"Bringing Telework Home: Working Beyond the Frontier"*

Introduction to Audrey Kinsella, HOME HEALTHCARE: WIRED AND READY FOR TELEMEDICINE -- THE SECOND GENERATION [Aloha, Or: Information for Tomorrow: 1998]

Ronald K. Goodenow, Ph.D., Telework Development Group, LLC

I had the pleasure of writing the introduction to Audrey Kinsella’s Home Healthcare: Wired and Ready for Telemedicine, published in early 1997. My title, "Home Health Care: The Emerging Telemedicine Frontier," reflected what was true then, and remains so now. As in a comment by Lisa Remington which I cited, "telemedicine is the future of the home health industry." And, as suggested in Kinsella’s findings, much of telemedicine’s future would be at home.

Audrey Kinsella’s first book struck a much-needed balance on several fronts. She heightened awareness of the vast potential for telemedical products and programs to meet the needs of people in their homes. Her approach was an integrated one that emphasized the importance of fitness, social interaction, getting one’s arms around cost/quality issues, and understanding the place of home telemedicine in a rapidly changing home health industry. Imporantly, she used examples and a style which, when all was said and done, were imminently practical. There was no jargon and there were well-deserved warnings about some of the hyperbole that accompanies product development in a relatively new industry.

Here, then, was a breath of fresh air to this writer, who as a non-medical specialist has attended many telemedicine events and poured over the literature of the field in some frustration in a quest for well-informed writing about a still controversial intersection of high technology and ancient practice. Happily, too, Kinsella was more ‘ground-up’ than rooted in the rarified halls of the high status physicians, CIOs, policy makers, vendors and engineers who have generally promoted the telemedicine cause.

Though only a year has passed, it is now possible to think ‘beyond the frontier’. As the title of this book suggests, we are into ‘Second Generation’ maturation processes needful of a focus on implementation - and barriers to it. Today, Kinsella writes in Chapter 1, home telemedicine has become part of a larger picture as a business/technical/human paradigm for the transmission of information and services. Always practical, she argues the use of available means, from the telephone to advanced communications technologies that establish added-value [emphasis mine] to home healthcare. This we know, is no simple task in a time of rapidly changing technologies, aggressive vendors and policies which themselves highlight the latest and greatest tools for making the ‘information superhighway’ a justifiable reality. Staring down difficult, and in terms of the 21st century, probably unpredictable, problems of reimbursement only makes matters more complex.

Quite clearly, these observations point us in the direction of vastly improved market research on conditions best treated, and more importantly, the specialized needs of targeted demographic groups - the patients, or ‘end-users’ of telemedical services.

Finally, if this new version of Audrey Kinsella’s work recognizes implicitly that home telemedicine is here to stay, it also reminds us that it is a very shifting target, with definitions of ‘home’ truly reflecting a changing national culture that also has seen an explosive acceptance of ‘networked’ services into the home. In medical settings, it is quite easy to understand that home is not just an apartment or house, but an assisted living center or nursing home. More importantly she and I believe, it is where people spend large amounts of time in the course of their daily lives: schools, workplaces and more mobile environments. Getting our arms around home telemedicine is therefore a very exciting challenge.


The rest of this essay is a reflection on this larger picture intended to introduce some crucial factors to be addressed on the issue of making telemedicine operations successful in today’s technology-enabled world. It is partly an on-going exercise in ‘context setting’. But it is also to issue my own caveat that if we take Kinsella’s approach seriously, we must think constantly about how diverse values, interests, skill levels, and cultures can work together to identify and target markets, select tools and methods, deliver care, and establish benchmarks for success.

This territory lies beyond some of the concerns that many of us expressed just a few years ago about measuring effectiveness or designing business models to reveal where to make investments that assure quality and cost effectiveness. We know now that the geography is a vast and challenging one that is highly distributed and intensely cultural.* In the oft-use phrase, we need to "get down from the 30,000 foot" level and focus on some very real problems that may stand as critical barriers to success. Identifying and overcoming some of these barriers are what I want to write about here.

My perspective is that of distributed work and services in new ‘virtual’ organizations, which are increasingly network dependent and spread out over very wide areas. They reach from university medical centers, to hospitals, to provider groups, clinics, nurses, financial and insurance specialists and members of the home.

With that as brief background, let me use the time-honored phrase: ‘paradigm shift’ to describe our frontier, for although there is a tremendous emphasis still on what I will call ‘point solution services’ [consultation, image reading, provider and patient education, etc.; the subject of most conferences], we are now coming to recognize that telemedicine/telehealth transcends diagnostic or consulting services, or ‘bringing the doctor to the patient’. And, it is more than providing a wide range of Internet wellness and other services.

Today, there is growing recognition that collaboration is taking place in a vast new workspace that is evolving with blinding speed. Though often touched upon it is not yet, in my opinion, addressed fully in telemedical research, conferences or publications - and most certainly not in the curricula of most training programs. But it must be included if we are to be successful in providing quality service, especially as the nature of health care in the world changes. People from diverse nations, backgrounds, and professions will need to work together increasingly - globally and inside domestic delivery systems.

As Matthew Holt, of the Institute for the Future, writes in the December 1997 Telemedicine and Telehealth Networks , we are entering a new phase wherein ‘cyberspace communities’ are becoming hallmarks of telehealth delivery - and the places where people work together ‘virtually’, something I’m sure many of you are doing already.

The organizational context for this work will therefore be changing apace. I agree with David Foote in a recent issue of CIO Magazine,* when he writes of "organizational models that feature more nimble entities, distributed management and highly participatory employee roles. There will be a far greater focus on relationship building, information sharing and communication between employees, partners and customers." I include many people engaged in delivering telemedical or telehealth services, whether collaborating with a radiologist from a remote site over a PAC system, or providing psychological consulting services to a clinic or prison 300 miles from the home office. My main argument is that unless these environments are highly integrated and robust, with people fully able to work in them, they will be wasteful of resources and provide poor services.

Here is a simple model we can use at the outset to look at integration.

Within each category there are critical factors to be taken into consideration as policies and procedures are put in place, technologies selected, people trained and ‘customers’ or end-users readied for services. In line with much in this current volume, the Internet, or Intranets for those within the system, will be a very common part of what is on the user’s desktop - on both the provider and end-user side. There will be some situations where the only telemedical technology will be a telephone - as in many ask-a-nurse programs - but increasingly we can come to expect that through cable television devices, highly portable laptops, or tailored computer workstations, or HANC-like hybred products a wide range of information will be exchanged and services provided.

Some of the barriers to healthy program implementation and use are suggested in an Ernst & Young study of health care,* where problems included rapid mergers, information systems that will not speak to each other, poor policies and procedures for employees, and the lack of standards which accompany the development of networked-based work.

Here are three problem areas I will elaborate upon: [1] scant understanding of the ‘virtual’ or telework phenomenon in which large numbers of individuals or groups work collaboratively with the assistance of modern computer-based communications technologies; [2] an abundance of poor data and unclear objectives on which to plan, train, launch and sustain programs; [3] a failure to provide integrated and readily usable technologies and communications support systems. These problems are not epidemic - there is no real data to suggest they are - but they, or problems like them, are appearing increasingly in literature, and I have encountered them, as noted below, in recent personal experience.

  1. The significance of the telework phenomenon is often not understood; change is coming so fast we are often very unself-conscious about what we are doing. When we do begin to understand it, there are many worries and concerns, many of which we have all encountered. Here are some I know about personally.
privacy in new network-enabled environments which permit easy monitoring of e-mail, work flow [and with a video connection, what the home worker is wearing!]; a phenomenon also noted in the recent Ernst & Young internet in health study. What do they mean for the quality of the work experience? I find that company policies and procedures which accommodate remote work and worker sensitivities are of special concern to those struggling with the new HMO environment.
  1. An abundance of poor data and unclear objectives on which to plan, train, launch, and sustain programs.
  1. A failure to provide integrated and readily usable technologies and communications support systems - webs, video-conferencing, remote facilities, distance learning tools, groupware. There remain too many ‘islands of automation’ as well as poor technology readiness. This circumstance creates enormous employee frustration [you know how bad you feel when your computer goes down, imagine the angst which comes in enterprise systems when the whole system seems to be unintegrated or tools don’t work].
From a ‘top-down’ management perspective, here are some principles our experience suggests should be applied. These are consistent with Audrey Kinsella’s recommendation for pulling together medical and business visions. They reflect the fact that we are moving from traditional technology-based management to knowledge-based management, with all that implies for the CIO, who must now be able to address technical, business and people issues Here is the previous depiction, with some elaboration on what should be addressed within each of the three main categories.

In the center box I have suggested that when integration is complete there will be a very high degree of performance. Without it, growing evidence suggests that there will be high levels of worker satisfaction and turnover, disillusionment with technology, and poor quality service to the end-user or customer.

We need to define and integrate ‘building blocks’, including a powerful network architecture, appropriate imaging/workflow technologies, comprehensive data warehouses, and, importantly, the policies and procedures [and reimbursement!] to integrate and make all of them work well together in a workplace of satisfied workers; this is the truly ‘robust enterprise’.

These are factors which, from my experience, should drive the development of a comprehensive telemedical program, whether it is oriented to home care or not. This integration will become increasingly important as the enterprise extends beyond health care.

In my previous introduction I argued that we begin to understand the integration of healthcare and other Internet-based services made possible by explosive changes in communications technologies and their public acceptance. We need to anticipate the overall integration of services - financial, educational, health - into the larger worlds of electronic commerce and distributed work that are the future of the global political ecnonomy. Failure to achieve a high performance workplace, and failure to work with people in ever expanding workplaces beyond traditional boundaries will put medical people at risk as consumer awareness increases and standards for services are further developed and regulated as a requirement for reimbursement and quality.