for the SAHC and to win support and sponsorship from vendors. Highlights included:

• production of a high quality videotape on the project, subsequently shown throughout Australia, Europe and the USA
• articles in TQEH, SAHC, metropolitan, country and national print media
• a report on Channel 7 news in Adelaide
• appearances by project management staff in videoconferencing seminars in Perth, Melbourne, Canberra, Sydney, Brisbane, Cairns and Newcastle
• discussions with health care officials in Singapore about collaboration
• discussions with commercial parties interested in collaborative ventures
• presentations to visitors from overseas.

The project management focus in the second six months of the project shifted predominantly to evaluation, research and development, while the Project Officer concentrated on implementing the operational procedures, such as training, booking procedures, technology maintenance and fault reporting. The research and evaluation components of the project are the subject of the remainder of this report.

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