Healthcare Technology in Context: Lessons for Telehealth in the Age of COVID-19 9811640742, 9789811640742

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Healthcare Technology in Context Lessons for Telehealth in the Age of COVID-19 Alan Taylor

Healthcare Technology in Context

Alan Taylor

Healthcare Technology in Context Lessons for Telehealth in the Age of COVID-19

Alan Taylor College of Medicine and Public Health Flinders University Bedford Park, SA, Australia

ISBN 978-981-16-4074-2    ISBN 978-981-16-4075-9 (eBook) https://doi.org/10.1007/978-981-16-4075-9 © The Editor(s) (if applicable) and The Author(s), under exclusive licence to Springer Nature Singapore Pte Ltd. 2021 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and ­transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Cover illustration: © dbayan / Alamy Stock Vector This Palgrave Macmillan imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Preface

Throughout a long career in the Australian public health sector, I continually asked myself, why some projects were successful while others were not? We are constantly reminded of the importance of technology in our work and daily lives, but what is the role of technology in our world? This project was born out of a quest for the answers to these questions in the specific context of telehealth services. During my career in the health sector, I have read and written countless official reports, strategies, conference presentations, academic articles and industry white papers about telehealth and eHealth projects. For me, most of this work generated more questions than answers. Based on longitudinal research undertaken between 2016 and 2021, this book is an attempt to explain how, why, when and where health technology in the form of telehealth services becomes useful in healthcare. The discovery of the highly infectious COVID-19 virus in 2020 was a critical event which triggered a complex series of cascading interventions across the world which enabled an examination of the trajectory for telehealth services in the light of the challenges to healthcare during the pandemic. My research for this project took place across two continents and cultures, Australia and Brazil. Both of these countries are vast territories with geographically isolated populations who have difficulty accessing the universal but imperfect care offered by their respective health systems. My approach to this research project was driven by persistent curiosity and v

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healthy scepticism. I hope readers will be able to emulate my approach when seeking answers to their own questions about the futures for the use of technology in healthcare, many of which may be hidden in plain sight—until we start looking! Bedford Park, SA, Australia

Alan Taylor

Acknowledgements

This book has been a long time in the making so there are many people who have helped me and deserve some thanks. I am extremely grateful to Professor Paul Ward for his persistent encouragement and insights. I also wish to thank Professor Michael Kidd for starting me on this journey of discovery. I received fantastic support for my fieldwork from innumerable people, but I would especially like to thank: • Abdel-rahman Bassal from the Country Health South Australia Local Health Network for supporting my research in South Australia, Australia • Phil Greenup from the Queensland Health Telehealth Unit and telehealth coordinators throughout Queensland for supporting my research in Queensland, Australia • Professor Ivan Torres Pisa, Federal University of São Paulo, for his support, mentoring and provision of facilities during my research in São Paulo, Brazil • Doctor Paulo Lopes from the Brazilian National Teaching and Research Network for his advice and friendship throughout this project • Thiago Lima Verde Brito from the Brazilian University Telemedicine Network for his essential support during my fieldwork in Sao Paulo, Brazil

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• Professors Celso Spada and Aldo von Wangenheim from the Federal University of Santa Catarina for their support, mentoring and provision of facilities during my research in Santa Catarina, Brazil • Professor Maria Inês Meurer from the Federal University of Santa Catarina for her enthusiasm and support for this project • Doctor Roberto Umpierre and Professor Marcelo Gonçalves from the Rio Grande do Sul Telehealth Centre for their support, mentoring and provision of facilities during my research in Rio Grande do Sul, Brazil • The 135 interviewees who made the research for this book possible by providing their informed consent to participate in this research. Their real names quoted in this book have been changed • My editors, Elizabeth Stevens and Elaine Ridge I am eternally grateful to my children Sean, Robin and Sasha for their unstinting encouragement, and my partner Kerry who has provided all manner of insight, support and love, without which this book would never have been finished. Finally I would also like to acknowledge the following organisations for providing their approval in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki to conduct the research referred to in this book. • Southern Adelaide Clinical Human Research Ethics Committee (SAC HREC EC00188), OFR Number: 113.17. HREC Reference Number: HREC/17/SAC/196 • Bolton Clarke Human Research Ethics Committee, NHMRC Registered Committee Number EC00349, Project No: 192 • Brazilian Ministry of Health and the Federal University of Santa Caterina, CAAE: 80481717.6.1001.0121, Project No: 141349/2017 • Flinders University Social and Behavioural Research Ethics Committee, Access to healthcare using telehealth services post-COVID-19, project 8668. The following Australian organisations provided research governance approvals (to conduct interviews with employees): Southern Adelaide Local Health Network, Northern Adelaide Local Health Network,

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Central Adelaide Local Health Network, Country Health Local Health Network, Central Queensland Hospital and Health Services, Children’s Health Queensland, Department of Health Queensland, Metro North Hospital and Health Services (RBWH and TPCH), Metro South Hospital and Health Services, North West Hospital and Health Services, and Townsville Hospital and Health Services.

Contents

1 Introduction  1 1.1 What Are Telehealth Services?   4 1.2 Understanding Telehealth Services   7 1.3 Telehealth Services in the Pandemic Era   9 1.4 Researching Telehealth Services  12 1.5 Outline of the Book  17 References 24 2 Organisational and Professional Practice of Telehealth 29 2.1 Organisational Contexts Provide a Place to Practise  31 2.2 Professional Contexts Define Practice  32 2.3 Contrasting Visions for Telehealth Services  35 2.4 Privacy, Confidentiality and Patient Consent  38 2.5 Maintaining Quality and Safety  39 2.6 Responsibility for and Relationships with Patients  41 2.7 Minimising Liability and Risk  42 References 44 3 Incorporating Technologies into Telehealth Services 49 3.1 Has Technology a Social Component?  50 3.2 Is Technology Designed or Tamed?  51 3.3 Acceptance of Technology  54 xi

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3.4 Cumulative Adoption of Technology  55 3.5 Incorporating Technology into Clinical Practice  57 3.6 The Sociotechnical Codes of Telehealth  59 References 61

4 Healthcare in Australia and Brazil 65 4.1 Universal Healthcare  66 4.2 Organisation of Healthcare  67 4.3 Access to Healthcare  67 4.4 Availability of Human Resources  69 4.5 Financing Healthcare Services  71 4.6 Information and Communications Technology  72 References 75 5 Telehealth Services in Australia and Brazil 81 5.1 Contrasting Contexts, Different Services  82 5.2 Evolution of Telehealth in Australia  87 5.3 Evolution of Telehealth in Brazil  95 5.4 Telehealth in the State of Queensland, Australia 106 5.5 Telehealth in the State of Santa Catarina, Brazil 109 References 112

6 Organisational Structures Influence Telehealth Services121 6.1 Organising Healthcare: Managing Inequities in Universal Care 123 6.2 Structuring Healthcare: Traversing the Boundaries 126 6.3 Automation of Care: Accessing and Sharing Health Records133 References 137 7 Contested Professional Practices When Care Is Separated141 7.1 Separation of Care: Challenging Usual Practice 143 7.2 Practice at a Distance: Adapting Norms 146 7.3 Controlling Separated Care: Aligning Technology 151 References 154

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8 Legitimising Telehealth Services157 8.1 Organisational Strategies Shape Norms 158 8.2 Guidelines and Regulations Shape Practices 162 8.3 Social Interactions Influence Practice 167 References 169 9 Building Confidence in Telehealth Practices173 9.1 Accepting Technology in Practice 174 9.2 Managing Risks of Practice 178 9.3 Creating Trust in Practice 182 References 187 10 Building Relationships to Underpin Telehealth Practices191 10.1 Collaboration Establishes Relationships 192 10.2 Relationships Provide a Means of Resolving Conflicts 197 10.3 Leadership Develops Relationships Across Boundaries 202 References 205 11 Applying Resources to Telehealth Services209 11.1 Distribution of Resources 211 11.2 Availability of Infrastructure 215 11.3 Workforce Distribution, Training and Education 217 11.4 Availability of Funding 221 11.5 Sustainability of Funding 225 References 229 12 How Contexts and Mechanisms Influence Telehealth Services233 12.1 Are Telehealth Services Sustainable Over Time? 234 12.2 Contexts Are Moments in History 237 12.3 Contextual Influences on Telehealth Services 240 12.4 Mechanisms as Social Forces 243 12.5 Critical Events Trigger Mechanisms 245 12.6 The Mechanisms of Telehealth Services 248 References 254

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13 Telehealth Services in the Age of the COVID-19 Pandemic257 13.1 Reorganising Healthcare 259 13.2 Changing the Culture of Healthcare 263 13.3 Legitimising Telehealth Services 265 13.4 Resourcing Telehealth Services 268 13.5 Building Confidence 271 13.6 Building Relationships 274 13.7 Adjusting to Separated Care 275 13.8 Changing the New Normal! 278 References 280 Glossary285 Bibliography287 Index289

Abbreviations

ACRRM ADHA AMA ATA ATHS CFM DTN FSMB GPs ICT ISO MBS NBN RACGP RDAA RUTE SA SDN SIGs SUS UNA-SUS UNA-SUS WA

Australian College of Rural and Remote Medicine Australian Digital Health Agency Australian Medical Association American Telemedicine Association Australian Telehealth Society Conselho Federal de Medicina Digital Telehealth Network Federation of State Medical Boards General Practitioners Information and Communications Technology International Organization for Standardization Australian Medicare Benefits Schedule Australian National Broadband Network Royal Australian College of General Practitioners Rural Doctors Association of Australia Rede Universitária de Telemedicina South Australia Service Delivery Network Special Interest Groups Sistema Único de Saúde Open University of the Brazilian Universal Health System Universidade Aberta do Sistema Único de Saúde Western Australia xv

List of Figures

Fig. 5.1

Map of Australian states and territories (the island state of Tasmania, is located south of Victoria. Canberra, the national capital, is also a territory under the Australian Constitution)83 Fig. 5.2 Map of Brazilian states 85 Fig. 5.3 Development of Australian telehealth services 87 Fig. 5.4 Australian MBS-funded telehealth consultations, 2013–2019. (Derived from Services Australia, 2020) 91 Fig. 5.5 Development of Brazilian telehealth services 96 Fig. 5.6 Growth of teleadvice services, Rio Grande do Sul, 2008–2018 105 Fig. 5.7 Queensland Health non-admitted patient telehealth services, 2012–2018. (Derived from Gray, 2019) 108 Fig. 5.8 Telediagnostic examinations in Santa Catarina, 2005–2016 111 Fig. 5.9 Teledermatology: Avoided referrals in Santa Catarina 2014–2017112 Fig. 12.1 How contexts and mechanisms influence telehealth services 249 Fig. 13.1 GP consultations in Australia during the pandemic (the left-hand vertical axis refers to the number of in-person consultations, and the right-hand vertical axis refers to the number of video conference consultations and telephone consultations). (Adapted from Snoswell et al., 2021) 261

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List of Figures

Fig. 13.2 Mental health consultations in Australia during the pandemic (the left-­hand vertical axis shows the number of in-person consultations, the right-hand vertical axis shows the number of telephone and video conference consultations). (Adapted from Snoswell et al., 2021)

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List of Tables

Table 2.1 Table 5.1 Table 5.2 Table 5.3 Table 12.1 Table 12.2 Table 12.3 Table 12.4 Table 13.2

Themes and processes contained in telehealth service guidelines34 Telehealth service volumes by state in 2018 86 Were Australian telehealth services routine or normal? (N = 44)95 Were Brazilian telehealth services routine or normal? (N = 38)105 Critical events in the history of Australian telehealth prior to 2020 247 Critical events in the history of Brazilian telehealth prior to 2020 247 Social and cultural processes influencing telehealth services 250 Macro and contributory mechanisms operating across telehealth services 252 Changes to professional culture during the pandemic (Taylor et al., 2021) 264

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1 Introduction

Abstract  This chapter introduces the reader to telehealth services and how they have come to be understood. My research across Australia and Brazil, upon which this book is based, largely took place before the COVID-19 pandemic hit the world, so in this Introduction I give a few samples of the impact the pandemic had on telehealth services, which I will explore later. Throughout this book I question whether the technology used in telehealth services shapes our healthcare, or do we, collectively, change and shape the technology and services used in healthcare? My investigations focus on Australian and Brazilian public health systems serving large regional populations where telehealth services have been used to overcome the challenges of healthcare provision at a distance. By understanding of how technology is used in telehealth services, this book attempts to improve our understanding of technology use in healthcare, and more broadly of innovation and change. In highly developed universal healthcare systems, access to healthcare is seen as a citizen’s democratic right. In these systems, the societal expectation of telehealth services is that by supporting healthcare activities at a distance using information and communications technology (ICT), © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 A. Taylor, Healthcare Technology in Context, https://doi.org/10.1007/978-981-16-4075-9_1

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access to health services can be extended and the costs of healthcare reduced. In contrast, a significant number of health professionals express concerns about the weight of evidence for the clinical safety of care delivered using telehealth services and the possible impacts on the relationships between doctors and patients when healthcare is delivered at a distance using technology (Standing et al., 2016). Underlying the concerns expressed by health professionals about the safety of healthcare and the relationships with patients are deeply embedded and contrasting views of the consequences arising from the deployment of technology in healthcare and the powers that may be attributed to it. In a wide-ranging examination of the role of information technology in shaping contemporary society, Zuboff (2019) traces the basis for these concerns to the perception of technology “as an autonomous force with unavoidable actions and consequences (which) has been employed across the centuries to erase the fingerprints of power and absolve it of responsibility” (p. 225). While Zuboff’s analysis shows that technology has been shaped by powerful concentrations of social power to support contemporary social and economic structures, she argues that collectively we can shape and repurpose technology to create alternative futures. In recognition of these underlying concerns, throughout this book, I question whether it is the technology used in telehealth services that shapes our healthcare, or whether we, collectively, change and shape the technology and services used in healthcare. An example of one such repurposing of technology occurred when telehealth services in many countries were employed to maintaining social distancing between doctors and patients, thereby minimising the spread of the virus during the COVID-19 pandemic while continuing the delivery of healthcare. This could perhaps be explained as a simple matter of technology stepping in to fill a new need, but deeper explanations are possible. In searching for these explanations, I consider the changes in the contexts for telehealth services we have seen over the past two decades and identify the ongoing social mechanisms which enabled telehealth services to become part of the overall response to the pandemic. To explore this question, I situate the technology used to deliver telehealth services within the contexts of the national health systems of Australia and Brazil. In these countries, telehealth services developed in

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different ways to support healthcare. My investigations focused on Australian state-based public health systems serving large regional populations in the states of South Australia, Queensland and the Brazilian states of São Paulo, Santa Catarina and Rio Grande do Sul. In each case, telehealth services were used to overcome the challenges of healthcare provision at a distance. By comparing how telehealth services developed within the Australian and Brazilian healthcare systems I was able to identify how the similar social mechanisms interacted within different contexts to influence and support telehealth services. By investigating how technology is used by telehealth services, this book aims to improve our understanding of how technology-based interventions become useful and are incorporated into healthcare and, more broadly, our understanding of innovation and change in healthcare. Key questions that will be discussed include how technology is designed and accepted into service, whether all technology automatically becomes useful in clinical practice or whether social factors determine the role of technology in delivering healthcare? I argue that greater clarity on these issues can be obtained by accepting that social needs are coded into healthcare interventions which are supported by technology; in other words, technology has a sociotechnical foundation. My investigations for this book commenced several years before the pandemic and continued during its spread around the world, enabling me to explore how pre-existing contexts shaped the telehealth services that were deployed during the pandemic, and how the healthcare contexts for these services changed over time, influenced by mechanism of social change. I hope that this book will contribute to a greater understanding of what makes telehealth services work and in what situations they may be most useful, which will be of value to those who seek to implement telehealth services in the years to come. To provide a foundation for readers who may not initially be familiar with telehealth services I begin with explaining what telehealth services are, introducing some of the debates on their operation and outlining how some of these services evolved during the pandemic. In concluding this chapter, I will explain how I undertook my research and outline the contents of this book.

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1.1 What Are Telehealth Services? Historically, the earliest documented application of electrical technologies for medical purposes occurred in the USA (1862) and in Australia (1874) when the telegraph system was used to communicate advice on patient care between a distant doctor and those involved in the immediate care of a patient (Bashshur & Shannon, 2009; Vladzymyrskyy et al., 2017). Since those early days, successive waves of communications and information technology have been appropriated for use in healthcare, including the telephone, radio communications, satellites, optical fibres and the internet. By the second half of the twentieth century, information technology in the form of computers, databases and artificial intelligence was being deployed in the UK National Health Service. In the case of contemporary telehealth services, technology is employed to support healthcare activity where a health professional or carer works with someone who is not physically present, to resolve a health problem using some form of communications technology. Inherent in this activity is the provision of healthcare to someone who would not otherwise be able to receive it. This conceptualisation positions telehealth services as seeking to improve access to healthcare based on need, rather than on ability to pay or proximity to healthcare facilities. As Jack and Mars (2014) concluded when reviewing ethical and legal guidelines supporting the use of telehealth in South Africa, it is this improvement in access which seems to motivate many health professionals to deliver telehealth services. Contemporary telehealth services can be categorised according to the healthcare application and technology used: • By healthcare discipline. Examples include telepathology, teledermatology, telecardiology, telerehabilitation, teleoncology and teleorthopaedics. • By type of healthcare. This can be divided into two sub-categories: firstly, direct-to-patient care, including teleconsultations, telephone advice, teleassessment and diagnosis, and virtual care or treatment; and secondly, healthcare providers assisting each other with telementoring, specialist opinion, teleeducation or case conferencing.

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• By mode of communication. Telehealth services may support immediate healthcare activities using synchronous communications services such as a telephone or video conversation, or delayed healthcare activities using asynchronous communications services such as email or secure messaging services. • By type of technology. Examples include video communication, medical applications on mobile devices and telemonitoring (health alarm systems and health status monitoring at home). An example of a telehealth application using video communications is an oncology service that has operated from Townsville in North Queensland, Australia, since 2007. This supported a cancer care model that provided shared care close to patients’ homes. The Townsville Cancer Centre commenced with six rural satellite faculties, which had increased to 21 by 2014. According to Sabesan and Brennan (2011): The model facilitates equitable and immediate access to medical oncology specialist services and allows reviews on an urgent basis within 24 hours without the need for costly inter-hospital transfers and inherent delays in transfer. Disturbance to family and work routine is minimised, inter hospital transfer costs are reduced and disruption to health systems and patients and their families is minimised. Under our model, immediate consultation is possible, with investigation initiated and treatment commenced within 48 hours. (p. 294)

A very different type of telehealth service in Brazil uses asynchronous communication to support primary healthcare. The telehealth centre in the state of Rio Grande do Sul, Telessaúde-UFRGS, delivers telediagnostic second opinions on treatment and education support to primary health professionals. In 2014, a telephone support line and contact centre was opened for national use. It has operated since then, except for one interruption due to a temporary suspension of federal funding in 2017. The service responds to queries from health professionals across Brazil and supports 24 telehealth centres and 44,800 users. For asynchronous second opinions between health professionals, the targeted response time for online queries is 72 business hours. It is estimated that between 2007 and

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2017 about 108,000 teleadvice sessions were provided, avoiding the referral of about 66% of cases to specialist care (Harzheim et al., 2016). The diversity of telehealth services, applications and terminology makes analysis difficult. All telehealth, telemedicine, mobile phone applications (mHealth), electronic medical health records (eHealth) and digital and virtual health initiatives depend on the same ICTs. In practice, the terms “eHealth”, “digital health” and “virtual health” tend to refer more broadly to the transfer of health information and the conduct of healthcare by electronic means and serve as a marketing tool for industry. In Australia and elsewhere, discussion of eHealth tends to focus more on health information systems and less on the support of healthcare at a distance. In the academic literature the use of the terms eHealth, telemedicine, telecare and telehealth significantly overlap, with telemedicine dominating the literature. In Australia, for instance, telehealth was, until recently, taken to be synonymous with videoconferencing consultations between patients and doctors. In the USA, the term telemedicine covers a wide range of technologies used by the medical profession, while in Brazil, specific vocabulary has been developed to describe second opinions provided by one doctor to another (teleconsultorias or teleadvice in English) and doctor to patient consultations (teleconsultas). Because the term telehealth is more widely used than telemedicine in the national health systems of Australia and Brazil,1 I use the term telehealth service as the primary term in this book and ask readers to see this term as including telemedicine and telecare services, while acknowledging contributions from the eHealth, mHealth, digital health and virtual health domains. The unifying definition that I use is the one used by the International Organization for Standardization (ISO) for a telehealth service: a “healthcare activity supported at a distance by information and communication technology service(s)”.2

 In Portuguese, “telehealth” translates as “telessaúde”.  This definition is contained in the international standard, ISO 13131:2021—Health informatics—Telehealh services—Quality planning guidelines (ISO, 2021). 1 2

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1.2 Understanding Telehealth Services The definition of a telehealth service as a user of ICTs, the use of the prefix of “tele” in telehealth and its association with contemporary technologies such as telecommunications, television or telephony guarantees the place of technology in any discussion of telehealth. In their book on the history of telemedicine in North America, Bashshur and Shannon (2009) refer to telemedicine as being driven by technology in a world where technology drives society and has a life of its own. Other literature reports on the clinical use of telehealth. A much smaller section of the literature seeks explanations for the use of, development of or changes linked to the use of technology by telehealth services. In this literature subset I found two broad discourses: firstly, on the acceptance of technology by users; and secondly, on the organisational impact of technology and social changes linked to the adoption of telehealth technologies. Theories about the acceptance of technology by users dominate the current literature. These theories include the technology acceptance model (Davis, 1989), the theory of planned behaviour (TPB) (Ajzen & Fishbein, 1980) and the unified theory of acceptance and use of technology (UTAUT) (Venkatesh et al., 2003). A less dominant discourse focuses on how organisations adapt to and apply technology-based initiatives. Organisational and system change theories which have been applied to telehealth service include normalisation process theory (May et al., 2009) and critical realist approaches (Collier et al., 2016). When considering the societal drivers of technological change in the context of telehealth services, many writers implicitly adopt the thinking of Rogers (1971) about the diffusion of innovations, based on research into changes of practice in American agriculture. In the broader literature on technological change, alternative views place technology alongside people as actors in the process of social change using actor network theory based on the work of Latour (2007). Some researchers such as Bijker et al. (1987) take a stronger stand, arguing that technological artefacts are entirely socially constructed. I propose an alternative way to view and analyse technology based on the concept of sociotechnical codes. The way in which the technologies

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are adopted within different contexts is influenced by sociotechnical codes which express the rules, habits, processes and practices which are part of and define how technology is adopted. Using this concept, social and technological changes associated with telehealth services can be analysed without implying that one or the other is a determinant or that the relationship between the social and the technical works in a particular way. In many countries, the development of telehealth services have not enjoyed sustained government support. There are a multitude of other, complex factors that have also influenced telehealth services. In 1996, the Institute of Medicine (US) Committee on Evaluating Clinical Applications of Telemedicine concluded: Telemedicine is not a single technology or a discrete set of related technologies; it is, rather, a large and very heterogeneous collection of clinical practices, technologies, and organizational arrangements. In addition, ­ widespread adoption of effective telemedicine applications depends on a complex, broadly distributed technical and human infrastructure that is only partly in place and is being profoundly affected by rapid changes in health care, information, and communications systems. (Field, 1996)

More than two decades later, the same issues remain. Costs, reimbursements, ease of use, safety, the geographic distribution of healthcare, privacy, legal requirements and training all remain important. Several themes in contemporary writing which are central to the development of telehealth services will be explored in this book. These include: • Visions for telehealth services are linked to structural changes in healthcare systems. • Contexts, particularly organisational and professional contexts, shape the development of telehealth services. • Applications of technologies used by telehealth services are mediated by rules, guidelines and codes. • Acceptance of modified practices incorporating technology is dependent on clinical assessment of risks and ability to build confidence in those practices.

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• The construction of relationships between clinicians, management and technologists mediates the control of healthcare and the resolution of conflicts between these groups. • Changes in contexts can be observed that reflect the normalisation of new and modified healthcare practices. Despite fluctuating levels of institutional support, the motivating vision for health professionals involved in telehealth services has been the need to support their regional colleagues and their patients. When COVID-19 was declared a pandemic in March 2020, the rising levels of COVID-19 infections meant that many countries put in place travel restrictions, social distancing and infection control measures. This precipitated the biggest change in the operating context for telehealth services in recent history. In particular, the need to support colleagues and patients remotely was intensified.

1.3 Telehealth Services in the Pandemic Era In the health sector, measures to control the COVID-19 pandemic discouraged in-­person appointments with patients and limited the ability of health professionals to travel to regional health centres. In particular, patients with COVID-19-like symptoms were encouraged to contact their doctor by phone for advice or to attend at testing centres. In the United Kingdom, NHS England advised that for older and vulnerable people, “Face-to-face appointments should only take place when absolutely necessary” (NHS England, 2020). By September 2020, 39% of appointments in the UK were taking place over the telephone (NHS Digital, 2020). For many jurisdictions the development of remote healthcare services was the only way to provide healthcare. As in-person consultations declined, regulations and funding packages were developed to improve the capacity of health services to talk to or see patients remotely using ICT. In Australia, the Federal Government allowed a wide range of medical professionals to claim government fee rebates for consultations that had not previously been eligible for telehealth support. For federally funded services, telehealth consultations (telephone and

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video) increased by a factor of 200 times: from about 22,000 per month in October 2019 to 4.1 million in October 2020. Videoconferencing was used for 8% of all telehealth consultations. Primary care by GPs and specialist and mental health consultations were the most used services. Specialist consultations, involving patients referred by GPs, made greater use of videoconferencing. Mental health consultations, for which videoconferencing is an established modality, were provided in almost equal proportions, using the telephone and videoconferencing (Snoswell et al., 2021). Australia had well-established telehealth services before the pandemic. Canada, New Zealand and the USA were similarly positioned. National and regional governments in these countries rapidly adjusted regulations and payments. As a result, in British Columbia, Canada, virtual consultations grew from 1800 each week to 19,000 a week (Canada Health Infoway, 2020). At their height, in New Zealand, telehealth consultations rose tenfold, to 34,500 per week (McBeth, 2020). In the USA, substantial increases in the proportion of consumers using telehealth consultations were reported (Koonin, 2020). American Well stated that 80% of care was provided using telehealth services compared with the previous figure of 20%, and patient use of telehealth services increased by a factor of nine. The Cleveland Clinic saw its use of telehealth services for ambulatory patients increase from 2% to 65% for these services (Hospital Israelita Albert Einstein, 2020). In France, teleconsultations increased to 11% of all consultations and any application was able to be used to conduct teleconsultations, including consumer applications such as Skype, WhatsApp, and Facetime. Telemonitoring of COVID-19 patients was performed by nurses and made 100% reimbursable (Chittim et al., 2020). Many countries developed telehealth services to specifically support the diagnosis, monitoring and treatment of COVID-19 patients. The West China Hospital of Sichuan University launched a video telemedicine system for consultations provided by a multidisciplinary team to deal with COVID-19 cases (Hong et al., 2020). Chilean private hospitals provided support for patients with COVID-19 symptoms via videoconferencing, mobile devices and computers (Garcia-Huidobro et al., 2020; Superintendencia de Salud, 2020). Portugal saw a 20–25% increase in the teleconsultations provided by hospitals (Servico Nacional de Saúde, 2020). In Russia, although the legality of remote consultations was in

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doubt, “many federal centres in the first quarter of 2020 completed the annual volume of telehealth consultations” (Russian News Agency, 2020). The Brazilian response to the pandemic was especially interesting. Prior to the pandemic, well-developed, large-scale telehealth services provided second opinion services and education to primary health professionals, but the use of remote consultations between doctors and patients had been prohibited by the Federal Medical Council (CFM). In response to the pandemic, the federal government overruled the medical council and passed regulations authorising the temporary use of ICT within the public and private health systems (Imprensa Nacional, 2020). Taking advantage of this new-found freedom to innovate, the public health sector established a series of services called TeleSUS based in different technologies (chatbots, mobile phone applications, telephony call centres and WhatsApp) to provide health advice at a distance (Ministério de Saúde, 2020). In the state of Santa Catarina a public paediatric outpatient service adopted video telephone and chat technologies (Lanzarin et  al., 2021). In the private sector, health insurance organisations and not-for-­ profit hospital groups created partnerships with the public sector to register health professionals who could provide virtual consultations using a range of technologies and applications. To coordinate case management and exchange experiences between public and private hospitals, the Brazilian university sector created a national discussion group on the treatment of the COVID-19 virus using a web-based conferencing platform (Caetano et al., 2020). The Brazilian private, philanthropic and university hospital sectors began to report the use of video consultations. The Einstein Hospital in São Paulo saw virtual consultations rise from 60 to about 800 consultations per day (Hospital Israelita Albert Einstein, 2020). The Hospital Alemão Oswaldo Cruz opened a multidisciplinary consultation service (2020). A similar initiative by the UNIMED-BH group of hospitals (Nascimento et al., 2020) provided video consultations, mobile apps and phone calls to suspected COVID-19 cases. Health insurance companies sold plans that included video and telephone consultation services for a monthly subscription. The Docplanner Group, an international healthcare company, reported the provision of 1000 teleconsultations per week (Doctoralia Brasil, 2020).

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Clearly, in many countries, the volume of telehealth services increased dramatically, and, according to an integrative review by Andrews et al. (2020), the satisfaction of patients with these services appeared to be high. In many situations, the use of telephone services was preferred to videoconferencing. This may indicate that there will be limits to the acceptability of some telehealth services once the pandemic is finally over. A survey of health professionals in New Zealand reported that 55% “have patients who struggle with telehealth” (University of Auckland, 2020). A Canadian survey found that while 38% of respondents to a patient survey would prefer telehealth services for initial advice, the majority “would like to have the option in the case of each of these virtual methods of contact with a doctor” (Canadian Medical Association, 2020). Although the preferences of patients are very important, in the research for this book I focused on exploring the issues relating to the acceptability and use of telehealth services from the viewpoint of health professionals. It is this group of workers who had been tasked with making telehealth services work within healthcare and were therefore best placed to provide explanations for how, why and when this type of health service is appropriate.

1.4 Researching Telehealth Services In any research project, the perspectives of and methods selected by the researcher significantly shape the outcomes. My research perspective rested on a critical realist lens, or ontology, described in sociology as critical realism. It takes the view that there are multiple levels of explanation for the changes in the world that we experience. The lens one uses to see the world, or one’s ontology, influences what may be discovered. How one gains knowledge of the world, or epistemology, directs the methods and focus of investigations. Hence, the choice of ontology and epistemology is inextricably intertwined. Critical realism is one of three major ontological belief systems used in contemporary Western sociology, identified by Liamputtong (2019) as:

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1. Idealist ontology, which sees reality as entirely socially constructed, that can be explained through understanding social interactions. 2. An empirical and realist ontology (also known as positivism), which sees reality as an object or experience that employs empirical observation of events (physical, social or individual) to determine predictive laws or correlations. 3. A critical realist ontology, which views reality as stratified into different levels of activity and observability, and looks for explanations of changes in reality in the form of generative causal mechanisms. My application of critical realist ontology provided a way of probing below and around the immediately visible features of telehealth services for deeper explanations or mechanisms. In a review of realist approaches to evaluating public health interventions Lacouture et al. (2015) defined a mechanism as: an element of reasoning and reactions of (an) individual or collective agent(s) in regard of the resources available in a given context to bring about changes through the implementation of an intervention. (p. 8)

My choice of epistemology, meaning how one derives knowledge of the world, shaped my investigative methods. In the school of physical sciences in which I was trained, I was taught always to be curious about the world and to look below the surface of events. An epistemology based on a critical realist ontology can probe different levels of reality using quantitative or qualitative methods, different data collection techniques and analytical processes that “serve as both a form of methodological triangulation … and also as a way of generating divergent perspectives, deepening rather than simply confirming our understanding” (Maxwell, 2012, p. 66). Importantly, a critical realist epistemology has the advantage of being able to consider experimental or observational boundaries pragmatically, within a feasible and finite investigative scope. In particular, I have adopted the approach to realist research proposed by Danermark et  al. (2019), known as explanatory research, which is suited to large-scale comparative investigations. Explanatory research uses an iterative and cyclic process to identify mechanisms. Using this

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approach my field research and subsequent analysis followed a number of interlinked stages: • Exploration of the contexts for telehealth services in each of the contexts with Australia and Brazil commencing with an initial review of the literature relevant to each context, selection of participants, testing of research instruments and use of a conceptual enquiry model. • Collection of all types of literature relevant to each context and conducting semi-structured interviews with professionals associated with telehealth services. • Analysis of information from the Australian and Brazilian healthcare contexts and telehealth services, and the analysis of interview transcripts to identify the key themes within this information. • Comparison and explanation of the influence of contexts and the development of telehealth services over time presented and the operation of mechanisms within each context. • Reflection on my research findings and conclusions through the use of a post-interview survey and further research on the evolution of telehealth services during the COVID-19 pandemic. Investigating the social and technical phenomena of telehealth services within healthcare contexts is challenging because descriptions of the complex, changing nature of contexts can generate large amounts of data. The analysis of large data sets poses dilemmas for researchers with limited resources. For instance, it is possible to reduce complexity within a field of investigation by restricting research to a case study of a single health service, hospital or program. However, when the research context is restricted to the program level, it becomes inevitable that wider insights may be missed. When conducting a case study, a researcher may be embedded in an organisation and able to capture detailed information. In contrast, when a research context is large, it is logistically difficult to become embedded in several organisations and even more difficult to analyse a large amount of detailed information. My pragmatic solution to this dilemma was to focus on telehealth services, largely operated by public sector healthcare organisations, in a small number of selected health systems where I could obtain access to collect information and interview professionals associated with telehealth

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services. There are three approaches to interviewing: explicitly theory-led interviewing for evaluation of programs, active or collaborative interviewing and ethnographic interviews. The interview techniques that I used combined elements of all three approaches. Interview questions were based on the themes thought to be important to the development of telehealth services and tested the associated hypotheses. Interview questions sought insider understandings of telehealth services in the ethnographic sense but were not intended to capture the full range of interaction with a participant of a pure ethnographic interview. Before commencing interviews, I collected data about the local contexts (national, state and organisational) for telehealth services. This information enabled subsequent interviews to be situated in the local context for the operation of telehealth services using an initial “icebreaker” question, followed by questions to elicit the understandings of interviewees about the operation of telehealth services (theory gleaning), identification of key mechanisms (refinement) and confirmation of how interviewees understood the mechanisms influencing telehealth services (consolidation). Subject to the need to obtain consistent information, some degree of interview customisation to the interviewee and their context was required. For instance, it did not make sense to ask specialist clinicians for their opinion on a specific information security protocol or, on the other hand, to discuss the role of a government regulation with an information technology specialist. The health professionals in the interviews I conducted were or had been: • employees of health services, government or professional bodies associated with the delivery of telehealth services; or • working in managerial, specialist, medical, nursing, logistical, information technology or similar roles associated with the delivery of telehealth services. In total, I interviewed 135 health professionals in 2017 and 2018, both in person and via videoconferencing, while travelling through Australia and Brazil. Of the 135 interview participants, 45% were clinically qualified, 36% were managers or coordinators of telehealth services who were often also clinically qualified and 19% were in support roles, including technologists. The number of interviews I was able to

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undertake in each location varied considerably.3 I conducted 84 interviews in Australia and 54 in Brazil. In the state of Queensland, I conducted 38 interviews and in South Australia 31 interviews, compared with the Brazilian states of Rio Grande do Sul (16), Santa Catarina (14), São Paulo (12) and 12 interviews with participants in other Brazilian states. This variation was due to two factors. Firstly, the phenomenon of saturation, where successive participants began to tell similar stories, was achieved more rapidly in some locations than in others. Secondly, the time available limited the number of interviews I could conduct. Because many of the health professionals were closely involved with telehealth services provided by in acute care settings (41%), coordinated telehealth services (18%) or managed health services (16%), additional interviews (25%) were sought with participants from states other than those listed, from insurers, aged care organisations, community health clinics and with general practitioners (GPs) to test whether these participants expressed significantly different views to those most involved in established telehealth services. In this respect it is worth noting that the majority of Brazilian participants were associated with telehealth services for primary healthcare, whereas Australian participants were often associated with acute care services. Subsequent research undertaken during the COVID-19 pandemic during 2020 included a follow-up survey of the original people I had previously interviewed (42 respondents), which served to confirm some of my research conclusions, and a national survey of subscribers to the Australian Telehealth Society (ATHS) newsletter. This survey elucidated 91 responses from GPs, medical specialists, nurses, allied health providers, health service managers, researchers and telehealth coordinators to questions about the contextual changes and the mechanisms involved in enabling telehealth services to respond to the pandemic. The empirical research on which this book draws can be considered representative of telehealth services operating in a wide range of organisational contexts, professions, locations and health services throughout Australia and Brazil over the 5 years between 2016 and 2020.  Interviews in Brazil were conducted in Portuguese.

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1.5 Outline of the Book This book analyses the use of technology by telehealth services supporting healthcare at a distance in the context of the Australian and Brazilian health systems from the late twentieth century to the period of the COVID-19 pandemic. The first part considers the processes and practices found in the frameworks, guidelines, regulations, policies, recommendations, rules or standards used by telehealth services and delves more deeply into the way in which technology has been applied to support separated care through a discussion of contemporary fears and beliefs about technology, organisational issues and the changes to professional medical practice that occur when care is separated. Subsequent chapters analyse the information derived from field research in these contexts and discuss the mechanisms that operate on telehealth services. Based on my research on how healthcare organisations have deployed telehealth services and how health professionals practise care at a distance, I propose a new model to understand how the use of technology becomes legitimate in healthcare services how confidence is built in its use; the importance of human relationships in practising care how to make the technology work; and the need for resources to extend universal healthcare as separated care becomes more widely deployed following the COVID-19 pandemic. In Chap. 2, to arrive at a deeper understanding of organisational and professional perceptions of telehealth services within different contexts, I review the literature of guidelines, frameworks and theories used in telehealth service implementation, operation and evaluation. Guidelines contain instructions written by health professionals on what to do or what not to do when operating telehealth services. Through examining such guidelines, I uncovered some of the processes and practices applied to telehealth services. Policymakers advocate visions for improvement of healthcare access and increased system efficiency arising from telehealth services. Providers seek to ensure that healthcare is effective and safe. Issues raised in this literature about the application of telehealth services include aspects such as quality and safety, responsibilities of clinicians4  The terms “clinician” and “health professional” are used interchangeably in this book.

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and ethical considerations such as privacy and confidentiality and management of liability or risk. Hitherto, the norms of medical practice have been place-based. This chapter charts how these norms have responded to the introduction of separated care using telehealth services. Understanding the nature of technology is central to any discussion of the influences on telehealth services. In Chap. 3, I explore the nature of the technology used by telehealth services and the processes by which it becomes useful and is incorporated into healthcare. In this exploration, I discuss how technology is designed and accepted into service and ask whether the diffusion of technology through society automatically leads to it becoming useful in clinical practice, or whether social factors determine its role in delivering healthcare? In the literature, acceptance of technology into practice has been studied using psychometric methods, while other approaches seek to explain how technologies diffuse through society and become normalised into clinical practice. I argue that our explanations should view technology not as an independent force or a predetermined object, but as a set of technical elements built with a social wrapping which determine how technologies are accepted in different contexts. I propose an alternative way to view and analyse technology based on the concept of sociotechnical codes.5 The way in which the technologies are adopted within different contexts is influenced by sociotechnical codes. Using this concept, social and technological changes associated with telehealth services can be analysed without implying that one or the other is a determinant or that the relationship between the social and the technical works in a particular way. The very different contexts for healthcare in Australia and Brazil shaped the development of telehealth services in each country. Chapter 4 provides a comparative outline of the aspects of the Australian and Brazilian healthcare systems which were key to influencing and supporting telehealth services. During my fieldwork, health professionals and the telehealth services with which they were associated provided me with information on their services and the healthcare systems within which these operated. My analysis of telehealth services is based on this  In Chap. 3 I define sociotechnical codes as the norms, processes and practices which form part of and simultaneously shape the way in which the technologies are adopted. 5

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information, supplemented by data obtained during my interviews with health professionals. It commences with an outline of the Australian and Brazilian universal healthcare systems, how healthcare is organised and accessed, the availability of human resources, financial arrangements and the ICT relevant to telehealth services. In these countries the provision of universal healthcare is a fundamental tenet of their healthcare systems. In both countries, healthcare is decentralised, and health service provision is limited by state boundaries, regional catchments, municipal boundaries or hospital localities. Consequently, access to care has been partly determined by the ability to access specialist services concentrated in metropolitan areas. Chapter 5 provides a historical view of the development of telehealth services. Though it has not always been sustained, the majority of these services have received government funding. The geographical focus of this chapter is the Australian states of South Australia and Queensland and the Brazilian states of São Paulo, Santa Catarina and Rio Grande do Sul. Throughout these states, I interviewed health professionals about the telehealth services with which they were involved. Telehealth services in both countries support regional health professionals. In Australia, prior to the pandemic, telehealth services were almost synonymous with videoconferencing-­based consultations between hospital-based specialists and patients in regional areas. In Brazil, telehealth services explicitly aimed at supporting the primary healthcare of patients in any location through synchronous and asynchronous advice services between specialists and practitioners, thereby supporting patients in family health centres and basic health clinics. Health professionals told me that telehealth services have passed through several phases, often marked by events identified as significant inflection points or markers of change. Prior to the pandemic, many health professionals involved in telehealth services felt these services were routine, although not yet fully part of normal practice. Chapter 6 marks the start of the second half of my journey. Here, I draw on the empirical research I conducted in Australia and Brazil, beginning with an examination of the organisational contexts for telehealth services. All organisations are the product of processes operating over time on different contextual components to produce contemporary contexts. Because change occurs over time, the historical structure of a

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healthcare organisation, acting as a contextual factor, shapes telehealth service delivery, but when contemporary structural reforms take place, the same feature can act as a mechanism, enabling or inhibiting telehealth services. In this chapter I explore the key processes which have historically contributed to the current organisational contexts for contemporary telehealth services. These processes are the organisation of healthcare, the structuring of care and the automation of care. The place where healthcare delivery takes place has been central to the way health professionals manage care. Chapter 7 discusses how the management of care changes when care is separated. Healthcare practices have been developed through more than a century of interactions between health practitioners and patients in a place of care. Changes to accommodate separated care impact the way appointments, examinations, procedures, administration and record-keeping are managed. Healthcare practices are encapsulated in the sociotechnical codes of healthcare adopted by health professionals working within their professional contexts. In professional contexts, practitioners are confronted with sometimes conflicting and sometimes complementary norms, processes and practices. Conflicts can arise when choices have to be made between providing patient-centred care at home or reliance on established practices and patient pathways. Associated with these conflicts is competition among information technologists, management and clinicians, collectively and individually, for control of the technology used by telehealth services. Is it management, clinicians or technologists that are now driving contemporary healthcare? Disputes over control of healthcare and technology, associated with competing sociotechnical codes, and the splitting of the care role between two or more places take time to resolve and require the active involvement of human actors to reconnect separated care by means of technology. When care is separated, new practices must be legitimised. The question that arises is whether organisational strategies, guidelines and regulations shape practice norms and help organisations to adapt to and improve access to healthcare? Chapter 8 describes how the practice of separated care becomes legitimate. Guidelines defining the healthcare processes, codes of practice, ethical principles, work instructions and protocols, and models of care which manage the risks of separated care are

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discussed. Guidelines in themselves may have limited influence, but when incorporated into regulations of an administrative, financial, technological or clinical nature, they can define the clinical processes to be undertaken between actors in a health system. Strategies, guidelines and regulations, whether explicitly written down or implicitly practised in clinical routines, form the sociotechnical codes that health professionals rely on in their practice of separated care. Legitimisation of separated care occurs when a norm is backed by and agreed to by social groups. Development of strategies, guidelines and regulations is a socially interactive process within organisations and stakeholder groups which encapsulate these norms into organisational sociotechnical codes. When adopted by social groups, these sociotechnical codes mitigate the risks to the safety of patients and the liabilities of clinicians. Chapter 9 discusses how confidence in separated care is built, how technology supporting separated care becomes accepted and how the risks of practice are negotiated. My interviews revealed that acceptance of telehealth services was seen as related to the skill base or digital literacy of physicians, the training received and the usability of the technology, all of which evolved over time. For telehealth services, acceptance of the technology was the first step in building confidence. The next step was to manage the perceived risks of separated care. Triaging of patients for clinical condition and suitability for participation in telehealth services were seen as a key process to control risk. Management of the risks and the development of trust combined to reduce conflicts over the limitations of telehealth services. Risk management and trust building by health professionals strengthen confidence in the ongoing use of telehealth services. The establishment of trust changes behaviour at the individual level (clinicians) and group level (organisations), assisted by interactions with implicit and explicit sociotechnical codes that inform practices, habits, mental models and routines. Confidence in separated care increased when sociotechnical codes supported modified routines and procedures. Social relationships are the fabric of the cultural structures that underpin healthcare. In Chap. 10, I explore how collaboration establishes relationships, how conflicts between different interest groups are resolved through collaboration and whether leadership matters. Health professionals I interviewed emphasised that collaboration and relationships

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between health professionals are an integral part of the culture of healthcare. Personal relationships take time and human agency to build. Building support for separated care using telehealth services requires clinical, managerial and technology communities to reach agreement and to collaborate on the aims and practices to pursue. When these interests did not coincide, conflict became visible, especially in regard to information technology, clinical practice and workloads. When care is separated between providers, relationships change. Leaders can develop relationships and collaborations spanning provider boundaries to resolve these conflicts. The power of leaders stems from their interactions within various groups, within and external to organisations. Relationship building facilitates the creation and operation of norms, processes and practices which form the sociotechnical codes of telehealth services. The uneven distribution of resources is at the very heart of the rationale for telehealth services which seek to compensate for the differential distribution of healthcare within imperfect universal healthcare systems. Chapter 11 considers how the distribution and availability of resources, staffing, training and financing of healthcare shapes the development of telehealth services. Resources can take many forms, including infrastructure, training, education for staff and funding for services. Healthcare resources have two dimensions: the resources available to health organisations and the resources available to care recipients. The differential distributions of funding, workforce and infrastructure available to rural, remote and regional health services and populations compared with metropolitan areas were the principal concern of the health professionals I interviewed for my research. Funding healthcare has been a policy challenge for governments because the benefits of improved health partially accrue outside of the health system. Many of the costs and benefits of telehealth services reside outside of the health organisations that provide these services. Consequently, resourcing the sustainable operation of telehealth services is inextricably linked with wider contexts. The aim of my journey through the telehealth services in Australia and Brazil was to understand the influences on their development and to reflect on whether the technology used in telehealth services shapes our healthcare, or whether we, collectively, change and shape the technology and services used in healthcare. In Chap. 12, drawing on the research

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presented in this book, I develop a meta-theoretical model which suggests that the development of telehealth services is not one of technology acceptance, normalisation or the attainment of sustainability, but is better explained as a process of contextual adaptation, the resolution of differing sociotechnical codes and the influence of social mechanisms. My model has two major components: organisational contexts and professional contexts. In each of these contexts, historical and contemporary processes shaped, and continue to shape, telehealth services. Within organisational and professional contexts, an ongoing process of mutual adaptation to telehealth services is influenced by macro-mechanisms operating at the group or societal level. This ongoing interaction between telehealth services, contexts and mechanisms can be represented as an interlocking set of processes. The outcome arising from these complex interactions is not normalisation or sustainability, but a new contextual state, or new normal, marking the beginning of a new adaptation cycle. The discovery of the highly infectious COVID-19 virus was a critical event which triggered a complex series of cascading interventions across the world. National responses enforced the physical separation of healthcare activities. Chapter 13 examines the trajectory for telehealth services in the light of the pandemic. This major contextual change for telehealth services triggered some of the key mechanisms of social change previously identified in this book, namely, the need to legitimise and resource telehealth services and to build confidence and relationships to support separated care. These mechanisms worked to extend and reorientate existing services and to create new services. Organisational work processes and professional practices, the sociotechnical codes of healthcare, adjusted to the new context triggered by the pandemic. New contextual states will be created in the future. These, in turn, will be shaped by continuing, modified or new mechanisms. Whether universal healthcare then becomes a reality for everyone as part of an evolving new normal will depend on all of us—healthcare clients, patients, healthcare professionals, managers and technologists.

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NHS England. (2020). Important and urgent – Next steps on NHS response to COVID-19. https://www.england.nhs.uk/coronavirus/wp-­content/uploads/ sites/52/2020/03/urgent-­next-­steps-­on-­nhs-­response-­to-­covid-­19-­letter-­ simon-­stevens.pdf Rogers, E. M. (1971). Diffusion of innovations (2nd ed.). Free Press. Russian News Agency. (2020). Readiness as the new reality: How COVID-19 made Russia’s healthcare system shift gears. TASS. https://tass.com/ society/1160663 Sabesan, S., & Brennan, S. (2011). Tele oncology for cancer care in rural Australia. https://doi.org/10.5772/17112 Servico Nacional de Saúde. (2020). Consultas em Telemedicina. https://transparencia.sns.gov.pt/explore/dataset/consultas-­em-­telemedicina/information/? sort=tempo&disjunctive.regiao&disjunctive.instituicao&refine.tempo=2019 Snoswell, C.  L, Caffery, L.  J., Hobson, G., Taylor, M.  L., Haydon, H.  M., Thomas, E., & Smith, A.  C. (2021). Telehealth and coronavirus: Medicare Benefits Schedule (MBS) activity in Australia. Centre for Online Health, The University of Queensland. https://coh.centre.uq.edu.au/ telehealth-and-coronavirus-medicare-benefits-schedule-mbs-activity-australia Standing, C., Standing, S., McDermott, M.-L., Gururajan, R., & Kiani Mavi, R. (2016). The paradoxes of telehealth: A review of the literature 2000–2015. Systems Research and Behavioral Science. https://doi.org/10.1002/sres.2442 Superintendencia de Salud. (2020). La telemedicina se afianza como alternativa de consultas médicas – La telemedicina se afianza como alternativa de consultas médicas. Sala de Prensa. Superintendencia de Salud, Gobierno de Chile. http://www.supersalud.gob.cl/prensa/672/w3-­article-­19577.html University of Auckland. (2020). Quick COVID-19 primary care survey. https:// covid-­19-­pc.auckland.ac.nz/ Venkatesh, V., Morris, M. G., Davis, G. B., & Davis, F. D. (2003). User acceptance of information technology: Toward a unified view. MIS Quarterly, 27(3), 425–478. Vladzymyrskyy, A., Jordanova, M., & Lievens, F. (Eds.). (2017). A century of telemedicine, Part 1. International Society for Telemedicine & eHealth (ISfTeH). https://www.isfteh.org/files/media/A_Century_of_Telemedicine_ Part_I.pdf Zuboff, S. (2019). The age of surveillance capitalism: The fight for a human future at the new frontier of power. Public Affairs.

2 Organisational and Professional Practice of Telehealth

Abstract  In this chapter, I review the literature of guidelines, frameworks and theories used in telehealth service implementation, operation and evaluation. Guidelines contain instructions written by health professionals on what to do or what not to do when operating telehealth services. Through examining such guidelines, I uncovered some of the processes and practices applied to telehealth services. Policymakers advocate visions for improvement of healthcare access and increased system efficiency arising from telehealth services. Providers seek to ensure that healthcare is effective and safe. Issues raised in this literature about the application of telehealth services include aspects such as quality and safety, responsibilities of clinicians and ethical considerations such as privacy and confidentiality and management of liability or risk. Hitherto, the norms of medical practice have been place-based. This chapter charts how these norms have responded to the introduction of separated care using telehealth services. Many discussions about the expectations for telehealth services—their safety, quality, privacy and the responsibilities of care providers who employ these services—remain unresolved. These questions remain difficult to answer because they cannot be fully understood outside of the contexts in © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 A. Taylor, Healthcare Technology in Context, https://doi.org/10.1007/978-981-16-4075-9_2

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which the practices and perceptions of ICT-supported healthcare are formed. Therefore, exploration of the relationship between ICTs and healthcare began by asking what are the practices, processes and perceptions of researchers or health professionals involved in telehealth services? Klecun-Dabrowska (2002), in a study of telehealth in the UK National Health Service, claimed that: “technology does not follow a pre-­ determinate path, but is shaped by people, who in turn are constrained by historical conditions and current structures” (p.  2). Organisational contexts provide the structural conditions, such as resources, management and technology, for telehealth services. Professional contexts encompass the interactions between people, where norms, processes and practices, and the codes of telehealth services, such as legal frameworks and ethical considerations (Wade et  al., 2012), are formed, tested and operationalised. Process and practices can exist as patterns of work, mental models (implicit guidelines), patterns of behaviour buried within contexts or as explicit norms (written guidelines). Written guidelines take many forms, including published guidelines from health organisations and professional bodies, fact sheets and procedures. All guidelines operate within a wider societal and technological context. This sociotechnical environment includes the organisational, professional and technological structures of healthcare delivery systems which provide the contexts for telehealth services. Organisational contexts provide the location where visions, processes and practices—the codes and norms of telehealth services—are formed, fought over and operationalised as health services. Professional contexts in healthcare draw on established clinical practices, authority, roles, culture, ethics and guidelines which function as professional codes that reduce differences and disagreements about how to practise medicine across and between organisations. The existence of guidelines legitimise changes to the processes and practices of healthcare. The process of legitimising changes narrows the gap between expectations contained in visions and current realities. Traversal of this gap forms the terrain for extensive discussions of the enablers or barriers to the take-up of telehealth services. In a review of the international literature, Kruse et al. (2018) identified 33 of these barriers. When discussing barriers to the adoption of clinical guidelines, Bosse et  al. (2006) observed that the contents of guidelines highlight the

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barriers to change at the structural level of organisations, at the personal level within professional contexts and at the environmental level in a wider societal context. Therefore, to obtain a deeper understanding of organisational and professional perceptions of the barriers that telehealth services encounter, I mined the literature for guidelines, frameworks and theories used in telehealth service implementation, operation and evaluation. Examining the guidelines on what to do or not to do when organisations operate telehealth services makes it possible to reveal the processes, practices and concerns that influence telehealth services.

2.1 O  rganisational Contexts Provide a Place to Practise For the most part, organisations (public, private institutions and small business), not individuals, provide telehealth services. They provide the physical infrastructure, such as buildings, communications and computing facilities, consulting rooms, diagnostic services and financial arrangements, where clinical and professional staff practise healthcare. Organisations provide the container within which the aims of telehealth services are conceived and their implementation, organisation, resourcing, financial assessment and evaluation are undertaken and codified. Organisations define the processes for the organisation of collective work. When these processes are documented, they function as guidelines for what to do or not to do when operating telehealth services. Vuononvirta et al. (2011), in a Finnish case study, identified that the compatibility of new organisational processes such as telehealth appointment scheduling and other workflows with existing processes are key to the operation of telehealth services. Nicolini (2006) supports the value of investigating telehealth services from an organisational perspective when he argued that “by observing telemedicine from this perspective, we can investigate to what extent this (new) way of doing medicine is aligned with the existing professional and institutional arrangements, and to what extent it deviates from them” (p. 2756).

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To resolve such misalignments, guidelines and codes provide organisations with a means of reducing the perceived risks of new practices. For instance, the International Organization for Standardization (ISO, 2021) provides generic guidelines for organisations implementing telehealth services that cover quality management, financial management, service planning, workforce planning, healthcare planning, responsibilities (of providers), facilities management, technology management and information management. Another supranational organisation, the European Union, sponsored the European Code of Practice for Telehealth Services (Telehealth Quality Group, 2016), which provides guidelines for home telecare service providers, and the Momentum Personalised Blueprint for telemedicine deployment (Momentum, 2014). With the advent of the COVID-19 pandemic, many organisations created guidelines intended to assist providers to rapidly establish telehealth services. Guidelines have been created for the evaluation of telehealth services carried out within organisations. Dattakumar (2013) created a framework empirically linked to the Australian Institute of Health and Welfare National Health Performance Framework. This framework considered patient, clinical, organisational and technology factors. Kidholm et al.’s (2012) report on the development of an evaluation model sponsored by the European Union covered safety, clinical effectiveness, patient perspectives, economic aspects, organisational aspects, sociocultural, ethical considerations, legal aspects and proposed employing various research paradigms. Guidelines for the implementation and evaluation of telehealth service delivery fall within the remit of service organisations. Guidelines generated by another type of organisation—professional associations—directly influence professional practice.

2.2 Professional Contexts Define Practice Many researchers argue that telehealth services are most successful when tailored to existing professional contexts. At the simplest level this may mean ensuring that a radiologist in Hong Kong does not have to climb stairs to access a system (Higa et al., 2009). Schatzki (2010) found that practice changes when care is separated because clinicians must relearn how to perform actions and know what to do in new situations. In

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professional contexts, healthcare practice encompasses a wide range of activities undertaken by individual health professionals when providing healthcare within organisations. Examples include the provision of information to patients and carers, recording health information, examination of patients, ethical behaviour and processes to maintain the safety and quality of care. Professional contexts are shaped by rules and procedures learned and internalised into habitual routines or explicitly codified by documented rules and processes that guide practice. Halford et al. (2010) described how from a workflow perspective, the physical separation of care can interfere with normal practice. Place-based healthcare requires the patient to attend at a physical facility which maintains its own workflow for managing activities for that patient. Logistical and scheduling complications arise when telehealth services are used alongside place-based service provision, in part, because a telehealth appointment or service requires a second workflow to be created at the other “end” of a telehealth service. Such aspects were cited by May et al. (2003) as leading to customisation of practices and workflows so that the diffusion of telehealth services can be accelerated or become normalised. Nicolini (2006) argued that telehealth services “interfered” with normal telecardiology and teleradiology practice in Italy when tasks were redistributed across places. If normal practice is understood as an existing, and perhaps thereby “normal” component of professional contexts, then clinical practices, rules and understandings exert a powerful influence on the development of telehealth services. The rules of professional practice are most evident in guidelines from professional associations. Guidelines for professional practices fall into two categories: generic guidelines that cover many aspects of practice such as privacy, confidentiality, patient consent and safety and a multitude of clinical guidelines or protocols that provide specific advice on the management of medical conditions. Between 2013 and 2014 while I was project leader of the ISO project to prepare quality guidelines for telehealth services (ISO, 2014), I collected 49 generic guidelines that originated in the English-speaking world. The majority of the guidelines were generated in the USA and Australia, followed by Europe and the UK.  The predominance of guidelines from Australia and the USA can be attributed to the greater utilisation of telehealth services in those countries at that time. Organisations publishing guidelines for telehealth services included the ISO, the Australian College

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of Rural and Remote Medicine (ACRRM), the Royal Australian College of General Practitioners (RACGP), the Rural Doctors Association of Australia (RDAA), the Federation of State Medical Boards (FSMB) and the American Telemedicine Association (ATA). More recently, many organisations have published guidelines aimed at supporting the use of telehealth in response to the  COVID-19  pandemic. Examples are the ATA Ocular Telehealth Special Interest Group (2020), the ACRRM (2020) and the Australianbased Centre for Online Health (University of Queensland, 2020). These guidelines cover clinical processes, technical questions such as how to use equipment, privacy or confidentiality concerns and maintenance of the quality of care. Table 2.1 shows the principal themes found in these guidelines and the processes or practices associated with each theme. Three discourses can be observed in these guidelines. The first focuses on organisational visions for telehealth, the second on changes to medical practice that occur when care is separated and the third on the role of technology. The remainder of this chapter will discuss the first two of these discourses, and the following chapter will turn to an examination of the role of technology in telehealth services. Table 2.1  Themes and processes contained in telehealth service guidelines Theme

Associated process

Access

Increasing opportunities for patients to receive healthcare Protection of patient information and privacy

Privacy and confidentiality Consent Quality of care Safety Evidence Risk Liability and legal Ethics Responsibility Relationships

Informing patients and gaining consent for treatment Confirming the consistency and quality of care provided to patients Protecting patients from harm Ensuring contemporary medical practice is based on best available evidence Documenting risks and use of explicit risk management protocols Protecting health professionals from legal liability arising from telehealth practice Compliance with professional ethical principles Clarification of responsibilities for care of the patient Supporting or maintaining a provider-patient relationship within the context of a telehealth activity

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2.3 Contrasting Visions for Telehealth Services Greenhalgh et al. (2012) suggested that telehealth service providers and their stakeholders lack an “organizing vision” (p. 1) due to their different backgrounds, interests and competing viewpoints. Additionally, national interests may not be the same as local ones. For instance, Hendy et al. (2012) studied the implementation of the Whole of Systems Demonstrator remote care project in the UK National Health Service and concluded that “a complex innovation such as remote care requires it to organically evolve, be responsive and adaptable to the local health and social care system” (p. 1). Clinical interests may not coincide with the interests of information technologists: as Andreassen et al. (2015) demonstrated, the innovation process becomes separated from routine practice when telehealth services are implemented using information technology projects. Organising visions for telehealth services advocate that they are a means to improve access to healthcare, to reduce the costs of care and to support system reforms. Such visions are strongly informed by a belief that technologies can solve systemic healthcare issues. The majority of guidelines which I reviewed contained visions of healthcare where improved access to healthcare (via telehealth services) resulted in better health outcomes and efficiency gains in the health system. A few guidelines specifically suggested that groups disadvantaged by other factors, such as ageing, medical condition or financial position, could enjoy more equitable access to healthcare via telehealth services. These included: • chronic care patients needing access to specialist services that may not be available in their local area; • enabling patients to manage and take control of conditions; and • increased access to specialist care which has in the past not been available. The desire to improve access to healthcare often arises from professional experiences. This is illustrated by a health professional I talked to

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in Brazil, who reflected on the work of a colleague to establish a telehealth service: I think he was, he’s a physician … and I think he had some social side. He was in India like me for a long time. We worked there. And I think he just saw a reality that’s much worse than ours. And he wanted to make things better and … and he saw how much money that could be used in healthcare was being thrown away in patient transportation. And so he wanted to change this. (Fabrício, Researcher)

Limitations of access to healthcare are not a new phenomenon. Long before the dawn of the internet, an editorial in The Lancet in 1910 suggested that London doctors could correctly diagnose a patient in the country using the transmission of stethoscopic sounds over the telephone network (Aronson, 1977). Improving the health of people living in regional areas is a focus for the Brazilian Universal Health System, as envisaged by Moura (2016): Telehealth will materialise as an integrated and shared network of health services and information systems, to contribute to the processes of care and continuing education, as well as to facilitate the creation of regional or inter-municipal health projects, managed in a shared, integrated and coordinated manner, ensuring the use of Telehealth to increase the reach and the quality of care. (p. 3)

As Moura illustrates, multiple, long-standing ambitions for telehealth services exist, and key among them are improvement of access to and quality of healthcare. A Brazilian advocate argued that education was key to quality improvement because “with the help of telehealth [the doctor] is able to improve his clinical reasoning, reduce the range of diagnostic hypotheses and will request less examinations” (André, Telehealth centre manager). One aspect of healthcare improvement—the application of patient-­ centred care and the ambitions of telehealth services to bring care closer to patients—requires members of multidisciplinary teams to work together to understand the diverse needs of patients. In reality, patient-­ centred care concepts continue to conflict with existing practices. A

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Brazilian primary health doctor, discussing cardiology care at a distance, felt that cardiologists should “review all their practice, abandon everything they were used to doing … I think it is intrinsic to put the patient perspective before one’s own interest … I think there is an important conflict here” (Ricardo, Family physician); a Queensland specialist frankly stated that if his colleagues had to do patient-centred care, “they would walk out” (Luke, Orthopaedic specialist). Some visions for telehealth services are driven by ambitions to redesign the health system, improve continuity of care and reduce costs. Darkins (2014), in a study of the United States Veteran Health Administration, indicates that “telehealth … is the forerunner of a wider vision, one in which the relationship between patients and the health care system will dramatically change with the full realization of the ‘connected patient’”. Reductions in costs of place-based hospital services resulting from the use of telehealth services are difficult to demonstrate, sometimes due to the unintended consequence that improved access to services can increase service demand. Nevertheless, the expectation of the Australian Digital Health Agency (ADHA) strategy (2018) that telehealth services “will lead to a reduction in hospitalisations, reduced patient transport costs, and shorter waiting lists” (p. 43) remains strong. A telehealth coordinator told me that they expected the efficiency of the health system would improve because: I’m going to get more money for my service. I’m doing this because it means more efficiency, it means my doctors are working more efficiently, it means my nurses can see more patients and it means that means there’s more beds for actually sicker patients. (Alice, Telehealth coordinator)

Barriers to the achievement of these visions “have challenged widespread telemedicine adoption by health care organizations for 40 years” (Lerouge & Garfield, 2013, p. 6472). My own research of guidelines and associated commentary uncovered four areas which are perceived as barriers to practice when care is physically separated. These are (a) privacy, confidentiality and patient consent processes; (b) maintaining quality and safety; (c) defining responsibility for patients and relationships with patients and (d) processes to minimise liability and risk.

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2.4 Privacy, Confidentiality and Patient Consent Protection of health information has largely been regulated through legislation, such as the Health Insurance and Portability Act (HIPPA) in the USA, in Australia through the Australian Privacy Principles (2020) and in Europe by the European Commission Data Protection Regulation (2015). Processes to protect patient privacy and confidentiality of information, and to gain consent for treatment, are advocated in almost all guidelines. Organisations define these processes, but it is health professionals who have to maintain privacy and confidentiality of information in their daily professional practice. Some guidelines acknowledge that the privacy and confidentiality requirements for separated care should be no different from those for “normal” consultations where technology does not mediate a consultation with a patient (e.g., RDAA, 2014). Other guidelines provide extensive advice on how to ensure privacy and confidentiality when relying on communications and information technology media. Some guidelines define specific requirements, such as password protection for computer screensavers (e.g., RACGP, 2011), using online conferencing (ADHA, 2020) or encryption of information (e.g., FSMB, 2014). Underlying the advocacy of technology-specific processes is the concern that, once patient information is located or transmitted beyond the physical reach of the provider, the provider ceases to have control over that information. Concerns over patient consent to participate in a healthcare activity when using telehealth services are illustrated by the requirements in a guideline from a college of GPs that “the patient gives explicit prior consent and repeats this consent on camera” (RACGP, 2011, p. 15). The way consent is obtained does depend on the policies of jurisdictions. Some require written consent (Queensland, Australia); in others, written consent is optional and oral consent suffices. In yet other contexts, obtaining informed consent may be more complex when: the patient has had limited exposure to and knowledge of ICT. There is an obligation to explain that the consultation will not be with a physician in

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the same room, but rather that sophisticated ICTs will be used.… This is a difficult task, even for the computer- and technology-literate doctor dealing with the computer-literate patient. (Jack & Mars, 2014, p. 60C)

Hence, the separation of care between places and the interposition of a technological medium in a healthcare activity has modified procedures for patient privacy, maintaining confidentiality of information and gaining consent. As a result, modified rules, processes, practices and behaviour now “patch” the previous place-based procedures to enable new services.

2.5 Maintaining Quality and Safety Bosse et al. (2006), in a study of clinical guidelines, suggested that when quality of care increases, safety should also improve, although measures of quality and safety are not synonymous and can be based on very different indicators. Mitchell (2008) noted that “quality is an abstraction and does not exist as a discrete entity. Rather it is constructed based on an interaction among relevant actors who agree about standards (the norms and values) and components (the possibilities)” (p. 1). Lack of physical contact in telehealth services is considered by some (e.g., Wade et  al., 2012) to result in a lower quality consultation. On the other hand, the possibility that telehealth technologies can improve access to (higher) quality health services originating from metropolitan providers for rural populations is suggested to be an important potential driver for telehealth service provision (Jack & Mars, 2014). Guidelines emphasise the need to maintain quality of care when using telehealth services. In Australia, the RDAA (2014) guideline stated that services “must adhere to the basic assurance of quality and professional health care in accordance with each health care discipline’s clinical standards” (p. 2). Stanberry (2006) argued that guidelines can help to describe a clinical standard of care. Viewing them from another angle, Loane and Wootton (2002) suggested that guidelines prove the maturity of a practice, and hence define a comparable service to face-to-face consultations for regulatory purposes. Because the maturity of clinical practice is often

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linked to the evidence base for that practice, the use of “evidence-based” guidelines is often proposed. An Australian GP college guideline asserts that practice should be based on: best available evidence in the context of current Australian general practice … (and) in the absence of well conducted clinical trials or other higher order evidence, the opinion of consensus panels of peers is an accepted level of evidence and may be the best available evidence at that time. (RACGP, 2011, p. 18)

While authors seem prepared to accept that telehealth services can improve the quality of healthcare, discussions of safety in telehealth usually sound a cautionary note: namely, whether telehealth is safe. In the USA the FSMB’s model policy states, “medical boards, in fulfilling their duty to protect the public, face complex regulatory challenges and patient safety concerns in adapting regulations and standards historically intended for the in-person provision of medical care to new delivery models” (FSMB, 2014, p.  3). The need to extend existing place-based standards to separated care is clear. In a study of the challenges for existing health safety standards in Australia, I found that “safety and quality health service standards may require extension to cover new risks introduced by telehealth healthcare delivery” (Taylor, 2015, p. 94). Examples of new areas of risk which mediate the delivery of healthcare when using telehealth are financial management to ensure telehealth becomes a sustainable mode of healthcare delivery; facilities management to provide an appropriate environment; technology management to underpin the delivery of services using telehealth; and information management to safeguard information privacy, security and health information. There is no doubt that separating care challenges existing healthcare practices and notions of safety. Guidelines for telehealth services have, to date, focused on safety from a technical perspective only; for example, the ATA guidelines for telerehabilitation (2010) highlight the “need to take appropriate measures to familiarize themselves with equipment and safety issues with client use” (p. 7). As the chain of healthcare is extended outside of the clinic walls into the patient’s home, as in the case of home monitoring, additional questions about who has responsibility for the

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quality and safety of healthcare of patients, carers and clinicians will become important.

2.6 Responsibility for and Relationships with Patients Ensuring that the responsibility for the patient is clearly defined when care is separated and healthcare activity is supported at a distance by ICT services is reflected in several guidelines. Execution of the implicit responsibilities of health service providers, often framed as a duty of care, plays an important role in building confidence or trust with patients and within the health profession. Telehealth services have to confront these problems in dealing with patients across geographical, organisational or jurisdictional boundaries because it is necessary to understand the relationships between providers and between providers and patients in order to decide who has responsibility for treating a patient. Changes in relationships occur when healthcare activity is supported at a distance, including the modification of health professional roles or practices and the emergence of conflicts between the different interest groups over these roles and practices. Perceived barriers to the maintenance of relationships with patients when using telehealth services are of particular concern to health professionals. Telehealth service guidelines have focused on the maintenance of relationships established during a face-to-face consultation between a doctor and a patient (e.g., ATA, 2014). Opinions differ on the importance of the in-person, face-to-face relationship compared with a telehealth-mediated consultation. Some evidence exists that telehealth service consultations may actually improve the experience for patients. In research conducted in Adelaide, Australia, assessing the outcomes of a telehealth service to the home trial for rehabilitation and palliative care, I found that the effectiveness of telehealth was judged by clinicians as equivalent to or better than a home visit, and clinicians rated the experience of conducting a telehealth session compared with a home visit as equivalent or better in 90.3% of the sessions (Taylor et al., 2015).

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In-person consultations permit a physical examination of the patient to take place, which may be required to identify some conditions. They also allow place-based relationships between providers and patients to be built as part of a business model where provider liabilities and risks are well understood. Despite positive experiences of separated care, the disruption of prior place-based norms, practices and business models when telehealth services mediate relationships can lead to conflicts over the norms and practices of medicine.

2.7 Minimising Liability and Risk When medical practices change, concerns over provider liability and risk arise. Many guidelines address legal or liability matters, practitioner competence (licensing and credentialing), safety (mostly patient safety), privacy and confidentiality and the responsibilities stemming from the nature of the relationship between the healthcare “provider” and the “recipient” of healthcare. The right of the medical professionals and their professional organisations to determine matters related to healthcare is supported by the dominant notion of the relationship between the medical “professional” and the “patient” where the patient is seen face to face by a health practitioner in their consulting rooms. Embedded in the norms of medical practice are the assumptions that the professional provides treatment; the patient receives treatment; the professionals are paid for their services by the patient, sometimes with a subsidy from the state; and the professionals have the expert knowledge needed by patients. As actors in these norms of medical practice, patients need to know whether a physician is legally qualified to treat them. Health systems need to be sure they are paying someone competent to deliver care. The credentialing and licensing of medical professionals by health professional associations and organisations such as regulatory bodies provides these assurances. Credentialing and licensing bodies involved in practitioner administration have grown from municipal associations or boards dealing with the local public health concerns in the twentieth century, or associations of medical practitioners (such as the British Medical Association) formed

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to promote the professional legitimacy of medicine through exchange of knowledge and representation to employers or government. Credentialing and licensing issues have been more significant for telehealth services which cross state borders, as in the USA. Until recently, each of the 52 states had responsibility for these matters, but steps are now being taken to try to harmonise practices. In contrast, in Australia (with six states and two territories), the Australian Health Practitioner Regulation Agency has responsibility for national assessment and accreditation. The power of credentialing and licensing norms to shape telehealth practice can be illustrated by the case of teleophthalmology services in Brazil. Umpierre (2019) explains that these services must include refractive diagnosis services because optometrists in Brazil, unlike their Australian counterparts, are not credentialed to provide prescriptions for glasses. Many guidelines reflected considerable concern about the possible legal liability resulting from inappropriate treatment by a telehealth service (e.g., Australian Nursing and Midwifery Federation, 2013). Opinions differed on whether telehealth reduced liability by increasing patient safety, especially in rural areas, or if it increased liability when a physical examination of the patient could not be made. Some authors expressed the opinion that the use of technology in healthcare fundamentally changes liability. Others were of the opinion that if a reasonable standard of care is provided through the technology, then the nature of the healthcare has not changed. From a legal perspective, Alverson (2014) considered that guidelines provide measures of a reasonable standard of care. Support for this view came from an ATA survey of users of its clinical practice guidelines reported by Krupinski et al. (2013) which found that most respondents felt that guidelines add credibility, standardise approaches and reduce liability. It is difficult to discuss liability without identifying the precise risks which may present. For instance, misdiagnosis and equipment failure are two different types of risk which require handling in different ways. All forms of guidelines recommend processes and practices to manage risk in some way, even when risk is not explicitly mentioned. Many guidelines recommend undertaking a risk analysis; however, one form of risk, the risk of not improving access to healthcare, receives little attention in guidelines, illustrating that risk assessment in these guidelines has come

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to reflect the viewpoint of medical professionals providing place-­ based care. We have seen in this chapter how the introduction of separated care raises new concerns about patient privacy, quality of care, and responsibilities and liabilities of providers. The technology that mediates separated care can easily become the object of these concerns. The following chapter will explore whether the technologies incorporated into telehealth services should be the focus of this attention, or if we should instead revise our conceptions of how technology is designed and how it becomes useful in the clinical practice of separated care. 

References ACRRM. (2020). Quick guide to getting started with telehealth in primary care. https://www.acrrm.org.au/docs/default-­s ource/all-­f iles/quick-­g uide-­t o-­ getting-­s tarted-­w ith-­t elehealth-­i n-­p rimary-­c are_factsheet.pdf?sfvrsn= 90fcb379_4 Alverson, D. C. (2014). When does telemedicine become a standard of care? The SciTech Lawyer, 10(3), 22. Andreassen, H. K., Kjekshus, L. E., & Tjora, A. (2015). Survival of the project: A case study of ICT innovation in health care. Social Science & Medicine, 132, 62–69. https://doi.org/10.1016/j.socscimed.2015.03.016 Aronson, S.  H. (1977). The Lancet on the telephone 1876–1975. Medical History, 21(1), 69–87. ATA. (2010). A Blueprint for Telerehabilitation Guidelines. American Telemedicine Association. https://www.americantelemed.org/resource_categories/practice-­guidelines/ ATA. (2014). Guidelines for TeleICU operations. American Telemedicine Association. https://www.americantelemed.org/resource_categories/practice-­ guidelines/ ATA. (2020). Telehealth resources for eye care during COVID-19. Australian Digital Health Agency. (2018). Australia’s national digital health strategy. https://conversation.digitalhealth.gov.au/australias-­national-­digital­health-­strategy Australian Digital Health Agency. (2020). Using online conferencing technologies securely. https://www.digitalhealth.gov.au/about-­the-­agency/digital-­health-­

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cyber-­s ecurity-­c entre/online-­c onferencing-­t echnologies-­f or-­h ealthcare-­ providers/Online%20Conferencing%20Technologies%20-­% 20 Connected,%20secure%20consultations.pdf Australian Nursing and Midwifery Federation. (2013). Guidelines for telehealth online video consultation funded through Medicare. ANMF. http://anmf.org. au/documents/reports/Telehealth_Guidelines.pdf Bosse, G., Breuer, J., & Spies, C. (2006). The resistance to changing guidelines – What are the challenges and how to meet them. Bailliere’s Best Practice in Clinical Anesthesiology, 20(3), 379. https://doi.org/10.1016/j. bpa.2006.02.005 Darkins, A. (2014). The growth of telehealth services in the Veterans Health Administration between 1994 and 2014: A study in the diffusion of innovation. Telemedicine and E-Health, 20(9), 761–768. https://doi.org/10.1089/ tmj.2014.0143 Dattakumar, A. (2013). A unified approach for the evaluation of telehealth implementations in Australia. IBES. https://networkedsociety.unimelb. edu.au/__data/assets/pdf_file/0019/1661311/Evaluation-­of-­TelehealthImplementations-­in-­Australia.pdf European Commission. (2015). Protection of personal data. http://ec.europa.eu/ justice/data-­protection/ Federation of State Medical Boards. (2014). Model policy for the appropriate use of telemedicine technologies in the practice of medicine. FSMB. https://www. fsmb.org/Media/Default/PDF/FSMB/Advocacy/FSMB_Telemedicine_ Policy.pdf Greenhalgh, T., Procter, R., Wherton, J., Sugarhood, P., & Shaw, S. (2012). The organising vision for telehealth and telecare: Discourse analysis. BMJ Open, 2(4), e001574. https://doi.org/10.1136/bmjopen-­2012-­001574 Halford, S., Lotherington, A. T., Obstfelder, A., & Dyb, K. (2010). Getting the whole picture? New information and communication technologies in healthcare work and organization. Information, Communication & Society, 13(3), 442–465. https://doi.org/10.1080/13691180903095856 Hendy, J., Chrysanthaki, T., Barlow, J., Knapp, M., Rogers, A., Sanders, C., Bower, P., Bowen, R., Fitzpatrick, R., Bardsley, M., & Newman, S. (2012). An organisational analysis of the implementation of telecare and telehealth: The whole systems demonstrator. BMC Health Services Research, 12, 403. https://doi.org/10.1186/1472-­6963-­12-­403 Higa, K., Sheng, O., Hu, P., & Au, G. (2009, April 20). Organizational adoption and diffusion of technological innovations: A comparative case study on

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telemedicine in Hong Kong. Proceedings of the Thirtieth Hawaii International Conference on System Sciences. https://doi.org/10.1109/HICSS.1997.663375 ISO. (2014). ISO/TS 13131:2014 – Health informatics – Telehealth services – Quality planning guidelines. International Organization for Standardization. https://www.iso.org/standard/53052.html ISO. (2021). ISO 13131:2021 – Health informatics – Telehealth services – Quality planning guidelines. International Organization for Standardization. https:// www.iso.org/standard/75962.html Jack, C., & Mars, M. (2014). Telemedicine a need for ethical and legal guidelines in South Africa. South African Family Practice, 50(2), 60–60d. https:// doi.org/10.1080/20786204.2008.10873698 Kidholm, K., Ekeland, A.  G., Jensen, L.  K., Rasmussen, J., Pedersen, C.  D., Bowes, A., Flottorp, S. A., & Bech, M. (2012). A model for assessment of telemedicine applications: Mast. International Journal of Technology Assessment in Health Care, 28(1), 44–51. https://doi.org/10.1017/S0266462311000638 Klecun-Dabrowska, E. (2002). Telehealth and information society: A critical study of emerging concepts in policy and practice [Proceedings of the 2nd International Conference on Pervasive Technologies Related to Assistive Environments]. https://core.ac.uk/display/4187723 Krupinski, E.  A., Antoniotti, N., & Bernard, J. (2013). Utilization of the American Telemedicine Association’s clinical practice guidelines. Telemedicine Journal and E-Health: The Official Journal of the American Telemedicine Association, 19(11), 846–851. https://doi.org/10.1089/tmj.2013.0027 Kruse, C. S., Karem, P., Shifflett, K., Vegi, L., Ravi, K., & Brooks, M. (2018). Evaluating barriers to adopting telemedicine worldwide: A systematic review. Journal of Telemedicine and Telecare, 24(1), 4–12. https://doi.org/10.117 7/1357633X16674087 Lerouge, C., & Garfield, M. J. (2013). Crossing the telemedicine chasm: Have the U.S. barriers to widespread adoption of telemedicine been significantly reduced? †. International Journal of Environmental Research and Public Health, 10(12), 6472–6484. https://doi.org/10.3390/ijerph10126472 Loane, M., & Wootton, R. (2002). A review of guidelines and standards for telemedicine. Journal of Telemedicine and Telecare, 8(2), 63–71. https://doi. org/10.1258/1357633021937479 May, C., Harrison, R., MacFarlane, A., Williams, T., Mair, F., & Wallace, P. (2003). Why do telemedicine systems fail to normalize as stable models of service delivery? Journal of Telemedicine and Telecare, 9(suppl 1), 25–26. https://doi. org/10.1258/135763303322196222

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Mitchell, P. H. (2008). Defining patient safety and quality care. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses. Agency for Healthcare Research and Quality (US). http://www.ncbi.nlm.nih.gov/ books/NBK2681/ Momentum. (2014). Personalised blueprint for telemedicine deployment. European Union. http://www.telemedicine-­momentum.eu/wp-­content/ uploads/2015/02/D3.4_v1.0_ValidatedBlueprint.pdf Moura, L.  A. (2016). The need for a strategy for telehealth. Journal of the International Society for Telemedicine and eHealth, 4(0), e2 (1–7). Nicolini, D. (2006). The work to make telemedicine work: A social and articulative view. Social Science & Medicine, 62, 2754–2767. https://doi. org/10.1016/j.socscimed.2005.11.001 Office of the Australian Information Commissioner. (2020). Read the Australian privacy principles. OAIC. https://www.oaic.gov.au/privacy/australian-­privacy-­ principles/read-­the-­australian-­privacy-­principles/ RACGP. (2011). Standards for general practices offering video consultations. Royal Australian College of General Practitioners (RACGP). https://www.racgp. org.au/FSDEDEV/media/documents/Running%20a%20practice/ Technology/Video%20consultations/Standards-­f or-­g eneral-­p ractices-­ offering-­video-­consultations.pdf Rural Doctors Association of Australia. (2014). Telehealth key principles. RDDA. http://www.rdaa.com.au/sites/default/files/public/Telehealth%2520 PUBLICATION%2520DRAFT_20150514114116.pdf Schatzki, T. R. (2010). The timespace of human activity: On performance, society, and history as indeterminate teleological events. Lexington Books. Stanberry, B. (2006). Legal and ethical aspects of telemedicine. Journal of Telemedicine and Telecare, 12(4), 166–175. https://doi.org/10.1258/ 135763306777488825 Taylor, A. (2015). Applying international guidelines for telehealth services – A case study. In A. Maeder & J. Warren (Eds.), Proceedings of the 8th Australasian workshop on health informatics and knowledge management (HIKM 2015) (pp. 87–95) https://doi.org/10.13140/RG.2.2.13263.69286 Taylor, A., Morris, G., Pech, J., Rechter, S., Carati, C., & Kidd, M. (2015). Home telehealth video conferencing: Perceptions and performance. JMIR mHealth and uHealth, 3(3), e90. https://doi.org/10.2196/mhealth.4666 Telehealth Quality Group. (2016). International code of practice for telehealth services. Telehealth Quality Group EEIG. http://www.telehealth.global/ download/TELEHEALTH-­CODE-­OF-­PRACTICE.pdf

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Umpierre, R. (2019). Tackling OPD waiting lists with teleconsultations and teleophthalmology – The experience in Brazil. Successes and Failures in Telehealth, Gold Coast, Australia. https://event.icebergevents.com.au/uploads/contentFiles/files/2019-­SFT/Roberto%20Umpierre.pdf University of Queensland. (2020). Quick start guide to video conferencing. https:// coh.centre.uq.edu.au/files/1998/COH_UQ_HP_Quick%20start%20 to%20VC_v1.pdf Vuononvirta, T., Timonen, M., Keinänen-Kiukaanniemi, S., Timonen, O., Ylitalo, K., Kanste, O., & Taanila, A. (2011). The compatibility of telehealth with health-care delivery. Journal of Telemedicine and Telecare, 17(4), 190–194. https://doi.org/10.1258/jtt.2010.100502 Wade, V. A., Eliott, J. A., & Hiller, J. E. (2012). A qualitative study of ethical, medico-legal and clinical governance matters in Australian telehealth services. Journal of Telemedicine and Telecare, 18(2), 109–114. https://doi. org/10.1258/jtt.2011.110808

3 Incorporating Technologies into Telehealth Services

Abstract  Understanding the nature of technology is central to any discussion of the influences on telehealth services. I discuss how technology is designed, used and ask whether the diffusion of technology through society automatically leads to it becoming useful in healthcare? Technology is not as an independent force, but a set of technical elements built for social purposes which determine how technologies are accepted in different contexts. Using the concept of sociotechnical codes, social and technological changes associated with telehealth services can be analysed without implying that one or the other is a determinant. In this chapter, I explore the nature of the technology used by telehealth services, the processes by which it becomes useful and how it is incorporated into healthcare. I discuss how technology is designed and accepted into service and ask whether as technology diffuses through society it automatically becomes useful in clinical practice, or do social factors determine its role in the delivery of healthcare? The acceptance of technology into practice has been studied using psychometric methods, while other approaches seek to explain how

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 A. Taylor, Healthcare Technology in Context, https://doi.org/10.1007/978-981-16-4075-9_3

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technologies are diffused through society and become normalised into clinical practice. I argue that our explanations should view technology not as an independent force or a predetermined object, but as a set of technical elements built with a social wrapping which determine how technologies are accepted in different contexts. I propose an alternative way to view and analyse technology based on the concept of sociotechnical codes. The way in which the technologies are adopted within different contexts is influenced by sociotechnical codes. Consequently, social and technological changes associated with telehealth services can be analysed without implying that one or the other is a determinant or that the relationship between the social and the technical works in a particular way.

3.1 Has Technology a Social Component? All of the literature on telehealth services discusses technology. Video cameras, vital signs monitors, computer records, imaging machines, information systems and human movement detectors are the most common manifestations of the technology used by telehealth services. Usually, these technologies capture information which is transmitted via an invisible communication network to a healthcare provider. Hence, ICTs are central to the operation of telehealth services. Whether telehealth services are simply components of ICT is still not clear in the literature. Dardelet (2001) defined telehealth as a “merging of information technology with medical activities” (p.  3). Vitacca et  al. (2009) extended this argument to include home telemedicine, describing it as being “not strictly ‘technology’, but an innovative instrument (based on healthcare personnel more than high technology instruments), which will help the doctors’ daily duties for patients and their families” (p. 96). Lehoux et al. (2002) described the technology used in telehealth services. By Canadian medical specialists as a communications tool. Whitten et al. (2000) referred to telemedicine as an access, economic and education tool. Most authors agreed that the relationship between technology and healthcare is a complex one in which technology is to some degree designed or configured to meet the specific requirements of healthcare.

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Having established that there is a degree of social malleability to technology, the question that remains is to what extent the form or function of technology is shaped by the social context in which it is used. Hard, less malleable technology can be conceived as the equipment, machines or systems, while a softer category, which may be socially shaped, comprises the instructions, rules, processes and individual perceptions regarding use of the equipment. However, the dividing line between hard and soft technology can become blurred or fluid when both are sold as products, which is particularly the case for processes encoded into computer programs (software). An example of such fluidity comes from palliative care nursing. According to Tieman et al. (2016), nurses providing such services add a layer of human activity to telehealth monitoring system alerts when they interpret each patient’s symptom scores using their prior knowledge of the patient’s condition and circumstances. The addition of a layer of human activity described in this case adds social criteria to the monitoring systems, without which the technology is useless. Feenberg (2002) made the point that this layer of human activity produces soft technologies which “meet social criteria of purpose in the very selection and arrangements of the elements from which they are built up” (p. 78). This social wrapping around and within the technical elements from which technologies are built is an essential social component of technology, varying from one context to another.

3.2 Is Technology Designed or Tamed? If we agree that there is a social component to the use of technology, then the relationship between social and technical factors becomes important. Obstfelder et al. (2007) argued that “new technologies alone do not create change. Rather, it is the interplay between technical and social factors that produces particular outcomes” (p. 1). According to Ulucanlar et al. (2013), there are three main conceptions of how technology interacts with society: First, the idea that a network of actors including technology itself shapes the direction of technology adoption; second, the idea that technology is represented and apprehended through information and “evidence” that is socially

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constructed and open to divergent views; and third, the idea that technology itself has material qualities that constrain and enable its use, including matters such as skills, user modifications and structures of work organisation. (p. 96)

When technology is viewed as an independent component with its own dynamic, a period of interplay between social and technical factors can be seen as a period of adaptation during which humans endeavour to use technology to fulfil its intended purpose. In the course of this adaptation, “technology has to be tamed, it has to be tinkered with to fit the practices of the users. The technology, however, is not meekly put to use (tamed), but is unleashed as well, affecting care practices in unforeseen ways” (Pols & Willems, 2011, p.  484). On the other hand, if technology is given socially neutral properties, its progress, use or deployment can be abstracted from social reality. This “ideal” state of a new technology has been described by Cho et  al. (2008) as one where technology has diffused through an organisation or society, is stabilised or is normalised in respect of its context and becomes embedded as a routine and taken for granted. When technology is cast as being free of a social component, then it becomes possible to assign time- and place-bridging properties to the technologies used by telehealth services. If technology has such properties, then, as Whitten and Cornacchione (2010) argued, the use of technology to deliver healthcare at a distance can free services from the restrictions of place-based care. Technical devices can thus traverse political, geographical and economic borders to improve access to healthcare and become new inhabitants of the home, as suggested by Oudshoorn (2012). In contrast, when technology is purposefully designed, the period of interplay between the social and technical factors is one during which explicit and implicit assumptions about technical and social functions, codes of practice, and guidelines come into play. Design methodologies mandate consideration of user-requirements where “the basic elements of the service, such as its aims and objectives, its content and its delivery, as well as the key outcomes and expected benefits should be laid down” (Kolitsi & Iakovidis, 2000, p. S2:38). Participation by users, or “co-­design” during the design phase, is an extension of the proposition that technology can be purposefully designed to meet user requirements. Co-design depends on the assumption that having users involved in all stages of the design

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process, as in the framework proposed by Esser and Goossens (2009), or taking account of socio-psychological factors, reduces the resistance to the subsequent implementation of an intervention. Linked to the co-design movement is the proposition that having the eventual users of a technology involved in its design will enable technologists to extract medical practices from users and to automate those processes in a technology. The inherent assumptions in co-design are that “sub-practices in care can be replaced with automated telecare devices without disrupting the overall care process …. [and] …. a symmetry between design and user contexts” (Kiran, 2012, p. 188). The expectation of co-design is that more usable devices will ease the integration of new telehealth services into mainstream healthcare, “operating more or less as ‘plug and play’” (Sugarhood et al., 2014, p. 86). These first two conceptions of how technology interacts with society assume that technology has a social dimension. The third conception of how technology interacts with society accepts that technology itself has material qualities that constrain and enable its use (Ulucanlar et al., 2013). During the period of interplay between the social and technical factors, technology with certain material qualities is assembled and configured to fulfil a social purpose. In this interplay, individual technologies are constructed from ‘‘decontextualized technical elements combined in unique configurations to make specific devices” (Feenberg, 2002, p. 78). A simple example would be the combination of transistors and resistors used to make an amplifier of electrical signals. How that amplifier is used depends on social norms or codes which Feenberg termed “technical codes”. Such assemblies of technical elements can be viewed as carrying a social component. This adaptation of technology to fit the needs of users has been described by Essén (2009) as bricolage, where “bricolage is the repurposing and refashioning of the old in making something new … and it involves recombining existing elements rather than fabricating them from scratch” (p. 102). Because place-based culture, practices and processes can shape or determine the feasibility and acceptance of technology used by telehealth services, it should be evident that “[it] does not, in any simple way, free us from place” (Dyb & Halford, 2009, p. 246). For example, acceptance by health professionals of new technologies is based on their judgements of whether the technologies used by telehealth services are compatible or incompatible with place-based clinical practices.

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3.3 Acceptance of Technology Acceptance of technology theories built on human behavioural sciences have  been extensively applied in healthcare  using differing definitions. Interpretations of technology acceptance depend on which stage of the acceptance process is under consideration (Nadal et al., 2020). Theories about the acceptance of telehealth services by users focus on the acceptance of technology by providers or patients, with the implication that high acceptance of a telehealth technology may lead to better health outcomes. Acceptance theories see acceptance or non-acceptance as being the only possibilities. They view the technology being studied as an invariant object rather than as a set of techniques, skills or methods used to assemble technical devices and systems evolving over time. Dominant theories used by these perspectives include the technology acceptance model (TAM) and the theory of planned behaviour (TPB), both derived from psychometric research into the use of information systems. These theories, in most cases, employ a mathematical analysis of people’s responses to surveys to establish relationships (both causal and predictive) between acceptance or intent to accept a technology and a number of psychometrically constructed variables, such as perceived usefulness and perceived ease of use. In a systematic review of applications of these theories, Koul and Eydgahi (2017) argued that “TAM and TPB will continue to serve as the fundamental means for researchers seeking to study the factors influencing consumers’ adoption intentions of various technologies” (p. 110). Chau and Hu (2002) found that “TAM may be more appropriate than TPB for examining technology acceptance by individual professionals” (p. 297), but in recognition of the possible limitations of technology acceptance modelling, given “the fact that none of the investigated models was able to explain half of the behavioural intention variance may signify the need for a broader exploration of factors beyond TAM and TPB” (p. 308). To improve the explanatory power of acceptance models, a number of authors extended these theoretical frameworks, using additional variables and different survey instruments. To account for the complexity of the interactions between technologies and professional contexts, Venkatesh

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et  al. (2003) developed the unified theory of acceptance and use of technology (UTAUT). This theory provides a complex model of technology use in a given context, focusing on four key variables: performance expectancy, effort expectancy, social influence and facilitating conditions. Like the TAM, UTAUT methods employ questionnaires and statistical analysis to determine causal correlation between variables and use behaviour. For example, Kohnke et al. (2014) applied UTAUT to a study of home care in Michigan and found that clinicians use new telehealth services if they believe they will work for them. The possibility of multiple explanations of telehealth service uptake has been indicated by Wade et al. (2014), who used stakeholder interviews and grounded theory to build a contextual model of clinician acceptance of telehealth services in South Australia. Wade’s model included seven factors: champions promoting telehealth services, good relationships between providers, positive beliefs about telehealth services, demand, resources, workforce availability and adequate technology. There are limitations to acceptance research. For instance, the contribution of contextual factors to consumer behaviour “for certain situations, which may be revealed in surveys or focus groups, may not actually play out in terms of actual behaviour during telemedicine encounters” (Turner et al., 2003, p. 104). Acceptance as a concept can potentially be extended. According to van Offenbeek et  al. (2013), a four-quadrant model comprising acceptance, non-acceptance, support and resistance provides a better measure of user reactions. Ultimately, all efforts to model the acceptance of telehealth services illustrate the need for multidimensional analysis of human behaviour.

3.4 Cumulative Adoption of Technology A popular conception of technology acceptance in the literature is based on a partial interpretation of the work of Rogers (1971) on the diffusion of innovations in the agricultural sector. According to this interpretation, technologies are “invented”, and then they are diffused through society causing social change. Diffusion is a process “by which a technology spreads across a population of organizations, in contrast to the notion of adoption, which focuses on the uptake of an innovation by a single

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adopter  – whether an individual or organization” (Cho et  al., 2008, p. 253). For Rogers, the “diffusion effect is the cumulatively increasing degree of influence upon an individual to adopt or reject an innovation, resulting from the increasing rate of knowledge and adoption or rejection of the innovation in the social system” (p. 161). A quick glance at Rogers’s work may give the impression that it supports the concept that technologies can, of their own volition, diffuse across an organisation or society. This interpretation has led to many commentators and consultancy companies promoting technologically deterministic views where the inevitability of technology diffusion through society is assumed, with little attention being paid to social factors. A closer reading of Rogers’s work reveals that he actually placed the responsibility for aspects of technology innovation, such as diffusion, adoption, normalisation and stabilisation, squarely on the shoulders of individuals, embedded in social processes, albeit influenced by various candidate factors enumerated by Rogers within the context of social change. Echoes of diffusion theory are widespread: Greenhalgh, Robert, Macfarlane, et al. (2004b) investigated the diffusion of innovation in the UK National Health Service; Rideaux (2015) studied the diffusion of telemedicine connecting veterans to healthcare; and Bashshur and Shannon (2009) linked the development of telemedicine to successive technological developments, such as the telephone, television and computers, during which telemedicine moved through pioneering, maturation and transformation stages. More recently, Steinhauser (2019) examined the diffusion of digital innovations using case studies of telemedicine networks in Germany. The multiplicity of available factors listed in Rogers’s (1971) original work (potentially 102 factors) that could influence an individual’s decision to adopt an innovation suggests that diffusion of innovation theory has more value as a complex model of contextual factors than as a theoretical explanation. The complexity of the contextual factors that could influence telehealth services was acknowledged by health professionals who recounted their experiences of extending a service from one context to another. Simple service duplication was not always successful: “the instruction was duplicate the Argentinian service in Brazil. But the legislation is different. I cannot just replicate what’s in the other country and bring it here” (Vincent,

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Hospital manager). Extension of a service within national or state boundaries where contexts may be similar can more successful. For instance, the Rio Grande do Sul teleadvice service and the Santa Catarina teledermatology service have been extended to other Brazilian states. The problem raised by treating technology as possessing linear, ever-­ increasing capabilities which will be sequentially adopted is illustrated by the experience of a telehealth centre in Brazil. Previously, it had relied on an online computer system but it decided to repurpose older technology—the telephone—which some considered had limited functionality to achieve greater penetrability of its services. The manager of the centre told me that: when we created telephone support, several telehealth centres ridiculed us like this, “Ah, using the phone is not Telemedicine.” “How are you going to discuss it over the phone?” Well, ever since they invented the phone, a doctor answers the patient on the phone! (Santiago, Health service manager)

There are a few examples of modelling the complexity of incorporating technology within healthcare contexts. One such example is the model of technology innovation within contextual domains that Greenhalgh, Robert, Bate, et  al. (2004a) developed as part of a report on how to improve innovation in the health system for the UK National Health Service (NHS). This model proposes the existence of an outer context and an inner context. The outer context includes the social and political climate, incentives, mandates and relationships with other organisations. The inner context consists of individual health professionals and the “hard” visible organisational structure and the “soft” medium of culture and practice, both of which vary enormously between organisations.

3.5 Incorporating Technology into Clinical Practice According to Esterle and Mathieu-Fritz (2013), there are three steps in the incorporation of technology in clinical contexts. The first involves “technical” framing where the technology is adapted to clinical requirements by ensuring that it can provide the required information or

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functionality (e.g., clarity of images) using procedures the clinician is able to learn. The second step provides the “social” framing, getting the remote patient and clinical staff ready for a scheduled teleconsultation (confirmation of identities, obtaining consent and accessing medical records). The third step involves fine-tuning the process, whereby remote clinical staff present clinical issues and diagnostic procedures. There are other essential steps, for instance, ensuring that the organisation will pay for the clinical time expended and that the teleconsultation is framed as a valid clinical activity by peers through the development of guidelines, all of which are preconditions for the successful appropriation of the technology. This sequence of implementation steps is aimed at aligning the intervention with current practices and is often codified in frameworks or guidelines. Another view of the clinical framing process stems from normalisation process theory (NPT). May (2006) defined normalisation as meaning “the embedding of a technique, technology or organizational change as a routine and taken-for-granted element of clinical practice” (p. 2). NPT is based on the notion I introduced in Chap. 1—that there are deeper explanations or mechanisms. Accordingly, the work undertaken by individuals to implement a (telehealth) intervention (i.e., an intervention which includes a technology) can be described as a mechanism. The four mechanisms proposed by NPT (May et al., 2009) operate within professional (clinical) contexts: • Coherence: work that defines and organises the objects of a practice; • Cognitive participation: work that defines and organises the enrolment of participants in a practice; • Collective action: work that defines and organises the enacting of a practice; and • Reflexive monitoring: work that defines and organises the knowledge upon which appraisal of a practice is founded. (p. 7) NPT implies that telehealth services become embedded in (clinical) practice as a result of the combined contributions of social agents, and these four mechanisms combine to sustain the intervention. Both individuals

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and collectives are required to work together as social agents to achieve normalisation and stability of an intervention. Normalising and routinising telehealth services are complex processes (Nicolini, 2010), driven by the need to realise clear benefits. For instance, Finch et  al. (2007) argued that the successful teledermatology services “that became normalized were those for which the perceived benefits, for example saving patients’ and/or health professionals’ travelling time and costs, or reducing waiting times, clearly outweighed the effort and commitment required to make the system work” (p. 523).

3.6 The Sociotechnical Codes of Telehealth My underlying conclusion is that the normalisation, routinisation or diffusion of telehealth services is contingent on social processes or mechanisms. Bearing in mind that in Chap. 1, I referred to a definition of mechanisms as the power of individual or collective reasoning of human agents to bring about changes in context, it should be evident that context changes over time as the result of social interactions. To clarify the meaning of context as used in this book, I draw on Pawson and Tilley (1997) in my definition of context as: the spatial and institutional locations of social structures and their material parts, together with the norms, processes, practices, and inter-relationships found in them (i.e., the cultural structures), which condition the potential interactions between social or cultural structures and individual or collective agency. (Author’s adaption of Pawson & Tilley, 1997, p. 216)

In this book I refer to organisational contexts as providing the structural conditions for telehealth services, such as resources, management and technology. Professional contexts represent the interactions between people over the norms, processes, practices and the codes of telehealth services. I argue that contexts, particularly organisations and professional contexts, shape the development of telehealth services, and that social mechanisms act within contexts to determine their outcomes. Axiomatically,

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context is not stable; it changes over time under the influence of mechanisms. An example of such changes was given by Whitten et al. (2000), when they described how telemedicine in the US state of North Carolina evolved over time until the context suddenly changed: “Initially, telemedicine in North Carolina was about doing consults within a prison setting. Suddenly a medical director was hired, and telemedicine was about outreach and education. New sites were established, and telemedicine became a process of scheduling and coordinating” (p. 128). Flichy (2007) also theorised that the evolution of contexts over time was linked to the concept of a frame of functioning and a frame of use. The frame of functioning is the social world which produces a technical object to undertake a particular function. An example might be the mobile phone technology standards agreed on by large industries and technical experts. The frame of use is the social world in which the technical object is actually deployed, in this case, the commercial market for mobile phones. According to Flichy, cooperation or interaction between the two social worlds is needed to achieve the stability of the technical object. Flichy described the unity of the two frames as a sociotechnical frame of reference where sociotechnical frames provide sites in which groups of people influence technological systems. Drawing on Flichy’s (2007) concept of “sociotechnical frames” and Feenberg’s (2002) “technical code”, I use the concept of sociotechnical codes throughout this book. I define sociotechnical codes as the norms, processes and practices which form part of and simultaneously shape the way in which the technologies are adopted.1 Sociotechnical codes, therefore, form parts of contexts. When sociotechnical codes are involved in interactions between human agents, they may change. Application of the concept of a sociotechnical code enables the social and technological changes associated with telehealth services to be studied without implying that one or the other is a determinant or that the relationship between the  I argue that a more recent conceptualisation, originating from within a critical realist tradition, of sociotechnical entities is analogous to my conceptualisation of the sociotechnical code: Sociotechnical entities comprise both human actors and material objects (Elder-Vass, 2017) where interactions between human actors take place within norm circles (Elder-Vass, 2010, p. 115) comprising members of social groups. Therefore, the concept of a sociotechnical code will continue to be used in this investigation. 1

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social and the technical works in a particular way. As Whitten et  al. (2000) argued, “to privilege the technology of telemedicine over the context of a telemedicine organisation would be a grave mistake” (p. 130). Recognising the need to understand the contexts in which telehealth services operate, in the next chapter I explore the premises on which the current health systems in Australia and Brazil have been built, and the constraints in these systems that shape the development of telehealth services in these countries.

References Bashshur, R. L., & Shannon, G. W. (2009). History of telemedicine: Evolution, context, and transformation (1st ed.). Mary Ann Liebert. Chau, P., & Hu, P. (2002). Examining a model of information technology acceptance by individual professionals: An exploratory study. Journal of Management Information Systems, 18(4), 191–229. https://doi.org/10.108 0/07421222.2002.11045699 Cho, S., Mathiassen, L., & Gallivan, M. (2008). From adoption to diffusion of a telehealth innovation. Proceedings of the 41st Hawaii International Conference on System Sciences, 245–245. https://doi.org/10.1109/HICSS.2008.177 Dardelet, B. (2001). In the kingdom of expertness, the profane is king. Carriers of medical innovations. Proceedings of the 34th Annual Hawaii International Conference on System Sciences, 8 pp. https://doi.org/10.1109/ HICSS.2001.926566 Dyb, K., & Halford, S. (2009). Placing globalizing technologies: Telemedicine and the making of difference. Sociology, 43(2), 232–249. https://doi. org/10.1177/0038038508101163 Elder-Vass, D. (2010). The causal power of social structures. Cambridge University Press. Elder-Vass, D. (2017). Material parts in social structures. Journal of Social Ontology; Vienna, 3(1), 89–105. http://dx.doi.org.ezproxy.flinders.edu. au/10.1515/jso-2015-0058 Essén, A. (2009). The emergence of technology-based service systems; A case study of a telehealth project in Sweden. Journal of Service Management, 20(1), 98–121. https://doi.org/10.1108/09564230910936878

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Esser, P. E., & Goossens, R. H. M. (2009). A framework for the design of user – Centred teleconsulting systems. Journal of Telemedicine and Telecare, 15(1), 32–39. https://doi.org/10.1258/jtt.2008.080601 Esterle, L., & Mathieu-Fritz, A. (2013). Teleconsultation in geriatrics: Impact on professional practice. International Journal of Medical Informatics, 82(8), 684–695. https://doi.org/10.1016/j.ijmedinf.2013.04.006 Feenberg, A. (2002). Transforming technology a critical theory revisited (2nd ed.). Oxford University Press. Finch, T.  L., Mair, F.  S., & May, C.  R. (2007). Teledermatology in the UK: Lessons in service innovation. The British Journal of Dermatology, 156(3), 521–527. https://doi.org/10.1111/j.1365-­2133.2006.07608.x Flichy, P. (2007). Understanding technological innovation: A socio-technical approach. Edward Elgar Publishing. Greenhalgh, T., Robert, G., Bate, P., Kyriakidou, O., Macfarlane, F., & Peacock, R. (2004a). How to spread good ideas a systematic review of the literature on diffusion, dissemination and sustainability of innovations in health service delivery and organisation. National Co-ordinating Centre for NHS Service Delivery and Organisation. http://www.netscc.ac.uk/netscc/hsdr/files/project/SDO_FR_08-­1201-­038_V01.pdf Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., & Kyriakidou, O. (2004b). Diffusion of innovations in service organizations: Systematic review and recommendations. Milbank Quarterly, 82(4), 581–629. https://doi. org/10.1111/j.0887-­378X.2004.00325.x Kiran, A. H. (2012). Responsible design. A conceptual look at interdependent design-use dynamics. Philosophy & Technology, 25(2), 179. https://doi. org/10.1007/s13347-­011-­0052-­5 Kohnke, A., Cole, M. L., & Bush, R. G. (2014). Incorporating UTAUT predictors for understanding home care patients’ and clinician’s acceptance of healthcare telemedicine equipment. Journal of Technology Management & Innovation, 9(2). https://doaj.org/article/65e0892d51614e55a0b01b1c5f1c01cd Kolitsi, Z., & Iakovidis, I. (2000). Improving user acceptance of health-care telematics. Journal of Telemedicine and Telecare, 6(suppl 2), 37–39. https:// doi.org/10.1258/1357633001935491 Koul, S., & Eydgahi, A. (2017). A systematic review of technology adoption frameworks and their applications. Journal of Technology Management & Innovation, 12(4), 106–113. https://doi.org/10.4067/S0718-­27242 017000400011

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Lehoux, P., Sicotte, C., Denis, J. L., Berg, M., & Lacroix, A. (2002). The theory of use behind telemedicine: How compatible with physicians’ clinical routines? Social Science & Medicine (1982), 54(6), 889–904. May, C. (2006). A rational model for assessing and evaluating complex interventions in health care. BMC Health Services Research, 6, 86. https://doi.org/1 0.1186/1472-­6963-­6-­86 May, C., Mair, F., Finch, T., Macfarlane, A., Dowrick, C., Treweek, S., Rapley, T., Ballini, L., Ong, B., Rogers, A., Murray, E., Elwyn, G., Legare, F., Gunn, J., & Montori, V. (2009). Development of a theory of implementation and integration: Normalization process theory. Implementation Science, 4. https:// doi.org/10.1186/1748-­5908-­4-­29 Nadal, C., Sas, C., & Doherty, G. (2020). Technology acceptance in mobile health: Scoping review of definitions, models, and measurement. Journal of Medical Internet Research, 22(7), e17256. https://doi.org/10.2196/17256 Nicolini, D. (2010). Medical innovation as a process of translation: A case from the field of telemedicine. British Journal of Management, 21(4), 1011–1026. https://doi.org/10.1111/j.1467-­8551.2008.00627.x Obstfelder, A., Engeseth, K., & Wynn, R. (2007). Characteristics of successfully implemented telemedical applications. Implementation Science, 2, 11. https:// doi.org/10.1186/1748-­5908-­2-­25 Oudshoorn, N. (2012). How places matter: Telecare technologies and the changing spatial dimensions of healthcare. Social Studies of Science, 42(1), 121–142. https://doi.org/10.1177/0306312711431817 Pawson, R., & Tilley, N. (1997). Realistic evaluation. Sage. Pols, J., & Willems, D. (2011). Innovation and evaluation: Taming and unleashing telecare technology. Sociology of Health & Illness, 33(3), 484–498. https:// doi.org/10.1111/j.1467-9566.2010.01293.x Rideaux, K. (2015). Diffusion of telemedicine: Connecting veterans to healthcare. Distance Learning, 12(3), 23–28. Rogers, E. M. (1971). Diffusion of innovations (2nd ed.). Free Press. Steinhauser, S. (2019). Network-based business models, the institutional environment, and the diffusion of digital innovations: Case studies of telemedicine networks in Germany. Schmalenbach Business Review. https://doi. org/10.1007/s41464-­019-­00076-­9 Sugarhood, P., Wherton, J., Procter, R., Hinder, S., & Greenhalgh, T. (2014). Technology as system innovation: A key informant interview study of the application of the diffusion of innovation model to telecare. Disability and Rehabilitation: Assistive Technology, 9(1), 79–87. https://doi.org/10.310 9/17483107.2013.823573

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Tieman, J., Swetenham, K., Morgan, D., To, T., Currow, D., Tieman, J., Swetenham, K., Morgan, D., To, T., & Currow, D. (2016). Using telehealth to support end of life care in the community: A feasibility study. BMC Palliative Care, 15. https://doi.org/10.1186/s12904-­016-­0167-­7 Turner, J. W., Robinson, J. D., Alaoui, A., Winchester, J., Neustadtl, A., Levine, B. A., Collmann, J., & Mun, S. (2003). Media attitudes vs. use: The contribution of context to the communication environment in telemedicine. Health Care Management Review, 28(2), 95–106. https://doi. org/10.1097/00004010-­200304000-­00002 Ulucanlar, S., Faulkner, A., Peirce, S., & Elwyn, G. (2013). Technology identity: The role of sociotechnical representations in the adoption of medical devices. Social Science & Medicine, 98, 95–105. https://doi.org/10.1016/j. socscimed.2013.09.008 van Offenbeek, M., Boonstra, A., & Seo, D. (2013). Towards integrating acceptance and resistance research: Evidence from a telecare case study. European Journal of Information Systems, 22(4), 434–454. https://doi.org/10.1057/ ejis.2012.29 Venkatesh, V., Morris, M. G., Davis, G. B., & Davis, F. D. (2003). User acceptance of information technology: Toward a unified view. MIS Quarterly, 27(3), 425–478. https://doi.org/10.2307/30036540 Vitacca, M., Mazzù, M., & Scalvini, S. (2009). Socio-technical and organizational challenges to wider e-health implementation. Chronic Respiratory Disease, 6(2), 91–97. https://doi.org/10.1177/1479972309102805 Wade, V. A., Eliott, J. A., & Hiller, J. E. (2014). Clinician acceptance is the key factor for sustainable telehealth services. Qualitative Health Research, 24(5), 682–694. https://doi.org/10.1177/1049732314528809 Whitten, P., & Cornacchione, J. (2010). The multiple contexts of borders that impact telemedicine as a healthcare delivery solution. Journal of Borderlands Studies, 25(3–4), 206–218. https://doi.org/10.1080/0886565 5.2010.9695782 Whitten, P., Sypher, B. D., & Patterson, J. D. (2000). Transcending the technology of telemedicine: An analysis of telemedicine in North Carolina. Health Communication, 12(2), 109–135. https://doi.org/10.1207/ S15327027HC1202_1

4 Healthcare in Australia and Brazil

Abstract  This chapter compares the aspects of the Australian and Brazilian healthcare systems which were key to influencing and supporting telehealth services. How healthcare in the Australian and Brazilian universal care systems is organised and accessed, the availability of human resources, financial arrangements and the available technologies all influence  telehealth services. In these countries the provision of universal healthcare is a fundamental tenet of their healthcare systems. In both countries, healthcare is decentralised, limited by state boundaries, regional catchments, municipal boundaries or hospital localities. In both Australia and Brazil, the contexts for healthcare have shaped the development of telehealth services. This chapter provides a comparative outline of the key aspects of the Australian and Brazilian healthcare systems which influenced and supported telehealth services. During my fieldwork, health professionals and the telehealth services with which they were associated provided me with information on their services and the healthcare systems within which these operated. My analysis in later chapters is based on this information, supplemented by data obtained during my interviews with health professionals in each country. In this chapter, © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 A. Taylor, Healthcare Technology in Context, https://doi.org/10.1007/978-981-16-4075-9_4

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my description of health services in Australia and Brazil commences with an outline of their respective universal healthcare systems: how healthcare is organised and accessed, the availability of human resources, financial arrangements and the ICT relevant to telehealth services. Central to the context for healthcare in these countries is the idea that the provision of universal healthcare is a fundamental tenet of healthcare. In both countries, healthcare is decentralised, and health service provision is limited by state boundaries, regional catchments, municipal boundaries or hospital localities. Consequently, access to healthcare in Australia and Brazil is in part determined by the ability to access specialist services concentrated in metropolitan areas.

4.1 Universal Healthcare Reform of the Australian and Brazilian healthcare systems towards the end of the twentieth century aimed at providing universal access to healthcare at minimal cost. Brazilians have a constitutional right to free healthcare provided by a universal healthcare system, Sistema Único de Saúde (SUS). In practice, the right to healthcare is limited by geographic variability in access to health services and the limited resources of public health services. In Australia, the health system aims at providing equitable access to care, also limited by geography and the cost of “out-of-­ pocket” expenses. The strategic aim of Brazilian health services has been to improve the capacity of primary healthcare. The key component of primary care is the Family Health Strategy launched in 1994. Family health teams are geographically based, multi-professional teams that are linked to local health facilities. Teams are responsible for whole-of-family care, including dental care (Gragnolati et al., 2013). By contrast, primary health services are well established in Australia. The focus of public health is managing disparities in access to higher levels of care for regional populations. Although healthcare in Australia and Brazil is notionally universally available, in practice, health service provision is defined by state boundaries, regional catchments, municipal boundaries or hospital localities. The basic unit of healthcare organisations is still limited—by an area or place—or by geographical borders defining the catchment area for patients.

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4.2 Organisation of Healthcare In both countries, healthcare is devolved to regional entities: in Australia, 146 local health networks coordinate primary care, while 136 hospital networks coordinate acute care; in Brazil, more than 5000 municipalities with an average size of 36,400 people (Organisation for Economic Cooperation and Development, 2018) provide primary care and hospital care. Democratisation of Brazilian state structures following the end of the former dictatorship led to a hugely increased role for municipalities in delivering healthcare (Fleury, 2014). Australian states provide public hospital services, as do some Brazilian states. Australia has 1331 hospitals of which the majority (52%) are public. Hospitals and primary health services are controlled by local hospital and primary health networks following a reform process that commenced in 2010. According to the Australian Institute of Health and Welfare (2017b), in 2015–2016 these provided a total of 94,000 beds of which 65% were in public hospitals. Commensurate with the larger population, the Brazilian public health sector is much larger than the Australian one. There are 438,243 hospital beds in 6810 hospitals and a majority (64%) are privately run (Ministério da Saúde, 2018). Health services in Brazil were decentralised between 1990 and 2001 to 5570 municipalities. Brazil relies heavily on the private sector to host public patients. Part of the challenge for providing public healthcare infrastructure in Brazil is the sheer number of health facilities. There are more than 46,000 health posts or primary health facilities in Brazil compared with around 7000 Australian general practices servicing primary healthcare (Swerissen et al., 2018). In the Brazilian primary health facilities I visited during my field research, it was clear that the most pressing need was the improvement of physical infrastructure, including according a lower priority to the installation of information technology equipment.

4.3 Access to Healthcare Both Brazil and Australia are large countries intensively settled in coastal regions. Population densities in large coastal cities in Australia vary from 2000 to 8000 people per square kilometre (Australian Bureau of Statistics,

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2014). Absolute population densities in Brazilian coastal regions are lower than in Australia, reflecting the larger geographical size of Brazilian cities. However, population densities in coastal regions of Brazil can exceed 500 people per square kilometre (Brazilian Institute of Geography and Statistics, 2010).1 In the case of Brazil, a significant proportion of the population lives in inland areas where the population density is lower than at the coast, ranging from 10 to 50 people per square kilometre (with the exception of Amazonas where densities are even lower). In keeping with the concentration of population on the coast in both countries, major hospitals are located in coastal capital cities. Notwithstanding a number of “hospital in the home” services in Australia, in which healthcare activities are separated by distance, the majority of care still takes place within the walls of a health facility and patients travel to the facility to receive healthcare. Geographic inequity of access to healthcare has major implications for people living in inland cities and settlements, who may have to travel large distances for treatment. Mapping of the movement of patients in Brazil, particularly for medium- and high-complexity treatments (Fiocruz, 2010), shows that vast numbers of patients attend hospitals in the coastal cities every year, using patient transport services provided by the health system. The situation is not so different in Australian states such as Queensland, where subsidised patient travel cost $75 million in 2014.2 Regional residents tend to fall into lower-income brackets, so the cost of healthcare and travel is important. Since the commencement of Medicare in Australia, the costs of accessing healthcare have increased due to a failure to index the subsidies given to patients for consultations to rising charges, leaving patients with a co-payment to make. The amount of this co-payment may range from $10 to $40 or more for a primary health consultation, to several hundred dollars for a consultation with a private specialist in a metropolitan area who is in high demand (Duckett, 2015).

 No upper limit is given in the data source.  Bryett, A. (2015). Telehealth in Queensland. Presented at the Success and Failures in Telehealth conference. 1 2

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In Brazil, similar linked forces are at play, limiting access to healthcare. For high-income earners or workers offered private health plans as part of their employment package (Gragnolati et al., 2013, p. 90), the key issue is the cost of services, the amount of co-payment and the coverage provided by the plan. For those who cannot afford private health plans or cannot use them for the type of care they require, the alternative is the public health system (Australian Medical Association [AMA], 2018; Briggs, 2017). There are long waiting lists for specialist treatment (e.g., for dermatology in Brazil, see Ribas, 2017; Von Wangenheim & Nunes, 2018), and access to specialist services for regional dwellers requires long journeys to centres in big cities. Private health insurance take-up in Brazil increased between 2000 and 2014, reaching 24.8% of the population, but has since decreased to 22.8% as a result of the decline in incomes following the recession in 2014. An increasing number of health insurance policies limit coverage for procedures and have reduced reimbursements (Massuda et al., 2018). This trend is mirrored in Australia where, according to the AMA, private health insurance membership for hospital admission has fallen from 50% in 1984 to 47.4% in 2015 and 46.5% in 2017 (AMA, 2018; Briggs, 2017). Indications are that regional populations in both Australia and Brazil with reduced income levels have few healthcare options.

4.4 Availability of Human Resources The health workforce is an essential resource for the delivery of telehealth services, so it is worth understanding its composition and distribution. It is difficult to compare the workforce composition in Australia and Brazil because different job classifications are used. Although Brazil has proportionally fewer health professionals than Australia, the difference is not huge. The geographical distribution of the workforce is more significant. In each country, the medical workforce clusters around their workplaces; in the main part, hospitals, located in larger population centres (Santos et al., 2018; Scheffer, 2018). In Australia, 72% of GPs are concentrated in the major cities (Australian Government Department of Health, 2018). The major employers of specialists and nurses are the big hospitals

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in Australia’s coastal cities. The picture in Brazil is similar, but more differentiated. For instance, the number of surgeons in Brazil varies between 1 and 2.6 surgeons per 1000 population, with the main concentration in the southern and south-eastern states (Alonso et al., 2017). Uneven distribution of health workforce, particularly specialists, is associated with differential access to health services and facilities for the general population. Australian telehealth service models attempt to reduce patient travel to specialist centres by diverting patients to peripheral facilities, which then host remote consultations. The Brazilian telehealth service model reduces patient travel to specialist centres by retaining patients in primary health facilities and providing advice to local clinicians (described as family doctors) on how to manage conditions, without initially requiring patients to make an appointment with a specialist. At the primary health level, about 50% of the Brazilian population is served by 42,999 family health teams covering about 73% of the country (Bousquat et  al., 2017). These teams manage patients locally within primary care, rather than referring them to specialist centres. In Australia, primary care is provided by private providers, operating as GPs, who are funded federally through the Medicare Benefits Schedule (MBS). These GPs charge time- and complexity-based fees. Patients requiring specialist opinions or treatment are referred to the public, state and federally funded sector, or directly to the private sector. In Brazil, the referral process from primary to specialist care is similar, but primary care doctors are salaried staff funded by municipalities. Brazilian citizens can also approach some private specialists directly without a referral from a primary health doctor. In some states, advice to these family doctors is provided by dedicated advice teams located in large cities. These, in turn, have to be resourced appropriately. In both Australia and Brazil, the difficulty of managing or treating regional patients is compounding the difficulties of retaining staff. Recruitment to primary care can be difficult. For instance, there were only 5486 family and community specialists registered in Brazil in 2018. To ameliorate this shortage, the More Doctors (Mais Médicos) Program supported family health teams with more than 18,000 additional doctors, mostly from Cuba (Massuda et al., 2018). The health professionals who work in rural and remote communities have limited access to education, training and ongoing support, as well as lack of peer support.

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4.5 Financing Healthcare Services Australian states fund about 50% of hospital costs. Brazilian states and municipalities contribute fixed percentages of their revenues to fund primary and secondary care. In both systems, the states retain some responsibilities for distributing healthcare resources across their territories. Total Australian health expenditure as a percentage of GDP was 10.3% in 2016. In 2015–2016, the estimated per person expenditure on health averaged $7096, totalling $154,671 million (Australian Institute of Health and Welfare, 2017a). Total Brazilian health expenditure as a percentage of GDP was 9.1% in 2016. In 2015, the estimated per person expenditure on health in Brazil averaged AU$1068, totalling AU$218,453 million at historical exchange rates (Rodrigues, 2015). In practice, due to the higher local purchasing power of the Brazilian currency, these figures are worth about 80% more in real terms (World Health Organisation, 2018). However, they are still below Australian per capita health expenditure. Australian state and territory governments contribute about 26% of total funding for healthcare. Brazilian states and municipalities increased healthcare expenditure from 22.3% and 25.5%, to 27.0% and 32.2%, respectively, between 2003 and 2016, although there are signs that this contribution is decreasing (Massuda et al., 2018). About $56 billion of total Australian health expenditure was spent on primary healthcare between 2014 and 2015 (Australian Institute of Health and Welfare, 2016). This is 35% of total health funding, similar to spending on hospital services (39%). Primary healthcare in Brazil is more difficult to quantify due to the different system and expenditure classifications used. In 2014, basic primary health expenditure, including dental care by government, was about 11% of overall expenditure, with emergency and urgent care in primary care accounting for an additional 4%. A conspicuous feature of Brazilian healthcare is the large number of buses that transport patients from the interior to city hospitals for their appointments. One of the fastest growing budget items for federal, state and municipal expenditure is patient transport, which in 2014 exceeded 0.4% of total health expenditure (about AUD$880 million; Ministério da Saúde & Fundação Oswaldo Cruz, 2018).

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In summary, health expenditure in Brazil is lower than in Australia, and total private sector expenditure accounts for a greater proportion than in Australia. There are three levels of government financing in Brazil, whereas Australia has two. Funding of primary health appears lower, but it is difficult to make like-for-like comparisons. Within this broad envelope of healthcare funding, Australian and Brazilian telehealth services draw on funds from state and federal governments for healthcare activity, for servicing incentive payments and for block funding in the form of grants for research and infrastructure.

4.6 Information and Communications Technology During the first decade of this century, the need for electronic health records began to dominate national health information agendas. In Australia, a review by the Boston Consulting Group in 2004 positioned telehealth services as a lower priority item (Boston Consulting Group, 2004) than electronic health record systems. The National Electronic Health Transition Authority (NEHTA) was established in 2005 by the Australian Commonwealth, State and Territory Governments to develop strategies and the foundations for electronic health records, including clinical terminologies and patient and provider identifiers. Likewise, the Brazilian Ministry of Health established an eHealth program in 2007 and has an eHealth strategy (Ministério de Saúde, 2016). The strategy is similar to the Australian approach in that it proposes to construct an eHealth system in a staged approach. The strategy aims to lay the basis for the long-term implementation of eHealth systems and suggests that telehealth services should promote the use of eHealth platforms. Within both countries, substantial resources ($1.26 billion in the state of Queensland alone) have been devoted to developing electronic health record (EHR) systems. According to the Queensland Audit Office (2018), the stated aim of these investments is to “build the foundation for accessing and sharing medical records across the health system” (p. 64). The

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anticipated reduction in adverse drug events and in staff time spent accessing information could be a major benefit in the long term. Such benefits will take many years to realise because these large systems take a number of years to implement, hospital by hospital. In addition, because these systems were designed for use in hospitals; care outside the walls of major hospitals is not directly supported by access to electronic medical records. Telehealth services and eHealth share a dependence on evolving ICTs. However, eHealth programs, in the main, focused on improving the level of automation and access to information in healthcare, while telehealth services are largely concerned with improving access to care. In Australia, an early agenda of using technology to improve access to healthcare was dominated by an eHealth agenda aiming to deliver improved quality, efficiency and safety through greater automation of health records, diagnostic results and prescription ordering. For instance, in 2019, the ADHA, despite having developed a strategy that referred frequently to telehealth services, was unable to fund any initiatives and was instead concentrating on national eHealth systems. The dominance of the eHealth agenda across the world appears not to have been examined in academic research, which largely considers the problems with its implementation and benefits (mainly still to be realised). In Australia, it is only recently during the COVID-19 pandemic that concerns about the focus on health information systems, in this case the Australian national health record (My Health Record [MHR]) resurfaced. One commentator previously critical of the MHR system felt that in the light of the pandemic, greater investment should be given to telehealth services: COVID, for all its horror and waste, has at once stripped the MHR of all its political cover and introduced a much more appropriate and practical successor for the digital future of the system. In very simple terms, if you have a dollar to spend on our digital healthcare future, and you had to choose between investing that dollar in telehealth, and investing it in the MHR, where would you invest now? (Knibbs, 2020)

At the turn of the twentieth century, the perception was that care at a distance was limited by the available technology, particularly the ability to

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transmit information electronically over modern telecommunications infrastructure (National Health Information Management Advisory Council, 2001). In Australia, it was argued that “the major impediment to the more widespread use of broadband in the health sector was consistently identified as availability at an affordable price” (National Office for the Information Economy, 2002, p. 4). Despite the high cost of broadband at that time, an Australian consultancy firm wrote a report in 2003 on the economic impact of broadband in hospitals claiming that a net benefit of more than $190 million over 10 years would arise from broadband connectivity to large and medium hospitals (Access Economics, 2003). In recognition of the need for broadband communications, between 2002 and 2009, the Australian Department of Communications, Information Technology and the Arts (DCITA) administered a number of broadband communications enhancement projects. These were funded under the Coordinated Communications Infrastructure Fund (CCIF), worth AUS$23 million, and the National Communications Fund (NCF), worth AUS$50 million. These funds jointly supported eight projects (National Broadband Strategy Implementation Group, 2005). By 2010, the health plans of the newly created Local Health Networks (LHNs) (Government of South Australia, 2010) began to refer to telehealth services. In the same year another Commonwealth program badged as Digital Regions provided AUS$2.5 million to the South Australian Digital Telehealth Network (DTN) to install about 100 new videoconferencing units connected through upgraded Telstra (a major telecommunications company) broadband services.3 By 2018, a survey of 1762 Australian GPs found that 87% were completely digital and maintained no paper records (RACGP, 2019). In comparison, an annual survey by the Brazilian Internet Steering Committee (Martinhão, 2017) of health facilities’ computer, internet and electronic health record use found that clinical information was maintained in an electronic format in 33% of public health facilities and in 61% of private health facilities.

 Schrader, G. (2013). An Evaluation of the Country Mental Health Digital Telehealth Network. Flinders University. Unpublished report. 3

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In contrast, the availability of ICT infrastructure in Brazilian healthcare facilities varies considerably according to geographic region. Catapan et al. (2020) estimate that in the northern region of Brazil, between 33% and 45% of primary healthcare facilities have a basic ICT system consisting of a computer and internet connection, compared with between 78% and 81% of units in the south of the country. Across the whole of Brazil, Catapan calculates that 68% of facilities have a computer, 60% have an internet connection and 24% have a camera attached to the computer. According to an annual randomised survey of 100 Brazilian health facilities (Martinhão, 2017), 35 had download speeds between 1 Mbps and 10 Mbps, 14 below 1 Mbps and 24 did not know their connection speed. Data from the same survey show that internet connectivity varies by state (São Paulo, 96%; Santa Caterina, 98%; Rio Grande do Sul, 85%). In Santa Catarina, the vast majority of primary health facilities are connected to the internet using asymmetric digital subscriber line (ADSL) technology with speeds less than 10 Mbps. ICTs, then, have played a dual role in shaping telehealth services. On the one hand, they are fundamental resources for enabling separated care; on the other hand, their availability has constrained the operation of telehealth services. How access to technology, human resources and financial resources shaped telehealth services in Australia and Brazil is considered in the next chapter.

References Access Economics. (2003). The economic impact of an accelerated rollout of broadband in hospitals. Australian Government. http://ict-­industry-­reports.com. au/wp-­content/uploads/sites/4/2013/10/2003-­Broadband-­in-­Hospitals-­ Economic-­Impact-­Access-­Economics-­DCITA.pdf Alonso, N., Massenburg, B. B., Galli, R., Sobrado, L., Birolini, D., Alonso, N., Massenburg, B. B., Galli, R., Sobrado, L., & Birolini, D. (2017). Surgery in Brazilian Health Care: Funding and Physician Distribution. Revista do Colégio Brasileiro de Cirurgiões, 44(2), 202–207. https://doi. org/10.1590/0100-­69912017002016

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AMA. (2018). AMA private health insurance report card 2018. https://ama.com. au/sites/default/files/documents/AMA%20Private%20Health%20 Insurance%20Report%20Card%202018_3.pdf Australian Bureau of Statistics. (2014). Australian population grid, 2011 [Map]. http://www.abs.gov.au/AUSSTATS/[email protected]/DetailsPage/1270.0.5 5.0072011?OpenDocument Australian Government Department of Health. (2018). General practice statistics. http://www.health.gov.au/internet/main/publishing.nsf/content/general +practice+statistics-­1 Australian Institute of Health and Welfare. (2016). Primary health care in Australia. AIHW. https://www.aihw.gov.au/reports/primary-­health-­care/ primary-­health-­care-­in-­australia/contents/about-­primary-­health-­care Australian Institute of Health and Welfare. (2017a). Health expenditure Australia 2015–16. AIHW. https://www.aihw.gov.au/reports/health-­ welfare-­e xpenditure/health-­e xpenditure-­a ustralia-­2 015-­1 6/contents/ dynamic-­data Australian Institute of Health and Welfare. (2017b). Hospital resources 2015–16. AIHW. https://www.aihw.gov.au/getmedia/d37a56cb-­ dc6b-­4b28-­a52f-­8e00f606ce67/21035.pdf.aspx?inline=true Boston Consulting Group. (2004). National health information management information & communications technology strategy. https://ozhealthithistory. wikispaces.com/file/view/Boston+Con+Gp+2004+Main+Report.pdf Bousquat, A., Giovanella, L., Fausto, M. C. R., Fusaro, E. R., de Mendonça, M. H. M., Gagno, J., & Viana, A. L. d’Ávila. (2017). Tipologia da estrutura das unidades básicas de saúde brasileiras: Os 5 R. Cadernos de Saúde Pública, 33(8). https://doi.org/10.1590/0102-­311x00037316 Brazilian Institute of Geography and Statistics. (2010). Densidade demográfica 2010 [Map]. BIGS. https://mapas.ibge.gov.br/tematicos/demografia Briggs, A. (2017). Private health insurance: A quick guide. Commonwealth of Australia. https://www.aph.gov.au/About_Parliament/Parliamentary_ Departments/Parliamentary_Library/pubs/rp/rp1718/Quick_Guides/ PrivateHealthInsurance Catapan, S. de C., Willemann, M. C. A., & Calvo, M. C. M. (2020). Estrutura e processo de trabalho para implantação da teleconsulta médica no Sistema Único de Saúde do Brasil, um estudo transversal com dados de 2017–2018. Epidemiol Serv Saúde, 21. https://doi.org/10.1590/s1679-­497420 21000100015

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Duckett, S. (2015). Medicare at middle age: Adapting a fundamentally good system. Australian Economic Review, 48(3), 290–297. https://doi. org/10.1111/1467-­8462.12120 Fiocruz. (2010). Saúde Amanhã [Interactive]. http://mapas.saudeamanha.icict. fiocruz.br/flx10sal.htm Fleury, S. (2014). Democracia e Inovação na Gestão Local da Saúde. In Fiocruz. https://portal.fiocruz.br/livro/democracia-­e -­i novacao-­n a-­g estao-­l ocal­da-­saude Government of South Australia. (2010). Mount Gambier 10 year local health service plan 2010–2019. http://www.sahealth.sa.gov.au/wps/ wcm/connect/public+content/sa+health+internet/health+reform/ strategy+for+country+health/priority+areas+of+the+country+health+strateg y/10+year+local+health+service+plans Gragnolati, M., Lindelow, M., & Couttolenc, B. (2013). Twenty years of health system reform in Brazil: An assessment of the sistema unico de saúde (No. 78682; pp. 1–131). The World Bank. http://documents.worldbank.org/curated/pt/909701468020377135/Twenty-­y ears-­o f-­h ealth-­ system-­reform-­in-­Brazil-­an-­assessment-­of-­the-­sistema-­unico-­de-­saude Knibbs, J. (2020). My health record vs telehealth: A government innovation and investment dilemma. The Medical Republic. http://medicalrepublic.com.au/ my-­health-­record-­vs-­telehealth-­a-­government-­innovation-­and-­investment-­ dilemma/33439 Martinhão, M. S. (2017). ICT in health survey on the use of information and communication technologies in Brazilian healthcare facilities. Brazilian Internet Steering Committee. http://cetic.br/media/docs/publicacoes/2/tic_ saude_2016_livro_eletronico.pdf Massuda, A., Hone, T., Leles, F. A. G., de Castro, M. C., & Atun, R. (2018). The Brazilian health system at crossroads: Progress, crisis and resilience. BMJ Global Health, 3(4), e000829. https://doi.org/10.1136/bmjgh-­2018-­000829 Ministério da Saúde. (2018). TabNet Win32 3.0: CNES – Estabelecimentos por Tipo – Brasil. http://tabnet.datasus.gov.br/cgi/deftohtm.exe?cnes/cnv/ estabbr.def Ministério da Saúde & Fundação Oswaldo Cruz. (2018). Contas do SUS na perspectiva da contabilidade internacional: Brasil, 2010–2014. http://bvsms. saude.gov.br/bvs/publicacoes/contas_SUS_perspectiva_contabilidade_internacional_2010_2014.pdf

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Ministério de Saúde. (2016). Plano Nacional de Saúde 2016–2019. Ministério da Saúde. http://conselho.saude.gov.br/ultimas_noticias/2016/docs/planonacionalsaude_2016_2019.pdf National Broadband Strategy Implementation Group. (2005). Broadband connectivity in the health sector. Commonwealth of Australia. National Health Information Management Advisory Council. (2001). Health online: A health information action plan for Australia 2. Commonwealth of Australia. https://ozhealthithistory.wikispaces.com/file/view/actionp_2. pdf/182746001/actionp_2.pdf National Office for the Information Economy. (2002). Broadband in health: Drivers, impediments and benefits. Commonwealth of Australia. Organisation for Economic Cooperation and Development. (2018). Brazil – Basic socioeconomic indicators. https://www.oecd.org/regional/regional-­ policy/profile-­Brazil.pdf Queensland Audit Office. (2018). Digitising public hospitals (No. 10). https:// www.qao.qld.gov.au/reports-­parliament/digitising-­public-­hospitals RACGP. (2019). RACGP technology survey. RACGP. https://www.racgp.org.au/ FSDEDEV/media/documents/Running%20a%20practice/Technology/ Member%20engagement/RACGP-­Technology-­Survey-­2 018-­r esults-­ updated.pdf Ribas, L. (2017). Teledermatologia em Florianópolis completa um ano de implantação com resultados positivos. http://site.telemedicina.ufsc.br/ teledermatologia-­e m-­f lorianopolis-­c ompleta-­u m-­a no-­d e-­i mplantacao-­ com-­resultados-­positivos/ Rodrigues, J. C. (2015). Conta-Satélite de Saúde 2010–2015: Em 2015, 9,1% do PIB foram gastos no consumo de bens e serviços de saúde. https://agenciadenoticias.ibge.gov.br/agencia-­s ala-­d e-­i mprensa/2013-­a gencia-­d e-­n oticias/ releases/18915-­conta-­satelite-­de-­saude-­release Santos, T.  R., Penm, J., Baldoni, A.  O., Ayres, L.  R., Moles, R., & Sanches, C. (2018). Hospital pharmacy workforce in Brazil. Human Resources for Health, 16. https://doi.org/10.1186/s12960-­017-­0265-­5 Scheffer, M. (2018). Demografia Médica no Brasil 2018. Conselho Federal da Medicina. https://portal.cfm.org.br/index.php?option=com_content&view =article&id=27509:2018-­03-­21-­19-­29-­36&catid=3 Swerissen, H., Duckett, S., & Moran, G. (2018). Mapping primary care in Australia (Grattan Institute Report No. 2018–09). https://grattan.edu.au/ wp-­content/uploads/2018/07/906-­Mapping-­primary-­care.pdf

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Von Wangenheim, A., & Nunes, D. H. (2018). Direct impact on costs of the teledermatology-centered patient triage in the State of Santa Catarina analysis of the 2014–2018 data. Instituto Nacional para Convergência Digital. https://doi.org/10.13140/RG.2.2.20044.92807 World Health Organisation. (2018). Global health expenditure database. https:// apps.who.int/nha/database

5 Telehealth Services in Australia and Brazil

Abstract  This chapter provides a historical view of the development of telehealth services. Though it has not always been sustained, the majority of these services have received government funding. Throughout Australia and Brazil, I interviewed health professionals about the telehealth services with which they were involved. Telehealth services in both countries support regional health professionals. In Australia, prior to the pandemic, telehealth services were almost synonymous with video conferencing-based consultations between hospital-­based specialists and patients in regional areas. In Brazil, telehealth services explicitly aimed at supporting the primary healthcare of patients in any location through synchronous and asynchronous advice services between specialists and practitioners, thereby supporting patients in family health centres and basic health clinics. Prior to the pandemic, many health professionals involved in telehealth services felt these services were routine, although not yet fully part of normal practice. In the previous chapter I outlined how the health systems of Australia and Brazil provide the organisational contexts for telehealth services in these countries. Telehealth services developed in different ways in each country but have a common purpose to improve access to healthcare. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 A. Taylor, Healthcare Technology in Context, https://doi.org/10.1007/978-981-16-4075-9_5

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During my research for this book, I spent more than 12 months during 2017 and 2018 in the Australian states of South Australia and Queensland and the Brazilian states of São Paulo, Santa Catarina and Rio Grande do Sul. During this time, I interviewed a total of 135 health professionals about the telehealth services in which they were involved. It became clear to me that the provision of universal healthcare is a fundamental principle supported by everyone I spoke to. As I outlined in Chap. 4, in both Australia and Brazil, health service provision is defined by state boundaries, regional catchments, municipal boundaries, hospital localities or geographic regions, and access to care is in part determined by place of residence. Inhabitants of highly populated costal and metropolitan areas have greater access to healthcare than do regional or rural inhabitants. Stratification of incomes meant that those who could afford private health insurance could buy more timely access to healthcare, including telehealth services. In both countries the uneven health workforce distribution, particularly of specialists who mainly work in metropolitan areas, forces residents outside those areas to travel long distances to access health facilities. This is most evident in Brazil where I saw fleets of buses from regional areas arrive at city hospitals each day. I learnt that in both countries, the development of telehealth services has been marked by periods of strong federal or state government support, which has not always been sustained. Despite these fluctuating levels of support, the motivating vision for health professionals involved in telehealth services was the need to support their regional colleagues and their patients. During my interviews with health professionals, I was told that over the last 30 years the development of telehealth services has passed through several phases, often marked by significant events influencing the way they operate. The following sections will chart some of these influences.

5.1 Contrasting Contexts, Different Services Australia and Brazil now have well-developed but contrasting telehealth services. While telehealth services in both countries grew out of the need to support the professional development of regional health professionals, there are some clear differences between Australian and Brazilian telehealth services. Until the COVID-19 pandemic, Australian services were almost

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synonymous with videoconferencing-based consultations between hospital-based specialists and patients in regional areas. In Australia, educational use for professional development dominated initially, followed by administrative meetings and clinical use (Kennedy et al., 2001). Subsequently, educational use has proportionately declined, while clinical use has greatly increased. Before the pandemic, telephone-based services were focused on providing advice directly to the public. Asynchronous services for regional populations were either slow to develop or existed under the banner of eHealth services exchanging diagnostic information between clinicians. In Australia, telehealth services are largely promoted by the federal government and the eight state or territory governments, six of which are shown in Fig. 5.1. The unlabelled state of Tasmania is the island to the

Fig. 5.1  Map of Australian states and territories (the island state of Tasmania, is located south of Victoria. Canberra, the national capital, is also a territory under the Australian Constitution)

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south of the mainland, and the capital of Australia, Canberra, is a territory. The federal government funds telehealth services subsidised under the MBS. States fund video consultations within their public hospital systems, using procedure-based funding frameworks. Primary healthcare network organisations exist which may not directly provide telehealth services but invest in infrastructure and support. As I mentioned in Chap. 4, per capita health expenditure in Brazil is lower than in Australia, and private sector expenditure on health accounts for a greater proportion than in Australia. This places particular limitations on the ability of patients to access the Brazilian public health system. Additionally, the comparatively lower level of health expenditure in Brazil has delayed growth in the use of information and communications in healthcare, including electronic medical records and telehealth services. In Brazil, professional development of the health workforce was also an initial focus for telehealth services. The Federal Government funded an educational network operated by higher education institutions that supports national discussion groups (Special Interest Groups [SIGs]) and the online open health university (UNA-SUS). Telehealth centres funded by the Federal Government that were operating in 24 of the 26 states in 2017 are shown in Fig. 5.2. Some state governments contribute to the operation of these centres, but municipalities do not generally fund, or are unable to directly fund, telehealth services. At the level of Brazilian states, many telehealth centres draw on a range of federal, state and philanthropic funding to provide telehealth services from state capitals into each municipality. In the states that I visited, telehealth centres operate in Rio Grande do Sul and in Santa Catarina. There is also one telehealth centre that covers the city of São Paulo, while a second covers the state. In Brazil, telehealth centres explicitly aim to support the primary healthcare of patients in any location, through synchronous and asynchronous advice services between specialists and primary health practitioners managing patients in family health centres and basic health clinics. Videoconferencing is the technical medium of choice, and asynchronous services support exchange of diagnostic information between health professionals. Prior to the COVID-19 pandemic, in both Australia and Brazil, telehealth services were not operating at a sufficient volume to contribute a

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Fig. 5.2  Map of Brazilian states

significant proportion of health service activity. For instance, in Australia, in Queensland and South Australia, non-admitted patient events were about 1.2 events per capita in 2016–2017 (Australian Institute of Health and Welfare, 2018) which is significantly greater than telehealth events during this period. Table  5.1 shows that telehealth service volumes (mainly comprising non-admitted patients) in four of the states I visited across Australia and Brazil represented a small percentage of healthcare activities on a per capita basis, although annual growth rates ranged from 17% p.a. to 35% p.a. prior to the pandemic.

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Table 5.1   Telehealth service volumes by state in 2018

State Queensland South Australia Rio Grande do Sul Rio Grande do Sul Santa Catarina Santa Catarina

Telehealth events per capita

Growth rate 2015 to 2018 (%)

Services commenced

Service modality

1998 1998

Videoconferencing 0.028 Videoconferencing 0.007

35.0 28.0

2008

Second opinion

0.003

22.0

2013

Diagnostics

0.001

21.0

2007

Second opinion

0.003a

–

2005

Diagnostics

0.131

17.0

Author’s estimates are based on unpublished documents collected during field research as well as publications (including Australian Department of Human Services, 2019; Gray, 2019; Telessaúde-UFRGS, 2021; Telessaude-UFSC, 2017; Umpierre, 2019) a Incomplete or limited data available

When I discussed this issue during my interviews, a Brazilian telehealth coordinator estimated: Today, Rio Grande do Sul has 10 million people living there. We have 10 million inhabitants, so we estimate that annually we’re going to have something like 20 million, 25 million primary care consultations. More or less, in Brazil today, we offer 2 to 2.5 consultations per inhabitant per year. It is a very low value. In a year, for teleconsultorias, as I recall there are about 50 thousand teleconsultorias for Rio Grande do Sul … so that’s going to be 0.2% or so. (Emanuel, Telehealth coordinator)

An Australian hospital-based telehealth service in Queensland, experiencing high rates of growth, reported that in their catchment area there were “around 800,000 outpatient consultations in a single year and we delivered just under 4,000 via telehealth. So the ratio is still very small … and out of those 800,000 many of them wouldn’t ever be appropriate for telehealth” (Jacob, Telehealth coordinator). However, individual clinical services achieved higher utilisation rates. A radiation oncologist reported that “referrals come in from all areas. But I think it’s probably somewhere around

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15 to 20%” (Sebastian, Radiation Oncologist). Ultimately, utilisation was felt to be limited by the available funding: “during the last 4 years we have not been able to grow because we do not have the financial support. We were growing at about 80% per year” (Emanuel, Telehealth coordinator).

5.2 Evolution of Telehealth in Australia Prior to the COVID-19 pandemic, telehealth service development in Australia can be traced through several distinct phases, summarised in Fig. 5.3. These phases can be roughly classified and marked by reports, legislation, changes to funding rules and commencement of projects, including: • Pilot projects in several states aiming to improve access to healthcare for regional populations (1995–2000); • Development of a national plan for telehealth services (1998–2000) by the Australian and New Zealand Telehealth Committee (ANZTC);

Fig. 5.3  Development of Australian telehealth services

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• Disbandment of the ANZTC in 2001; • Prioritisation of health information systems over telehealth service development (2002 ongoing); • Building communications infrastructure able to support telehealth services (2000–2009); • National accreditation of health practitioners in 20101; • Initiation of the National Broadband Network (NBN) and national telehealth pilot projects using the NBN following the election of a new government in 2007 (2012–2014); • Improvement of national broadband capacity through construction of the NBN; • Health and hospitals reform commenced (2010), devolving control of health services to regional, locally controlled bodies; • Creation of funding items under the MBS for a limited range of consultations (2011 ongoing) in regional Australia; • Gradual addition of funding items under the MBS in response to specific events such as the widespread bushfires in 2020, when telehealth items for mental health consultations were added; and • Publication of a national strategic plan for digital health by the ADHA in 2018, calling for “widening access to telehealth services, especially in rural and remote Australia” (Australian Digital Health Agency, 2018, p.  6), although it remains to be seen what concrete actions will be taken. Telehealth services first attracted significant national attention when, in 1995, the Australian Federal Department of Human Services and Health produced a report known as the Project for Rural Health Communications and Information Technology (PRHCIT). That report argued for greater support for regional health professionals using technology (Australian Rural Health Research Institute, 1996). Subsequently, interest in telehealth at the federal government level declined, and at the beginning of this century, the Australian Federal Government was criticised for:  Prior to 2010 Australian practitioner registration was state based, therefore requiring telehealth service providers to obtain several registrations (Australian Government Department of Health; Health Workforce Division, 2019). 1

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[taking a] back seat in the telehealth process, and is perhaps best described as a rather cold, distant parent that is uninterested in its telehealth baby. As such, it has not adequately resourced the National Telehealth Committee, has not provided any support despite requests for the development of professional national bodies in telehealth, has made few attempts to integrate the various state programs, and has pursued a deliberately slow policy on the creation of Medicare Benefit Schedule (MBS) item numbers for reimbursement for telehealth. (Yellowlees, 2001, p. S2:30)

As early as 1998, a report commissioned by the Australian Federal Department of Industry, Science and Technology warned that the lack of a national approach to telemedicine meant that: Telemedicine is currently a fragmented, immature industry in Australia. If it is to develop and to influence the delivery of health care services in Australia, and to live up to its potential, it will need to be integrated with mainstream IT in health care. (Mitchell, 1998, p. 5)

In 2001, the Australian and New Zealand Telehealth Committee (ANZTC) presented a national plan. The plan argued for promotion of telehealth services within the health workforce; encouragement of greater consumer involvement; provision of predictable funding; development of clinical, national and international standards; and responding to gaps in the telecommunications infrastructure (Australian National Telehealth Committee, 2002). Surprisingly, in 2001, the ANZTC was disbanded (National Health Information Management Advisory Council, 2001). Only in 2011 did a replacement body emerge in the shape of the National Telehealth Advisory Committee. In 2010, a new government commenced structural reform of the health system. Hospitals were decentralised from state control into local, geographically based hospital networks run by boards consisting of locally based members appointed by state governments. Primary healthcare providers were grouped into similar networks. For telehealth services the major impact has been on states which previously ran state-wide telehealth service. These have now been placed under the control of local hospital networks.

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In 2007, a new Australian Labor government under the then Prime Minister, Kevin Rudd, promised to build the NBN based on an optical fibre telecommunications network. The NBN was planned to provide broadband access to 93% of the Australian population at 100 Mbit/s, with rural areas to be provided broadband access through fixed wireless and satellite. Construction began in Tasmania in 2010 and was largely completed by 2020. In order to establish the potential of telehealth services on the NBN, the Department of Health and Ageing in cooperation with the Department of Broadband, Communications and the Arts initiated a AUS$20.6 million NBN Telehealth Pilots Program in 2012 (Australian Department of Health and Ageing, 2012). Nine projects were established across the country where early roll-out of the NBN was anticipated. These projects aimed to develop and deliver telehealth services to broadband-enabled homes with a focus on aged, palliative or cancer care services, including advance care planning. Unfortunately, although several articles have been published (e.g., Banbury et al., 2014; Celler et al., 2014; Crotty et al., 2014), reports of these projects are not publicly available. In 2009, the National Health and Hospitals Reform Commission made copious recommendations to fund telehealth services, such as “email, telephone, telehealth (e.g., video conference) – that do not involve physical presence of patient. Payment for these services may be part of episodic payment or grant payments” (Department of Health and Ageing, 2009, sec. 4.3.1). Subsequently, only a limited number of videoconferencing-­ based services were funded. Prior to the COVID-19 pandemic, the Australian Federal Government limited support for telehealth services to a selective range of payments to specialists and GPs for video-based consultations as part of the MBS. Between 2012 and 2019, these telehealth MBS items were subject to only minor adjustments, but as Fig. 5.4 demonstrates, use of these items steadily increased during this period. In this chapter I focus on the Australian state of Queensland, but there are other Australian states that have deployed significant telehealth services in the public sector. In New South Wales a variety of telehealth services provide aged care, chronic disease, mental health, wound management, renal, critical, pain, palliative, cardiology, neurology, paediatrics, haematology,

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MBS funded telehealth consultaons

250,000

200,000

150,000

100,000

50,000

0

2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2017-18 2018-19

Fig. 5.4  Australian MBS-funded telehealth consultations, 2013–2019. (Derived from Services Australia, 2020)

rehabilitations, dermatology and several other. In addition to servicing clinical needs, videoconferencing supports administrative support, supervision, education and mentoring. The greatest use of telehealth has been in the Western Sydney, Northern New South Wales, Hunter New England and Mid North Coast regions (NSW Ministry of Health, 2015). In 2020, NSW Health saw significant growth in the use of technology to support virtual care across all telehealth modalities. In response to the pandemic, COVID-19 focused communities of practice and a new multiagency unit were established to ensure patients have full access to the best telehealth-­enabled models of care. An enhanced videoconferencing platform now supports specialist outpatient care, and a target for local health districts of delivering 10% of non-admitted patient activity through virtual care has been set (McDonald, 2020). In the Northern Territory, telehealth services are structured into seven service domains including critical care focusing on quality and timely

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access for remote patients; specialist clinics to improve logistics and access to ambulatory care; clinical education, training, clinical supervision and procedural support; case management for multidisciplinary interventions; inpatient access to specialists; family support for patients and virtual visits; and sonography real-time connections to specialists for diagnosis (Northern Territory Government, 2019). South Australia hosted some of the earliest telehealth services in Australia. With a total land area of 983,482 square kilometres and a population of 1.7 million people, South Australia has the most centralised population of any Australian state. Since 1991, teleradiology and teleultrasound services have been available in several regional centres. By 1994, telerenal dialysis were operating from the Queen Elizabeth Hospital in Adelaide (JMA, 1995). Telepsychiatry services, education and training from Glenside Hospital in Adelaide commenced in 1994 (JMA, 1994). Initially the psychiatry service operated as a centrally driven service, but is was soon realised that “a fundamental shift was required, to a system that was responsive to rural health professionals, including emergency clinical assessments, rather than a service that was initiated from the city” (Kavanagh & Hawker, 2001). In 2010, the Federal Government funded the South Australian DTN mentioned earlier in this chapter. The DTN provided South Australia with a broadband network linking health facilities similar to the one established earlier in Queensland. The rationale for the DTN came from the SA Mental Health Act of 2010. This act requires a psychiatrist to review an involuntary treatment order within 24 hours of a GP making that order. Once this has been done, the patient may be admitted to a psychiatric unit in Adelaide. Using videoconferencing, an Adelaide-based psychiatrist can review the patients while they are still located in the country, thus avoiding the need to transport the patient (Bidargaddi et  al., 2015). The DTN also supports cancer care nursing, oncology reviews, respiratory care, renal care nursing, palliative care and rehabilitation and the linking of doctors with patients and their local nurses in country emergency departments. Another South Australian beneficiary of Federal Government funding was the Flinders University Telehealth in the Home trial for which I was the project manager between 2013 and 2015. Funded by the NBN

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Telehealth Pilots Program, this trial investigated the use of technology to support rehabilitation, aged and palliative care patients based on a team approach that integrates the patient, carer, GP or primary healthcare provider, aged care facility and specialist services. Subsequently a state-wide telerehabilitation service was established (Crotty et al., 2014; Leverington & Bassa, 2019). Tasmania experienced a significant surge in demand for telehealth services with the onset of the COVID-19 pandemic in 2020, with a 1200% increase from March to June, although usage has since reduced as the pandemic has been controlled. There was a significant increase in the use of telehealth services for outpatient services across the state and an uptake in specialities that had not previously used telehealth. Allied health services have been keen adopters and use telehealth across a number of disciplines. Telehealth services expanded into other settings, including antenatal classes, cardiac rehabilitation programs, telerehabilitation, prehabilitation for cardiothoracic surgery, hospital in the Home services, mental health Hospital in the Home services, remote monitoring for quarantine hotels, virtual ward rounds and virtual clinical support to district hospitals. Telehealth use in Victoria has grown significantly in the past four to five years (2015–2020), with funding from the Department of Health and Human Services targeting particular aspects of care, including stroke telemedicine, access to specialist clinics and various aspects of at-home care. In Victoria, telehealth activity spans clinician video consulting, including multidisciplinary care both within and between health services; store-and-forward diagnostic services; emergency and urgent care via video, primarily clinician-clinician support. This includes support from retrieval services and regional tertiary hospitals and support from specialist centres such as the Royal Children’s Hospital, The Alfred Hospital and the Victorian Stroke Telemedicine Program; remote patient monitoring is used for chronic disease management, and increasingly to support hospital avoidance and at-home care, and clinical support and education. In Western Australia (WA), video conference and telephone services support access to care closer to home in emergency, inpatient, outpatient and community settings across a variety of conditions and specialties including asthma, diabetes, antenatal, plastic surgery, orthopaedics,

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haematology, gastroenterology and respiratory medicine. The WA Country Health Service (WACHS) developed emergency telehealth support for clinicians in small rural towns, introducing the Emergency Telehealth Service in 2012, providing rural doctors and nurses in 58 regional emergency departments with 7-day-a-week access to emergency specialists via telehealth. In 2019, WACHS brought together emergency and specialty services in a 24/7 virtual clinical hub including emergency mental health services for 85 regional locations. The COVID-19 pandemic saw a rapid shift to telehealth at a time when people were required to stay at home or physically distance. Between March and June 2020, there was a 200% increase in medical specialist outpatient appointments for people at home or in a health facility. Among the people I interviewed in Queensland and South Australia there was a recognition of the progress made in developing telehealth services, although some were more cautious in their assessments; “I think although we’re not there yet, I think in the last 17 years we’ve moved away from telemedicine or telehealth being seen as something special, nice to do, quite unique” (Owen, Researcher). The overwhelming sentiment of the health professionals I met who were involved with long-standing telehealth services, particularly in Australia, was that services were routine. However, opinions on the extent to which services were a normal healthcare practice were generally more cautious. Austin, a telehealth manager, summarised this sentiment: I would consider us a maturing program. I wouldn’t consider us a mature program but we have managed to get telehealth embedded into a very broad range of specialties. Is it embedded. No, not yet but it’s well on the way. It’s embedded in many locations but it’s not embedded right across the state. (Austin, Telehealth manager)

Where possible, I asked health professionals participating in my research, “Now telehealth services have been operating for some time, are they seen as routine, or still perceived as risky? Why?” Twenty-seven Australian participants responded to this question, with smaller numbers also elaborating on whether services were normal (n = 17). Participants placed the following meanings on these terms: routine, where there was

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Table 5.2   Were Australian telehealth services routine or normal? (N = 44) Assessmentsa

Fully (%)

Partially (%)

Not yet (%)

Routine (n = 27) Normal (n = 17)

58 85

26 10

18 5

a

Participants made assessments of whether telehealth services were routine or normalised. More than one assessment was possible, so percentages may not add up to 100%

regular use of telehealth services within their organisation; and normal, where telehealth services were seen as ordinary care and a readily available healthcare delivery mode. Table  5.2 breaks down interviewees’ assessments according to the extent that services were considered fully, partially or not yet routine or normal. Many Australian participants who felt that telehealth services were part of normal practice had been practising using telehealth services for many years and reported that their telehealth service “hasn’t changed in the last 10 years. We still are referred by somebody else, by another specialist usually” (Maya, Endocrinologist); a South Australian psychiatrist recalled that they “joined Country Health in 2011 and that [telehealth] is actually something which works.… Yeah. It’s just part of our repertoire” (Henry, Mental health specialist). A private specialist who had built a practice using telehealth services told me: I’ve built up a large practice … and it also links it to our Endocrine training in Flinders Medical Centre here in South Australia. So we actually do eight lists in the space of 2 days. It’s very high speed. We’re a bit buggered.… Personally I love it. It’s improved my life and I think it’s improved the quality of the service delivery … I don’t have a nurse or anyone in the room with me it’s just as if I were doing an ordinary consultation. (Ethan, Endocrinologist)

5.3 Evolution of Telehealth in Brazil Prior to the COVID-19 pandemic, telehealth service development in Brazil can be traced through several distinct phases, summarised in Fig. 5.5. These phases can be roughly classified and marked by legislation, funding changes and commencement of programs, including:

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Fig. 5.5  Development of Brazilian telehealth services

• Creation of a Ministry of Health Working Group on telehealth; • Pilot projects in several states aiming to improve access to healthcare for regional populations (2000–2006); • Growth of several state-based telehealth services (2004–2006); • The pilot stage of the Brazilian Telehealth Networks Program by the Brazilian Ministry of Health (2007–2011) and the Open Health University from 2008; • Integration of the National Telehealth Networks Program with the Primary Health Program (2011 ongoing); • In 2009, telehealth services were restricted by regulations from the Brazilian Federal Medical Council to the provision of second opinion services with no direct patient consultations. Telediagnostic services were permitted with some restrictions from 2009 onwards; • Expansion of the Brazilian Telehealth Networks Program to include telehealth centres in the majority of states (2011–2015);

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• Increased use of referral regulations requiring primary care doctors to consult specialists prior to referral of patients using teleadvice services operating from state-based telehealth centres (2015 ongoing); and • Budgetary restrictions were placed on health and telehealth services as part of national austerity measures (2015 ongoing). Initial interest in telehealth was coordinated by a Ministry of Health working group in 2000 (Angélica Baptista Silva et al., 2020). This was followed by pilot projects in the states of Amazonas, Belo Horizonte, Minas Gerais, Maranhão, São Paulo, Mato Grosso, Santa Catarina (teleradiology) and Rio Grande do Sul (Medeiros, 2009). In 2007, after extensive national discussions, the Brazilian Ministry of Health provided funding to nine universities to establish Telehealth Centres (subsequently increasing to 12 universities) as part of a national telehealth pilot. In 2001, this pilot was renamed the Brazilian Telehealth Networks Program (Angélica Batista Silva, 2014) providing teleconsulting, telediagnosis and provision of second opinions. In the Brazilian context, where computing and internet connectivity may vary between regions, as I outlined in Chap. 4, teleconsultation does not generally take place in real time or use videoconferencing. There is an asynchronous second opinion advice or diagnostic service available online or by telephone to all health workers for medical, management and patient referral matters. Brazilian telehealth services have the following components (Harzheim et al., 2018): • Inter-professional teleconsulting: responding to questions from primary care workers about a clinical case, procedure or decision. • Telediagnosis: reporting for cardiology and radiology. • Teleeducation: professional training for health professionals and primary care workers. • Second opinions (teleadvice): providing and generating good-quality, evidence-based practice useful to primary care workers. The initial phase of these services was driven by educational objectives. By 2010, the university and hospital-based Brazilian University Telemedicine Network (RUTE) project had points of presence in 19 federal and state university hospitals (Silva, 2014). As of 2018, the National

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Telehealth University Network had 133 points of presence in all 26 Brazilian states and work continues to improve the physical connectivity of the network in many states. SIGs use this network to hold regular discussions using videoconferencing specialities involving both academic staff and students. RUTE now supports more than 57 SIGs in many medical specialities and other topics with the participation of 3176 health professionals in 2016 (Lima Verde Brito, 2016). At the state level, some “specialist” telehealth services have developed, such as teleultrasound in Espírito Santo (Messina & Filho, 2013), paediatric cardiology in northeast Brazil (Mattos et  al., 2015) and stomatherapy in Rio de Janeiro (Monteiro & Neves, 2015). Between 2007 and 2012, the Virtual Health Library (BVS) and Virtual Health Campus online resources for the open university in health (UNA-­ SUS) were developed to support the family health program (Haddad, 2012). UNA-SUS is a collaborative network of 25 tertiary education institutions. Courses are designed and updated to be relevant to solving current health issues. Students can choose courses based on their experience and interests and can enrol at any time in their careers. Educational material is available as text, audio, video or e-books on computers or mobile devices. In 2011, a tripartite commission comprising representatives from Federal Government, the states and municipal governments was established to manage the Brazilian Telehealth Networks Program (Ministério da Saúde, 2011a). Several pieces of Federal Government legislation required telehealth centres to: • be responsible for teleadvice services, telediagnostics and second opinion services; • create and maintain a team of specialists to respond to issues raised in teleadvice; • promote the training of specialists providing teleadvice; • provide annual activity reports to the Ministry of Health; • comply with and support interoperability of systems (separate legislation; Ministério da Saúde, 2011b) and establish protocols to be used to implement interoperability between electronic health information systems across the public and private health sectors);

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• promote the development of protocols supporting the triaging of patients requiring referrals to secondary and tertiary care centres or emergency treatment; • evaluate the performance of teleadvice services in order to improve the experience of patients; and • develop education programs relevant to regional needs and national health priorities. The Brazilian Federal Government has provided block funding for state-based telehealth services supporting primary care and makes some volume-based payments to municipalities for diagnostic services. While a formal national strategy document for Brazilian telehealth services is lacking, a significant publication—A Telehealth Manual for Primary Health Care (Ministério da Saúde & Universidade Federal do Rio Grande do Sul, 2012)—provides a comprehensive, national guide to the organisation, activities and referral processes for teleadvice and management of telehealth centres. Some states incorporate telehealth services into state healthcare strategies (Governo do Estado do Rio Grande do Sul, 2017). The possible extent of national government support for the Brazilian Telehealth Networks program following the pandemic is unclear given that prior to 2015 there was significant federal backing (Haddad et al., 2016), but that support diminished with changes of government. According to Maldonado and colleagues (2016): [the] organisation and regulation of telemedicine in Brazil is generally fragmented, characterised by diverse laws, decrees, regulations, standards, instructions, protocols, resolutions and codes from different organisations with distinct interests. (Maldonado et al., 2016, p. S8, author’s translation)

Prior to the pandemic, Brazilian telehealth was regulated by the Federal Medical Council (CFM) whose regulations effectively limit the practice of telehealth because direct doctor-to-patient teleconsultations are prohibited, although these regulations did not have the full status of government legislation (Botrugno et al., 2019), and diagnostic reporting services are permitted. The CFM first defined telehealth in Brazil in 2002 (Federal Medical Council, 2002). Subsequently, several regulatory instruments

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adjusted the scope of application of telehealth technologies, including the prohibition of direct consultations with patients using technology such as videoconferencing in 2009 (Federal Medical Council, 2009). Some of these restrictions have been liberalised, with the use of messaging technologies between doctors becoming allowable. Reform proposals in late 2018 from the CFM for more extensive liberalisation of the use of communications technologies in patient care proved controversial (Federal Medical Council, 2018), and in 2019, these regulations were revoked, marking a return to the previous restrictive rules. Other professional bodies, such as the psychology or nursing councils, issue their own regulations to members. As a consequence, psychologists have been able to provide consultations directly to patients. Despite these difficulties, Catapan et al. (2020) estimated that 61% of Brazil’s 33,000 family health teams use some form of telehealth service. Two of the Brazilian states that I visited, Santa Catarina and Rio Grande do Sul, ran high-volume synchronous and asynchronous advice, education and telediagnostic services. These services were aimed at primary care practitioners and were funded by a mix of federal, state, research and philanthropic health organisations. São Paulo, while it is the most populous and richest state in Brazil, has been slow to develop telehealth centres and has yet to achieve large service volumes. Many telehealth centres offer specialist services, radiology reporting (4), cardiology and electrocardiograms (8), teleophthalmology (2), telestomatology (3), telerespiratory (2) and teledermatology (3). All offered teleadvice and education services and were connected to the RUTE network: eight centres were active in creating formative second opinions and five centres were linking telehealth services to a triaging process to reduce waiting lists. In this chapter I focus on the Brazilian state of Santa Catarina, but other Brazilian states provided significant telehealth services from telehealth centres operating under the Brazilian Telehealth Networks Program. In the Amazon region, satellite-based ICTs play a key role in delivering health and education services due to the lack of terrestrial communications and the high costs and delays associated with air and water transport. The State University of the Amazon first established a telehealth node in Manaus, the capital, during 2004, which services more than 60 isolated primary health facilities. Teleconsultations, second

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opinions and online courses were provided asynchronously through a web portal, supplemented by an internet-based television channel. More than 500 of the 800 municipalities had access to the services of the centre. The state of Maranhão is the eighth largest state in Brazil. Telehealth activities began in October 2006. Activities undertaken by the centre included live surgery transmissions, teleadvice, formative second opinions and online courses. The centre provided support to 271 facilities in 47 municipalities using a custom software platform. The Mato Grosso do Sul Telehealth Centre was established in 2007 as part of the National Telehealth University Network (RUTE). Activities undertaken included teleadvice, formative second opinions, support for the national electronic primary health record, online courses and teledentistry. In the neighbouring state of Mato Grosso, the telehealth centre established in 2009 was not able to offer teleadvice until 2013 due to delays in funding. Funding issues were partially overcome through a partnership between the state health department, the Fundação Uniselva and the Hospital Universitário Júlio Müller in 2015. Financing for teleadvice was limited, so a partnership with the hospital university allowed professionals to work part-time in the centre. Activities undertaken by the centre include teleadvice, formative second opinions, online courses using web conferencing and telediagnostics providing reports on electrocardiograms for 15 municipalities as of 2017, leading to a 50% reduction in waiting lists. Minas Gerais is larger than the Australian state of Victoria but smaller than New South Wales. It has a population of about 20 million people. Following an early initiative funded by the European Union, the Minas Gerais Telehealth Centre was founded in 2005 through a partnership between six universities and the Hospital Clinicas in the capital city of the state, Belo Horizonte, which was linked to the Federal University of Minas Gerais. The centre was funded by state and federal governments and other agencies to service almost all of the 853 municipalities in the state. A telecardiology project based on remote electrocardiogram examination started in 2007, and usage increased steadily. The telediagnostics services provide ECG exams (30,000–50,000 per month), retinal, Holter and arterial pressure exams. The volume of teleadvice during 2017 and 2018 varied between 700 and 2400 per month, and 74% of patients supported by teleadvice were treated in the primary health facility and not

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referred further in the health system. In a recent quality review of telehealth services in Minas Gerais based on the ISO quality guidelines for telehealth services, Dramos et  al. (2021) found that just over 50% of municipalities in the state provided high-quality telehealth services although the availability of a skilled workforce and infrastructure remained a problem. In the state of Pernambuco there were two telehealth centres based in the capital, Recife. Telessaúde Pernambuco provides teleadvice, telecardiology, teleeducation and intra-hospital videoconferencing between six hospitals. The second centre, Rede de Núcleos de Telessaúde, has been running since 2003 and works with two other university-based telehealth centres in the state to provide teleadvice, telecardiology and teleeducation. In the state of Rio Grande do Sul telehealth services commenced with a pilot in the year 2000 between local partners and European Union providing videoconferencing over broadband links with 8 hospitals. The state telehealth centre, Telessaúde-UFRGS which I visited during 2028, was initially funded by the Ministry of Health in 2007. By 2016, the state telehealth centre employed 190 professionals operating across the state (Messina & Filho, 2013) to deliver telediagnostic reporting, teleadvice and education support for primary health professionals. Teleadvice was provided by telephone advice lines using a free 0800 number and a web-based interactive platform, developed using open source software. The centre also supported implementation of a national electronic record for primary healthcare. Distance education formed a major part of the work of the telehealth centre. As of 2016, more than 28 online courses were available for users throughout Brazil (Harzheim et  al., 2016). Telessaúde-UFRGS runs four telediagnostic services (Umpierre, 2019): • DermatoNet which enables doctors in five regional hubs to take photos of skin lesions via the online platform, or a mobile phone and camera application, and forward these using an associated information system for reporting by dermatologists who advise on treatment and referral options (Estado do Rio Grande do Sul, 2017). • An oral medicine (Stomatology) diagnostic service, in which clinicians are able to send photos via an online service or mobile phone applications to specialists for diagnosis and suggestions.

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• A respiratory medicine (RespiraNet) service for chronic respiratory illnesses. The service deployed telediagnostics services for respiratory examinations in 2013 in the municipality of Santa Rosa, which was extended state-wide in 2014 through a partnership between the State Health Department and the Hospital de Clínicas de Porto Alegre. • A teleophthalmology service which provides optometry, ocular pressure and fundus examinations in regional cities. The service was based on a public-private partnership between TelessaúdeRS-UFRGS, the state health department and the Moinhos de Vento Hospital. Ophthalmology units in regional centres are linked through live video feeds and a specialised electronic record to a diagnostic centre in Telessaúde-­ UFRGS.  Ophthalmologists work with nurses in each of the distant centres to test the eyesight of patients and take fundus photos which are diagnostically reported to the referring primary care doctor. An important part of the telehealth program in Rio Grande do Sul is a referral service called RegulaSUS.  This program aimed to reduce the waiting time for patients referred from primary healthcare for specialist treatment. A large number of these referrals arise because health professionals lack the experience and knowledge to manage patients locally. RegulaSUS has developed and published about 200 clinical management protocols to triage patients according to a risk profile and support care at the primary healthcare level. Medical professionals working for RegulaSUS apply these protocols to patients on the waiting lists and discuss patient management and referral options with the primary care physician. The specialities targeted by these protocols include endocrinology, nephrology, pulmonary medicine, oral medicine, urology, neurology, neurosurgery, rheumatology, thoracic surgery, gynaecology and infectious diseases (Harzheim et al., 2016). The state of São Paulo, which I visited in 2018, is one of the most affluent states in Brazil with a high concentration of medical facilities, but it was slow to develop telehealth services. Telehealth services in São Paulo originated from interdisciplinary health informatics research activities through a collaboration between the Federal University of São Paulo (UNIFESP) and the University of São Paulo from 1999 onwards. The UNIFESP Telehealth Centre was opened in 2011 and provides teleadvice

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services and education courses (mental health, dental and primary healthcare) to 130 municipalities in the state (excluding the city of São Paulo). In 2018, due to delays in renewing federal funding, the centre suspended operations. To service the city of São Paulo, the São Paulo Telehealth Network was formed in 2014 and now provides similar range of services to the UNIFESP Telehealth Centre. In the private health sector, the Albert Einstein Hospital offers a range of services via videoconferencing to its private patients. Triaging for specialist appointments in the Brazilian public health sector is generally channelled through centralised state referral centres using online systems which are increasingly becoming integrated with many state teleadvice services. Catapan et al. (2020) estimate that 28% of family health teams have processes in place to make referrals to specialists through these centres. These regulations required primary health doctors to request advice from the service as part of the triaging process for patient referral to some specialists with long waiting lists. For example, an online, web-based service to primary health doctors in Rio Grande do Sul provided an online triaging advice. Figure 5.6 illustrates the increase in activity of this service since state referral regulations were amended in 2015 to require doctors to use online triaging services. The greatest growth in telehealth activity, as shown in Fig. 5.6, was the national telephone advice provided to primary health doctors via a 0800 free call number. The national telephone advice service offered by the Rio Grande do Sul Telehealth Centre since 2013 had the same aims as the computer-based service, but “gave people the opportunity to deal with doubts quickly. It is a much more agile service which gives support when it is needed. We answer 80% of issues in the same call within 10 minute” (Edson, Telehealth coordinator). Telephone advice had greater uptake, providing national coverage because “requesting doctors can call the service during the consultation or shortly afterwards. This gives them the flexibility to fit the support services within their own work routine” (Edson, Telehealth coordinator). When I asked Brazilian health professionals whether telehealth services were seen as routine or normal, many felt that although they were routinely used there was room for improvement; only a small number felt

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Number of advice sessions per month

3,500 3,000 2,500 2,000 1,500 1,000 500 0

08

10

0800 Telephone Advice (National)

12 14 Year (2008 to 2018)

16

18

Web Referral Triaging Service

Web Advice Service

Fig. 5.6  Growth of teleadvice services, Rio Grande do Sul, 2008–2018 Table 5.3  Were Brazilian telehealth services routine or normal? (N = 38) Assessmentsa

Fully (%)

Partially (%)

Not yet (%)

Routine (n = 27) Normal (n = 11)

64 19

32 54

12 27

a

Participants made assessments of whether telehealth services were routine or normalised. More than one assessment was possible, so percentages may not add up to 100%

that telehealth services could be considered normal. Table  5.3 breaks down interviewees’ assessments according to the extent that services were considered fully, partially or not yet routine or normal. During the period of my research in Brazil (2018), the impact of austerity was beginning to be felt. This period of austerity, combined with the challenges of dealing with large numbers of municipal health services, probably contributed to the lower confidence in the operation of telehealth service than in the Australian context. In Santa Catarina, a manager felt that only 22 municipalities were routinely participating in telehealth services (Brazilian states usually have several hundred

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municipal areas). In another state with a large telehealth centre, I was told that: “20% of doctors use teleconsultorias (telehealth advice services) in routine care; 80% do not use it. I’m just talking about the doctors who have used the service once” (Emanuel, Telehealth coordinator).

5.4 Telehealth in the State of Queensland, Australia Queensland is less centralised than other Australian states. The total land area of Queensland is 1850 square kilometres with a population of 4.78 million people in a land area stretching 2500 km from north to south and 1800 km from east to west. In June 2015, the population of Brisbane (the state capital city) was 2.31 million people, accounting for 48% of the state’s total population, followed by the Gold Coast with 570,000 people, Cairns with 67,000 people and Townsville with 52,000 people (Australian Bureau of Statistics, 2014). These cities also host the majority of higher acute care facilities. Queensland has some of the most developed telehealth services in Australia in terms of service volume and use by over 50 clinical specialities of videoconferencing consultations. The state department of health (Queensland Health) was entirely responsible for telehealth services until 2012 when many of its functions were devolved to 17 regional hospital and health services. Following devolution of health services, Queensland Health retained overall responsibility for ICT and telehealth service infrastructure and regional health services continued to operate their own telehealth services for outpatients and hospital inpatients using this infrastructure. The Queensland system is by far the largest and oldest dedicated telehealth system in Australia. In 1996, the Queensland Telehealth Network, with funding from Queensland Health, was established (Kennedy et al., 2001). As in South Australia, the first major use of videoconferencing was for mental health services (Kennedy & Yellowlees, 2000). Other clinical uses followed, including foetal ultrasound (Chan et al., 1999), intensive care (Bailey et  al., 1998), neonatology, obstetrics and echo cardiology

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(Whitehall et al., 1998), genetics counselling (Gattas et al., 2001), ophthalmology (Rosengren et al., 1998) and pathology. Two early projects laid the foundations for the future of telehealth services in Queensland: an intensive care unit telemedicine project based at the Royal Brisbane Hospital (Crowe & McDonald, 1997) and a remote foetal ultrasound diagnosis initiative by the Kirwin Hospital in Townsville (Chan et  al., 2002). Videoconferencing was used to support critical care, treatment of alcohol and drug addiction, general medical education and rural and remote practitioners (Watson et  al., 2001). Educational grand rounds discussing best practice in a range of clinical disciplines (fulfilling a similar purpose to Brazilian SIGs) used videoconferencing to connect regional facilities to presentations broadcast from Brisbane (McCrossin, 2001). These experiences informed the development of the Queensland Health Service Delivery Network (SDN) which I project-managed. The SDN set out to renew the Queensland Health telecommunications system by deploying a broadband network to reduce the costs of carrying video traffic for telehealth services, to increase quality and to carry key applications such as pathology results and radiology imaging. While implementation of the SDN was valuable for larger health facilities, it did nothing to help rural and remote sites. Fortunately, a succession of federal funding initiatives between 2000 and 2010 improved regional telecommunications infrastructure and enabled expansion of high-quality videoconferencing to smaller regional facilities (Russell & Taylor, 2011). By 2014, in the northern area of Queensland, 34 facilities were equipped to participate in consultations supporting stabilisation and aeromedical retrieval of critical patients (Kyle et al., 2012). According to Kyle et  al. (2012), “use of telehealth for an expanded range of patient referrals to the retrieval service was beneficial in either changing the decisions of medical coordinators, or confirming the decisions already made” (p. 150). During this period a dedicated telehealth centre at the Princess Alexandra Hospital, Brisbane, was established to assist telehealth services across the entire hospital concentrating on geriatrics, cardiology, dermatology and endocrinology. The centre “encouraged the development of services appropriate to clinical need of various departments of the hospital” (Martin-Khan et al., 2015, p. 11). Figure 5.7 shows that the use of telehealth services in Queensland has been increasing steadily for many

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120,000

Number of Telehealth services

100,000

80,000

60,000

40,000

20,000

0 2012-13

2013-14

2014-15

2015-16

2016-17

2017-18

Fig. 5.7  Queensland Health non-admitted patient telehealth services, 2012–2018. (Derived from Gray, 2019)

years. In the financial year 2017–2018, there were 94,788 non-admitted patient events, 23,808 mental health consultations and 10,531 emergency department consultations. While there has been significant growth in activity, a state-wide coordinator provided a nuanced view of the use of telehealth services in the health system: The model that we, or the service that we provide or facilitate is usually fairly new to those places … so getting clinicians to embed it is probably the really difficult thing. It’s very rare to find resistance in my experience. That certainly occurs. There are some people that will put up barriers … very variable I would say across the state. There’s some places that have been using us for quite a while and they’re really individual places … these sort of places use us regularly, often every day or at least every couple of days, and I think it’s really embedded there where it has been normalised in their processes. But that’s a small minority.…

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I think, certainly in rural Queensland, there’s a familiarity with using t­ elehealth in an emergency through Retrieval Services, who have been doing it for 10–12 years now. (Blake, Nurse)

The adoption of telehealth models of care varies according to speciality. Some specialities found that that telehealth services fitted their model of care well, as illustrated by the clinician managing a non-invasive neurosurgery service that dealt with up to 20% of out-patient follow-up using telehealth services, who simply stated, “it’s just ordinary care. Within the Gamma Knife we don’t necessarily see it as an innovation. We just see it as part of ordinary care … that is just because it’s been there from the start” (Sebastian, Radiation Oncologist).

5.5 T  elehealth in the State of Santa Catarina, Brazil Santa Catarina is a southern Brazilian state with an estimated population of 6,727,148 (Brazilian Institute of Geography and Statistics, 2016) in a land area of 95,703 sq. km. The most distant city is located 783 km from the capital, Florianópolis. There are two major population centres: Florianópolis, situated on Santa Catarina Island (population 880,000 in 2010) and Joinville in the north (population 540,000 in 2010; Brazilian Institute of Geography and Statistics, 2016). These cities also host the majority of higher acute care facilities. Santa Catarina provides some of the most developed telehealth services in Brazil. The emphasis has been on diagnostic services, advice services and education for primary healthcare. Telehealth services in Santa Catarina developed stemmed from a research project at the Federal University of Santa Catarina (UFSC) between 2001 and 2006 on networked systems for transmitting and storing radiology images (picture archiving and communications systems— PACS). The technology was designed to work over the low network bandwidths available at the time, using web-based technologies. The state government funded initial implementation of a telediagnostic network in 2005 to four municipalities including electrocardiograms and radiology.

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The original impetus for telehealth services in Santa Catarina was the purchase by the health department of medical resonance equipment for several hospitals and digital electrocardiogram equipment for primary healthcare centres (Maia et  al., 2006) which were linked to a network using a converter developed by UFSC. This step marked the beginning of a long period of collaboration between the state government and the university. In 2007, the Santa Catarina Telehealth Centre joined the RUTE network connecting six universities in the state. By 2018, telehealth services were available in all 295 municipalities of the state. The Santa Catarina Telehealth Centre—Telessaúde-UFSC—is based at two locations in the state capital: UFSC and the State Health Secretariat. A substantial staff (more than 20, full- and part-time, including postgraduate students) manage teleadvice, publicity, reporting of diagnostic imaging and educational services. Enrolment in online medical courses grew from 32 participants in 2010 to 2062  in 2016 (Savaris & Von Wangenheim, 2017). A large amount of medical reporting, including electrocardiograms, is done remotely by doctors. The Cyclops research group and the university Laboratory of Telemedicine provide technical support, development research and maintenance of user and technical documentation. Telecardiology examinations grew to 200,000 exams per  annum in 2016 (Giuliano et  al., 2012), significantly reducing waiting times and patient travel costs (Piccoli et al., 2015). Figure 5.8 shows the number of diagnostic exams in radiology, telecardiology and pathology between 2005 and 2016. Examinations across the eight modalities managed by the Santa Catarina telehealth service network increased from 531 exams in 2005 to 929,459 exams in 2016 (Telessaúde-UFSC, 2017). Telediagnostic services in Santa Catarina enjoyed long-term state funding and have become taken for granted, “once we reduced the waiting lists. [since] people have a hard memory and they don’t remember how it was 15 years ago” (Fabrício, Researcher). The Federal Government funded an online advice service for primary healthcare workers in Santa Catarina from 2012. Prior to 2015, fewer than 4000 responses were recorded annually to questions posed by users on this service. Then, in 2015, the state issued regulations making it compulsory for primary healthcare facilities to use the teleadvice system when

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Telediagnostic Examinations per annum

400,000 350,000 300,000 250,000 200,000 150,000 100,000 50,000 0

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Radiology (CR)

Pathology Reports

Telecardiology (ECG)

Fig. 5.8  Telediagnostic examinations in Santa Catarina, 2005–2016

wishing to refer patients to secondary or tertiary care for dermatology, orthopaedics, rheumatology, endocrinology, wounds, mental health, ophthalmology, nutrition and audiology services. Figure 5.9 shows how the number of referrals to dermatologists decreased from 2015 onwards, following the introduction of these regulations in 2015 for dermatology referrals (Telessaúde-UFSC, 2017). As a result, larger numbers of patients are managed at the primary care level, instead of travelling to see a specialist. A family doctor felt that the service “now it has become a routine, there have been 13 years of operation, since 2005, there are still cities there that were in from the beginning” (Felipe, Family physician). In this chapter, we have seen how in many Australian and Brazilian states telehealth services expanded and offered an increasing range of services. In many instances these services became routine element of the health system although prior to the pandemic, the proportion of healthcare delivered using telehealth services compared to in-person care was small. In the following chapters, I analyse the empirical research I

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Avoided Dermatology referrals per annum

30,000 25,000 20,000 15,000 10,000 5,000 0 2014

2015 Patients not Referred

2016 Patients Referred

2017

Fig. 5.9  Teledermatology: Avoided referrals in Santa Catarina 2014–2017

undertook across Australia and Brazil to identify the explanations for the development of these telehealth services and the constraints they faced. The starting point for my analysis will be understanding how organisations changed and professional practices evolved when care was separated.

References Australian Bureau of Statistics. (2014). Australian population grid, 2011 [Map]. http://www.abs.gov.au/AUSSTATS/[email protected]/DetailsPage/1270.0.5 5.0072011?OpenDocument Australian Department of Health and Ageing. (2012). NBN Enabled telehealth pilots program. Australian Government. http://www.health.gov.au/internet/ main/publishing.nsf/content/ehealth-­nbntelehealth-­pilots/$File/Fact%20 Sheet.pdf Australian Digital Health Agency. (2018). Australia’s national digital health strategy. https://conversation.digitalhealth.gov.au/australias-­national-­digital­health-­strategy

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Australian Government Department of Health; Health Workforce Division. (2019). National registration and accreditation scheme (NRAS). Australian Government Department of Health. https://www1.health.gov.au/internet/ main/publishing.nsf/Content/work-­nras Australian Institute of Health and Welfare. (2018). Non-admitted patient care 2016–17. Australian Institute of Health and Welfare. https://www.aihw.gov. au/getmedia/a6c9c592-4e8b-4b53-b7f6-3a01d91ed801/aihw-hse-206.pdf Australian National Telehealth Committee. (2002). National telehealth plan for Australia and New Zealand. Commonwealth Dept. of Health and Ageing. Australian Rural Health Research Institute. (1996). Telehealth in rural and remote Australia: Report of the project for rural health communications and information technologies. Australian Rural Health Research Institute. http:// www.healthinfonet.ecu.edu.au/key-­resources/bibliography/?lid=8480 Bailey, Q., Bryant, J., Hayes, L., Jensen, M., & Whiting, R. (1998). ICU telemedicine – Where we are today. Australian Critical Care, 11(2), 60. https:// doi.org/10.1016/S1036-­7314(98)70461-­8 Banbury, A., Parkinson, L., Nancarrow, S., Dart, J., Gray, L., & Buckley, J. (2014). Multi-site video conferencing for home-based education of older people with chronic conditions: The telehealth literacy project. Journal of Telemedicine and Telecare, 20(7), 353–359. https://doi.org/10.117 7/1357633X14552369 Bidargaddi, N., Schrader, G., Roeger, L., Bassal, A., Jones, L., & Strobel, J. (2015). Early effects of upgrading to a high bandwidth digital network for telepsychiatry assessments in rural South Australia. Journal of Telemedicine and Telecare, 21(3), 174–175. https://doi.org/10.1177/1357633X15569955 Botrugno, C., Goldim, J. R., & Fernandes, M. S. (2019). O telessaúde Brasil redes: Um sistema tecnologico “socialmente engajado.” Latin American Journal of Telehealth. http://cetes.medicina.ufmg.br/revista/index.php/rlat/ article/view/271 Brazilian Institute of Geography and Statistics. (2016). Arranjos Populacionais e Concentrações Urbanas do Brasil (2nd ed.). Brazilian Institute of Geography and Statistics. ftp://geoftp.ibge.gov.br/organizacao_do_territorio/divisao_ regional/arranjos_populacionais/arranjos_populacionais.pdf Catapan, S. de C., Willemann, M.  C. A., & Calvo, M.  C. M. (2020). Estrutura e processo de trabalho para implantação da teleconsulta médica no Sistema Único de Saúde do Brasil, um estudo transversal com dados de 2017–2018. Epidemiol Serv Saúde, 21. https://doi.org/10.1590/ s1679-­49742021000100015

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Celler, B. G., Sparks, R., Nepal, S., Alem, L., Varnfield, M., Li, J., Jang-Jaccard, J., McBride, S. J., & Jayasena, R. (2014). Design of a multi-site multi-state clinical trial of home monitoring of chronic disease in the community in Australia. BMC Public Health, 14, 1270. https://doi.org/10.1186/1471-­2458-­14-­1270 Chan, F. Y., Whitehall, J., Hayes, L., Taylor, A., Soong, B., Lessing, K., Cincotta, R., Cooper, D., Stone, M., Lee-Tannock, A., Baker, S., Smith, M., Green, E., & Whiting, R. (1999). Minimum requirements for remote realtime fetal teleultrasound consultation. Journal of Telemedicine and Telecare, 5(3), 171–176. Chan, F. Y., Taylor, A., Soong, B., Martin, B., Clark, J., Timothy, P., & Lee-­ Tannock, A., Begg, L., Cincotta, R., & Wootton, R. (2002). Randomized comparison of the quality of realtime fetal ultrasound images transmitted by ISDN and by IP video conferencing. Journal of Telemedicine and Telecare, 8(2), 91–96. Crotty, M., Killington, M., Van Den Berg, M., Morris, C., Taylor, A., & Carati, C. (2014). Telerehabilitation for older people using off-the-shelf applications: Acceptability and feasibility. Journal of Telemedicine and Telecare, 20(7), 370–376. https://doi.org/10.1177/1357633X14552382 Crowe, B., & McDonald, I. (1997). Telemedicine in Australia: Recent developments. Journal of Telemedicine and Telecare, 3(1). Department of Health and Ageing. (2009). A healthier future for all Australians final report. Commonwealth of Australia. http://www.cotasa.org.au/cms_ resources/documents/news/nhhrc_report.pdf Dramos, L. M. M., & Santos, A. de F. dos, Sena, M. I. B., Freitas, M. A. C. de, Silva, E. M. de S., Mello, M. do C. B. de, & Torres, R. M. (2021). Quality of telehealth services in primary care in the State of Minas Gerais. Telemedicine and E-Health. https://doi.org/10.1089/tmj.2020.0262 Federal Medical Council. (2002). Resolução CFM no 1.643/2002. http://www. portalmedico.org.br/resolucoes/cfm/2002/1643_2002.htm Federal Medical Council. (2009). Aprova o Código de Ética Médica. http://www. portalmedico.org.br/resolucoes/cfm/2009/1931_2009.htm Federal Medical Council. (2018). Resolucao N° 2.227, de 13 de dezembro de 2018. Imprensa Nacional. http://imprensanacional.gov.br/ materia/-­/ asset_publisher/Kujrw0TZC2Mb/content/id/62181135/ d o 1 -­2 0 1 9 -­0 2 -­0 6 -­r e s o l u c a o -­n -­2 -­2 2 7 -­d e -­1 3 -­d e -­d e z e m b r o -­ de-­2018-­62180763 Gattas, M. R., Macmillan, J. C., Meinecke, I., Loane, M., & Wootton, R. (2001). Telemedicine and clinical genetics: Establishing a successful service. Journal

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of Telemedicine and Telecare, 7(2_suppl), 68–70. https://doi. org/10.1258/1357633011937191 Giuliano, I. C. B., Barcellos, C. L., Von Wangenheim, A., & Sergio, M. (2012). Issuing electrocardiographic reports remotely: Experience of the telemedicine network of Santa Catarina. Archive of Brazilian Cardiologists, 99(5), 1023–1030. Governo do Estado do Rio Grande do Sul. (2017). Plan Estadual de Saúde 2016–2019. https://saude.rs.gov.br/upload/arquivos/201701/05153251-­ pes-­2016-­2019-­sesrs.pdf Gray, L. (2019). The state of telehealth in Australia: Is there a need for policy change? Successes and Failures in Telehealth 2019, Gold Coast, Australia. https:// event.icebergevents.com.au/uploads/contentFiles/files/2019-­SFT/Len%20 Gray.pdf Haddad, A.  E. (2012). Experiência Brasileira do Programa Nacional Telessaúde Brasil. GoldBook, UREJ. http://www.telessaude.uerj.br/resource/goldbook/pdf/2.pdf Haddad, A.  E., da Silva, D.  G., Monteiro, A., Guedes, T., & Figueiredo, A. M. (2016). Follow up of the legislation advancement along the implementation of the Brazilian telehealth programme. Journal of the International Society for Telemedicine and eHealth, 4(0), e11 (1–7). Harzheim, E., Gonçalves, M.  R., Umpierre, R.  N., da Silva Siqueira, A.  C., Katz, N., Agostinho, M. R., Oliveira, E. B., Basso, J., Roman, R., Dal Moro, R.  G., Pilz, C., Heinzelmann, R.  S., Schmitz, C.  A. A., Hauser, L., & Mengue, S. S. (2016). Telehealth in Rio Grande do Sul, Brazil: Bridging the gaps. Telemedicine Journal and E-Health: The Official Journal of the American Telemedicine Association, 22(11), 938–944. https://doi.org/10.1089/ tmj.2015.0210 Harzheim, E., Katz, N., Ferri, C., Fernandes, J. G., & Barbosa, I. (2018). Guia de Avaliação, Implantação e Monitoramento de Programas e Serviços em Telemedicina e Telessaúde. Universidade Federal do Rio Grande do Sul. http:// rebrats.saude.gov.br/images/MenuPrincipal/Guia_Avaliacao_telessaude_ telemedicina.pdf JMA. (1994). The challenge to embed telepsychiatry. John Mitchell & Associates. http://www.jma.com.au/view/publications/health-­innovation JMA. (1995). Two leading edge telemedicine projects: Lessons learnt. ATA Telecon’95 conference. http://www.jma.com.au/view/publications/healthinnovation

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Kavanagh, S., & Hawker, F. (2001). The fall and rise of the South Australian telepsychiatry network. Journal of Telemedicine and Telecare, 7(Suppl 2), 41–43. https://doi.org/10.1258/1357633011937083 Kennedy, C., & Yellowlees, P. (2000). A community-based approach to evaluation of health outcomes and costs for telepsychiatry in a rural population: Preliminary results. Journal of Telemedicine and Telecare, 6(1_suppl), 155–157. https://doi.org/10.1258/1357633001934492 Kennedy, C., Blignault, I., Hornsby, D., & Yellowlees, P. (2001). Video conferencing in the Queensland health service. Journal of Telemedicine and Telecare, 7(5), 266–271. https://doi.org/10.1258/1357633011936516 Kyle, E., Aitken, P., Elcock, M., & Barneveld, M. (2012). Use of telehealth for patients referred to a retrieval service: Timing, destination, mode of transport, escort level and patient care. Journal of Telemedicine and Telecare, 18(3), 147–150. https://doi.org/10.1258/jtt.2012.SFT106 Leverington, S., & Bassa, A. R. (2019). A state-wide telerehabilitation service for South Australia. Australian Telehealth Conference, Brisbane. https://www. hisa.org.au/slides/atc19/ScottLeverington.pdf Lima Verde Brito, T. (2016). Análise da Colaboração nos Grupos de Interesse Especial (SIG) da Rede Universitária de Telemedicina (RUTE). Universidade Federal de São Paulo. Maia, R. S., von Wangenheim, A., & Nobre, L. F. (2006). A statewide telemedicine network for public health in Brazil. 19th IEEE Symposium on ComputerBased Medical Systems (CBMS’06), 495–500. https://doi.org/10.1109/ CBMS.2006.29 Maldonado, J. M. S. de V., Marques, A. B., & Cruz, A. (2016). Telemedicine: Challenges to dissemination in Brazil. Cadernos de Saúde Pública, 32(suppl 2). https://doi.org/10.1590/0102-­311X00155615 Martin-Khan, M., Fatehi, F., Kezilas, M., Lucas, K., Gray, L.  C., & Smith, A. C. (2015). Establishing a centralised telehealth service increases telehealth activity at a tertiary hospital. BMC Health Services Research, 15. https://doi. org/10.1186/s12913-­015-­1180-­x Mattos, S. D., Hazin, S. M., Regis, C. T., de Araujo, J. S. S., Albuquerque, F. C., Moser, L., Hatem, T., de Freitas, C. P. G., Mourato, F. A., Tavares, T., Gomes, R., Severi, R., Santos, C. R., Da Silva, J., Rezende, J., Vieira, P. C., & de Lima, J. (2015). A telemedicine network for remote paediatric cardiology services in North-East Brazil. Bulletin of the World Health Organization, 93(12), 881–887. https://doi.org/10.2471/BLT.14.148874

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McCrossin, R. (2001). Successes and failures with grand rounds via video conferencing at the royal children’s hospital in Brisbane. Journal of Telemedicine and Telecare, 7(suppl 2), 25–28. https://doi.org/10.1258/1357633011937047 McDonald, K. (2020). eHealth NSW sets up virtual care accelerator for telehealthenabled models of care. Pulse+IT. https://www.pulseitmagazine.com.au:443/news/ australian-­ehealth/5859-­ehealth-­nsw-­sets-­up-­virtual-­care-­accelerator-­for-­ telehealth-­enabled-­models-­of-­care Medeiros, R. A. (2009). Study of three cases of telemedicine in Brazil for the periods 2005 and 2006: Context and developments [PhD, Universidade Federal de São Paulo (UNIFESP)]. http://repositorio.unifesp.br/handle/11600/9557 Messina, L. A., & Filho, J. L. R. (Eds.). (2013). Impactos da Rede Universitária de Telemedicina, Phase 1 2006–2009. E-papers Serviços Editoriais. http:// www.e-­papers.com.br Ministério da Saúde. (2011a). Programa Nacional Telessaúde Brasil Redes. http:// bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt2546_27_10_2011.html Ministério da Saúde. (2011b). Regulamenta o uso de padrões de interoperabilidade e informação em saúde para sistemas de informação em saúde no âmbito. http:// bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt2073_31_08_2011.html Ministério da Saúde & Universidade Federal do Rio Grande do Sul. (2012). Manual of telehealth for primary health care. http://189.28.128.100/dab/ docs/portaldab/publicacoes/manual_telessaude.pdf Mitchell, J. (1998). Fragmentation to integration: National scoping study of the telemedicine industry in Australia. Department of Industry Science and Technology. http://www.jma.com.au/view/publications/health-­innovation Monteiro, A., & Neves, J. P. (Eds.). (2015). The history of telehealth in the city and State of Rio de Janerio. Universidade do Estado do Rio de Janeiro. http:// telessaude.uerj.br/livro National Health Information Management Advisory Council. (2001). Health online: A health information action plan for Australia (2nd ed.). Commonwealth of Australia. https://ozhealthithistory.wikispaces.com/file/view/actionp_2. pdf/182746001/actionp_2.pdf Northern Territory Government. (2019, August 7). Telehealth in the Northern Territory. https://health.nt.gov.au. https://health.nt.gov.au/professionals/ ehealth/telehealth NSW Ministry of Health. (2015). Strategic review of telehealth in NSW: Final report. https://www.health.nsw.gov.au/telehealth/Documents/strategic-­ review-­of-­telehealth-­in-­NSW.PDF

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Piccoli, M.  F., Amorim, B.  D. B., Wagner, H.  M., & Nunes, D.  H. (2015). Teledermatology protocol for screening of skin cancer. Anais Brasileiros de Dermatologia, 90(2), 202–210. https://doi.org/10.1590/abd1806-­4841. 20153163 Rosengren, D., Blackwell, N., Kelly, G., Lenton, L., & Glastonbury, J. (1998). The use of telemedicine to treat ophthalmological emergencies in rural Australia. Journal of Telemedicine and Telecare, 4(1_suppl), 97–99. https:// doi.org/10.1258/1357633981931650 Russell, B., & Taylor, A. (2011). Mobile digital breast screening: An evaluation of the Queensland experience. Electronic Journal of Health Informatics, 7(1), 4. Savaris, A., & Von Wangenheim, A. (2017). O Sistema Integrado Catarinense de Telemedicina e Telessaúde (STT/SC). Revista Catarinense de Saúde Da Família, 7, 66. Services Australia. (2020). Statistics – Item reports. http://medicarestatistics. humanservices.gov.au/statistics/mbs_item.jsp Silva, A.  B. (2014). Telessaúde no Brasil: Conceitos e aplicações. Editora DOC Comércio e Serviços Ltda. Silva, A. B., Silva, R. M. da, Ribeiro, G. da R., Guedes, A. C. C. M., Santos, D. L., Nepomuceno, C. C., & Caetano, R. (2020). Three decades of telemedicine in Brazil: Mapping the regulatory framework from 1990 to 2018. PLoS One, 15(11), e0242869. https://doi.org/10.1371/journal. pone.0242869 Telessaúde-UFRGS. (2021). Núcleo de Telessaúde do Rio Grande do Sul. TelessaúdeRS-UFRGS. https://www.ufrgs.br/telessauders/ Telessaúde-UFSC. (2017). Revista Catarinense de Saúde da Família. http://portalses.saude.sc.gov.br/index.php?option=com_content&view=article&i d=5438&Itemid=692 Umpierre, R. (2019). Tackling OPD waiting lists with teleconsultations and teleophthalmology – The experience in Brazil. Successes and Failures in Telehealth, Gold Coast, Australia. https://event.icebergevents.com.au/uploads/contentFiles/files/2019-­SFT/Roberto%20Umpierre.pdf Watson, J., Gasser, L., Blignaultr, I., & Collins, R. (2001). Taking telehealth to the bush: Lessons from North Queensland. Journal of Telemedicine and Telecare, 7(suppl 2), 20–23. https://doi.org/10.1258/1357633011937344 Whitehall, J., Bliganault, I., French, C., Carson, V., & Patole, S. (1998). Telemedicine in neonatology: Lessons from North Queensland. Australian Journal of Rural Health, 6(3), 140–143. https://doi. org/10.1111/j.1440-­1584.1998.tb00300.x

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Yellowlees, P. (2001). An analysis of why telehealth systems in Australia have not always succeeded. Journal of Telemedicine and Telecare, 7(suppl 2), 29–31. https://doi.org/10.1258/1357633011937056

6 Organisational Structures Influence Telehealth Services

Abstract  Here, I draw on the empirical research I conducted in Australia and Brazil, beginning with an examination of the organisational contexts for telehealth services. All organisations are the product of processes operating over time on different contextual components to produce contemporary contexts. The historical context of healthcare organisations shape the delivery of telehealth services, but when contemporary structural reforms take place, they can act as a mechanism, enabling or inhibiting telehealth services. I explore how the organisation of healthcare, the structuring and automation of care have historically contributed to the current organisational contexts for contemporary telehealth services. The previous chapters in this book outlined how separated care delivered via telehealth services was constructed within organisational contexts and implemented by health professionals; how technology was incorporated into care; the healthcare systems’ contexts for telehealth services; and the development of telehealth services in Australia and Brazil prior to the pandemic. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 A. Taylor, Healthcare Technology in Context, https://doi.org/10.1007/978-981-16-4075-9_6

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This chapter marks the start of the second half of my journey where I draw on the empirical research I conducted in Australia and Brazil. During this time, I interviewed many managers, clinicians and technologists involved in telehealth services in order to understand the underlying processes and mechanisms that shaped their work. The practitioners interviewed for my research were experienced, had already adopted telehealth services, were confident users and were primarily concerned with managing change within their organisations when telehealth services were used to extend healthcare. Organisational change is a continuous phenomenon. All organisations are the product of processes that have operated over time on different contextual components to produce contemporary contexts. Because change occurs over time, the historical structure of a healthcare organisation, acting as a contextual factor, can shape telehealth service delivery, but when contemporary structural reforms take place, the same feature can act as a mechanism, enabling or inhibiting telehealth services. For this reason, Shaw et  al. (2018) made the point that “researchers must judiciously and clearly identify why certain contexts are treated as contexts, and others as mechanisms in a given analysis” (p. 11). Therefore, in this chapter and the ones that follow, I seek to generalise beyond the level of specific events seen in organisational contexts by identifying the holistic processes that shape the interactions between telehealth services and healthcare organisations. In the context of health systems, processes such as health reform, commencement of a telehealth program or changes in government priorities are obvious starting points. We can observe most of these processes readily (such as establishment of telehealth programs), but other processes and transformations (such as the building of electronic information systems) may be less observable or may take place over extended periods. In this chapter, I explore the key processes that have historically contributed to the organisational contexts for the operation of telehealth services. Organisational contexts provide the structural conditions such as resources, management and technology for telehealth services. The processes that shape these conditions, operating within organisational contexts, are the organisation of healthcare, the structuring of care and the automation of care.

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6.1 O  rganising Healthcare: Managing Inequities in Universal Care When examining how healthcare is organised it is worth remembering that in Australia and Brazil, historically, political struggles influenced the organising principles for healthcare by creating universal healthcare systems. Hence, the rationale for delivering healthcare within a universal healthcare system links telehealth services operating in those contexts to wider cultural norms and values. For instance, Botrugno et  al. (2019) described the Brazilian Telehealth Networks Program as a “socially engaged” technological system (p. 44). In Brazil, the movement to prioritise healthcare as a democratic right helped to create the Brazilian universal healthcare system following the fall of the Brazilian dictatorship in 1988. Similarly, in the UK, Tudor-Hart (2000) argued that the UK National Health Service provides a material basis for “rehumanising society” (p. 10). Within universal healthcare systems inequities in healthcare provision remain, which raises questions about the prioritisation of care within these systems. Perkovic et  al. (2014) asked what is the contemporary meaning of “universality” (of healthcare), because of the inequities in access to healthcare in Australia. Operating at the nexus between universal healthcare and inequitable care, telehealth services are able to provide “separated” healthcare to underserved populations within universal healthcare systems as described by Gonçalves et al. (2017) for primary healthcare in Brazil, and by Carey et  al. (2013) for remote care in Australia. Consequently, the rationale for telehealth services is inherently a political one and inextricably linked with the notion that healthcare should be universally available as a democratic right. A key component of this rationale is the aim to provide healthcare to underserved populations across geographical and organisational boundaries using technology. In Australia, the Project for Rural Health Communications and Information Technology report, which I mentioned in Chap. 5, argued the case for greater support of healthcare to underserved regional populations using technology and provided the rationale for many early telehealth pilot projects. But under subsequent Australian governments,

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support for telehealth fell away. It was only in 2007, when a new Labor government undertook major organisational health reforms that priorities changed, additional payments for telehealth consultations were provided and nine telehealth pilot projects were established that focus on aged and chronic disease care (Celler et al., 2018). Under the family health strategy the Brazilian Telehealth Networks Program prioritised the improvement of care to underserved regional and economically disadvantage populations through its support for primary care. As one primary healthcare doctor, who was a key player in the design of the program and very committed to working in a universal healthcare system, explained: “We just wanted to build what was best for the Unified Health System. This technical and therefore also moral approach enabled us to generate support and to overcome even [our own political attitudes] at that critical moment” (Antônio, Family physician). This national strategy successfully supported many state health organisations in improving primary care services. A state telehealth centre manager told me: the question was how to improve the referral process and avoid unnecessary referrals, by doctors connecting via the online advice platform, and then with the aid of a response deciding that the patient did not need to see a specialist, thereby reducing waiting lists is what we did in Rio Grande do Sul. So the idea was this, concentrate on primary care. Subsequent expansion would not just focus on the Family Health Strategy, but also help basic health facilities, which are slightly separate. There is also an opportunity for public telehealth to be brought to the secondary and tertiary healthcare level, principally the small hospitals and emergency facilities. (Eduardo, Family physician)

When advocating the need for a Brazilian national telehealth strategy, Moura (2016) noted that the socially progressive “Lula” government prioritised funding for primary healthcare and education of the medical workforce and referred to the founding principles of the Brazilian Telehealth Networks program as directly supporting primary healthcare. It is, therefore, not surprising that many providers of telehealth services interviewed for my research felt it was a priority to increase the availability of healthcare to underserved populations and to support primary health professionals who are the first responders to the needs of these populations.

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Telehealth services often emerge as solutions to increasing the availability of services during periods when the broader health system is undergoing reform driven by political priorities. In South Australia, a “Transforming Health” initiative (Government of South Australia, 2015) had the “premise of transforming health … there was a complete realignment of services. There was a focus on increasing ambulatory rehab and there was a real sort of redesign of a lot of the rehab services” (Sasha, Physiotherapist). Sasha felt that this provided an opportunity for powerful senior clinicians on a state-wide committee to argue, “because the numbers you are talking about … one of the premises is treat(ment) at your home reducing travel, all that sort of thing. We can’t do that unless we have telehealth”. Political support may be crucial to prioritising telehealth services, but health services remain constrained by organisational structures defined by geographical boundaries, legal structures governing responsibilities for healthcare and financial rules. Boundaries become significant when they delineate the provision and availability of health services. Boundaries can be described as formal or informal rules defining the locations where healthcare can be delivered and the health conditions defining the responsibilities for treating patients. Nicolini (2007) noted that healthcare practices carry “deeply embedded some very specific spatial assumptions … [and] by altering them, and by affecting in particular the fundamental spatial relationships of proximity and distance, telemedicine produces significant misalignments, tensions, and contradictions” (p. 914). The health professionals I interviewed were concerned about the impact of place-based organisational structures and payment rules on the availability of healthcare. Geographical boundaries influence responsibilities for care: in Australia and Brazil, the availability of health services is defined by state boundaries, regional catchments, municipal boundaries or hospital localities. For instance, until 2007, a number of independent hospital boards served regional South Australia. It was only when Country Health Local Health Network, a single organisation covering all of regional South Australia, was created that it proved possible to implement the South Australian Digital Health Network to support a state-­ wide psychiatric service. Similarly, a telehealth service manager in Queensland argued that:

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We need to create an environment that is very easy for the clinical workforce to operate within. So yes there are challenges that are represented through the establishment of the HHS [Hospital and Health Services in Queensland] that has to do with catchments and referral flows, what patients belong where and around cross HHS funding arrangements. So again you know you start talking about all Metro North’s [a Queensland Hospital and Health Service] no longer going to provide a service and it’s going to be delivered in Roma. (Robin, Health service manager)

Commenting on the impact of boundaries on the admission of patients, a children’s telehealth worker said: “there’s some areas are a bit contested around where those patients should go and what happens when they show up to another hospital” (Luna, Nurse). While some specialities in major hospitals provide telehealth services across an entire state, at every level, organisations decide if they will pay for patient treatment outside of their notional boundaries. Hence, the structural form of the health system is a key influence on the healthcare available to underserved populations.

6.2 S  tructuring Healthcare: Traversing the Boundaries The structure of health systems reflects the priorities for healthcare derived from political struggles over the distribution of care. One of those struggles has been over the proposition that reform of large, national or state-based systems to provide greater local control of healthcare organisations will result in more equitable access to healthcare. Greater local control or decentralisation is one of the most significant reforms made to the legal boundaries of healthcare organisations in Australia and Brazil during the last 20  years. Decentralisation of healthcare took place in Australia from 2010 (Bennett, 2013) and in Brazil between 1990 and 2001 (Fleury, 2011) and aimed at strengthening local democratic control of healthcare organisations with the intention of improving access to healthcare for geographically marginalised populations, particularly in Brazil. The positive health outcomes linked to this organisational

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configuration have been described by Guanais and Macinko (2009) and Paim et  al. (2011). However, decentralisation introduces additional boundaries in the health system, usually based on geographical or political criteria, and this has had mixed consequences for development of telehealth services. Decentralisation builds legal structures reflecting geographical boundaries. For instance, until 1999, Queensland Health was a state-wide unitary organisation which then transitioned over a number of years to a decentralised system. Between 1999 and 2001, it was able to construct a broadband network linking health facilities within state borders, specifically designed to support telehealth services, as mentioned in Chap. 5. During this period, information technology governance was centralised into a single state-wide organisation. When eventually, in 2011, 17 Hospital and Health Services (HHS), each a legal entity, replaced the state Department of Health (Queensland Health), the original centralised structural imprint for information technology services remained and telehealth services in Queensland are still supported by a state-wide unit. This had unintended consequences for telehealth practice: it was that [if] you’re a specialist within your own HHS, you were credentialed to provide that state by telehealth. Along came the establishment of independent statutory authorities and suddenly it was “you’re no longer credentialed outside of your own HHS”. (Robin, Health service manager)

Subsequently, decentralisation also had an impact on the provision of technology-supporting telehealth services. A technologist reported that: due to the decentralised nature of Queensland Health now. I’ve got 17 CIOs [Chief Information Officers] each with their own roadmaps, their own agendas, their own policies and it’s very hard to please all of them.… So I would say that decentralisation is one of our largest challenges out of our control … it was far easier to provide a state-wide ICT service when everyone was buying the same thing. (Leon, Technology manager)

The managers I talked to during my research often expressed the view that decentralisation complicated the task of maintaining state-wide, infrastructure-carrying telehealth services, because funding and

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operational agreements have to be crafted across multiple organisations. Maldonado et  al. (2016) also noted the unintended consequence of decentralisation of healthcare for small Brazilian municipalities that led to fragmentation of healthcare. Brazilian participants reported numerous problems in collaborating with smaller municipalities due to their lack of human and financial capacity to provide and manage the resources required for telehealth services. One unintended consequence of decentralisation in Brazil was that it gave “significant autonomy to management that had little capacity to manage” (Edson, Telehealth coordinator). There have also been unintended consequences of decentralisation of Australian health services to independent regional entities, because “the idea of central state-run coordination of (telehealth) services has really taken a bit of a hit because each one sort of functions as its own little feudal fife” (Lincoln, Psychiatrist). Geographical boundaries are reinforced by financial rules. Although the Australian MBS has national coverage for video consultations, prior to the COVID-19 pandemic payment was only permitted beyond a line set by the distance by road between a specialist or consultant of 15 km, and the patient had to reside outside of a major city. Wade (2014) records that before 2012, the 15 km criterion did not exist and outer metropolitan areas were eligible for video consultations. The impact on telehealth services of this change was significant, according to a private provider: “there was a psychiatrist working for me in Brisbane, she was seeing patients on the Gold Coast and the Sunshine Coast. So for those patients it’s around a 4-hour round trip. So they all instantly became ineligible [because the patient lived in a major metropolitan area]” (Adam, GP). The capacity of organisations to resource telehealth services, the difficulties in dealing with decentralised autonomous organisations and the division between primary and acute care accentuated the difficulties experienced by smaller, decentralised healthcare organisations in operating and providing telehealth services. Paradoxically, larger facilities seemed to have greater difficulties in allocating resources for telehealth services than did smaller ones. A telehealth coordinator charged with expanding telehealth service coverage explained that “[in] some of the larger centres … where we have not even been able to make inroads into their EDs [Emergency Departments] to provide the support for their rural

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facilities. They’re like, no, we’re way too busy” (Penelope, Telehealth coordinator). Yet, a nurse in a small facility indicated that she also faced difficulties resourcing telehealth services: “You’ve got 2 hours to prep this clinic. It might take 2 hours, it might take an hour. But if we were then to add two telehealth patients about 20 minutes each, we’ve blown that out of the water” (Abigail, Nurse manager). These views illustrate how greater organisational size and centralisation favoured greater coverage by telehealth services and creation of the foundational infrastructure for telehealth services. On the other hand, the same process of decentralisation can have different and contradictory outcomes depending on the size, capacity and operating context of a health service. One outcome of boundary changes has been the emergence of new processes patching the gaps in the provision of services between organisations. Boundary changes in health systems provide an opportunity to redesign services to improve continuity of patient care. In regional South Australia prior to 2006, health services were fragmented, with each of the 64 country hospitals having their own boards. Once “Country Health SA was created as an entity it meant that the CEO [Chief Executive Officer] of that service could sit around the table with the metro CEOs and have an equal place at the table (Aria, Health service manager). Aria went on to recall that: in the latter part of 2006 the then CEO of Country Health SA asked me to lead an initiative looking at the needs of people travelling to access health services from anywhere in country South Australia. We called it the patient journey initiative…. Out of that, our then chief medical adviser … and I created what was then called the culture and innovation committee for Country Health SA. He was really interested in covering off some of the gaps that he saw in terms of country health services and access to country health services and really understanding how technology could be an answer.

In the absence of centralised healthcare organisations, substitute structures emerge. In Brazil, representative bipartite and tripartite commissions that were formed under the Pact for Health (Viana et  al., 2017)

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now coordinate primary healthcare pathways across each state, including telehealth services across Brazilian municipalities. In Australia, these pathways for patients are less clear. Primary care is provided by general medical practitioners, who are funded federally with fees based on the duration and complexity of consultations. Patients requiring specialist opinions or treatment are referred to state public hospitals or federally subsidised specialists or directly to the private sector. As a result, they may miss out on coordinated care because they cross the divide between state and federal funding. The high-level structure of healthcare shapes the way patients traverse the system, whether for access to in-person or to telehealth services. When the structures of the health system create boundaries, the ability of services to provide care across the boundaries between acute and primary care generates contradictory outcomes and conflicting responsibilities between sectors. In both countries, a transfer of responsibility for funding and care of patients occurs when they are referred to a specialist or hospital located in another place. An Australian clinician felt that: if we do primary healthcare good, if we do general practice … that has a flow­on effect in general well-being … of decreasing the amount of unnecessary hospitalisation, that decreases a stay in hospital. (Nicholas, Health service manager)

Brazilian telehealth services have, to date, avoided this dilemma because telemedicine has been conceived as an aid to improve primary healthcare. However, the consequence of this orientation towards primary care is that specialists in hospitals “cannot connect with telehealth centres. Only those who are in primary health clinics can connect” (Pedro, Family physician). By contrast, in Australia, when local hospitals provide telehealth services, primary healthcare providers may not be involved. A Queensland GP commented: [T]hey forget about the GP and they send everybody to the local hospital. It’s probably turned out to be a bit of a perverse driver, where it’s increased outpatient service usage at the hospital.… It’s just one of the constant barriers that you see between GPs and hospitals. (David, GP)

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The contradictory consequences of organisation of the health system, particularly decentralisation and the divisions between primary and acute care for the operation of telehealth services, extend to the way care is structured as models of care. Models of care encompass agreements on how to treat and manage the care of people within and across a healthcare service. Agreements among physicians, clinical departments, hospitals and health organisations define the processes to be used in care. Processes guide and refer patients through the system, from consultation to consultation and procedure to procedure. These agreements are commonly known as patient pathways or referral pathways. They include guidelines, contractual arrangements and processes that reflect long-standing accepted practice which can be difficult to change. A specialist confirmed the size of this problem: I don’t think the attitudes change dramatically. I’ll tell you why. I still don’t think they understand the gravity of what can be done…. So I pushed them … saying look we can do very simple telehealth outreach…. That could save someone go on the waiting list…. Well I tried to get that started for almost 8 years now. Our director … feels as though they should all come and get these 2-­minute consultations. And (then) be put on the waiting list. (Luke, Orthopaedic specialist)

Pathways are a good example of sociotechnical codes encapsulating agreements of a social, financial and clinical nature between actors in a health system and the technical (clinical) processes to be undertaken by these actors. Models of care incorporating telehealth services for cancer care have been described by Sabesan et al. (2014) and for intensive care by Boots et al. (2011). An Australian researcher described how models of care could change when telehealth technologies are used: [R]edesigning models of care is important because that takes into account a whole range of things. So how are referrals made. Who ultimately has responsibility for the patient. How is information shared. How are services billed, how they’re scheduled. How is information transmitted back to the primary care provider … it’s taking a much wider perspective on the whole journey of care. (Owen, Researcher)

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Patient care pathways are normally rooted in practices established within existing healthcare contexts based on existing relationships. For new services, those relationships do not exist. Thus, a Queensland radiation teleoncology service had an opportunity to design “right from the start … an advantage, nothing to change … so I wrote the model of service” (Sebastian, Radiation Oncologist). In contrast, existing relationships may inhibit the creation of new pathways for care. A Brazilian state health department secretary described the reliance on existing relationships as causing services which “are fragmented within the same type of service, among types of service, levels of care, primary care, specialized care, hospital care” (Santiago, Health service manager). As part of system reforms, Brazilian states such as Rio Grande do Sul have been able to progressively implement models of care containing mandatory referral protocols defining the clinical criteria for referral of a patient from primary healthcare to a specialist. A state-wide review of services in Rio Grande do Sul in 2006–2007: evaluated the waiting lists for the specialties and … identified the most frequent reasons for referrals from the interior to Porto Alegre in each specialty. We identified that seven to eight reasons account for 80% of requests for specialised consultations. Once the most frequent reasons had been defined, our team reviewed the literature and defined, based on the evidence, the clinical situations that the specialised care will really make a difference in the care of that person. (Edson, Telehealth coordinator)

The implementation of these reforms meant that by 2018 there were 15 specialities covered, including referral protocols using telehealth services. According to a protocol for referral of neurological cases in Rio Grande do Sul, a referral must include signs and symptoms, treatment and examinations to date and reference to any discussion of the case with the telehealth advice line (Telessaúde-UFRGS, 2018). In situations where referral protocols were implemented, clinical outcomes improved and, according to a telehealth centre manager, “out of every three patients that we assessed, two we could solve in primary care” (Emanuel, Telehealth coordinator).

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6.3 A  utomation of Care: Accessing and Sharing Health Records Ideally, healthcare pathways and telehealth services should be supported by information systems which freely exchange patient information among the organisations treating a patient. According to Savage (2009), “healthcare technology serves as an untapped catalyst for higher efficiency, lower cost and broader access to care” (p. 1). As in the case of decentralisation, healthcare automation has had complex and contradictory influences on telehealth services. Telehealth services have had to compete for financial and human resources with health information projects for over two decades, and information exchange between health facilities has remained difficult. In Australia, information system development in healthcare was prioritised in the year 2000 when the ANZTC was wound up and national efforts were refocused on electronic health information systems (Mitchell, 1999). Despite this effort, in Australia, which now has a high level of penetration for electronic medical records in the primary and acute sectors, interoperability has been difficult to achieve (McDonald, 2015) and was of significant concern to the Australian health professionals I interviewed. According to one manager: [D]ifferent jurisdictions use different systems … the data goes to the central repository of that system and I think there’s eight or nine primary care systems in place in Australia. It’s ridiculous. You can’t get consistency in data collection because not only did the systems not talk to one another. The systems themselves are set up to gather different information slightly differently. A child health check might have different age thresholds for different things. (Ashton, Health service manager)

Yet, when information on patients could be shared between organisations, it was highly valued. An Australian physiotherapist commented, “I can look up any of their records and know what their history and what was done on a Tuesday of 2:00 o’clock. It’s brilliant” (Sasha, Physiotherapist). In Brazil, the challenges involved in sharing information are even greater: of the 48,000 health facilities, only about 58% have some form of electronic health record. Municipal health departments are able to

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decide which systems to use in their facilities and how they should connect with other systems. In the absence of state or national systems, some Brazilian health organisations are opting to collaboratively create their own local interoperability between systems. A Brazilian health technologist described how: last year we have acquired our own software, we opted for it. So we started, replacing the E-SUS system [an electronic medical record] of the Ministry…. Today, our primary care network is integrated with the mental health network, the CAPS, so we already see the same chart … we will have a unique medical record in our network for primary care, hospital, emergency or mental health. (Patricia, Telehealth coordinator)

One reason nominated for these difficulties in sharing information has been suggested by Thatcher (2016) as being rooted in the “immature IT solutions available from vendors” (p. 240). This immaturity of information technology is often attributed to the complexity of healthcare and, in the case of primary health, the “cottage industry” character of many providers (Department of Health and Ageing, 2012). Behind these explanations lie two inter-related issues shaped by the organisational contexts of healthcare. Firstly, when healthcare information is increasingly hosted within electronic information systems to support care, professionals use devices such as computers or smartphones to access information repositories or systems. Systems have evolved within the boundaries of hospitals and organisations and been designed to serve the needs of healthcare activities within those boundaries. But now, when technology-supported care at a distance has the capacity to extend health services outside the physical walls of health facilities and providers need to exchange information across places, “a shared record was almost a prerequisite to anything that was done … at a distance … or telehealth between facilities … and that is one of the fundamental building blocks” (Michael, Health service director). Communications networks that connect electronic information systems are also designed to service the needs of health professionals working within geographical boundaries, legal structures and financial rules set by each organisation. So, for example, when the devices used by health

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professionals for telehealth services are outside network boundaries, continuity of care becomes more difficult. A South Australian telehealth service reported that their devices “sit outside the SA Health network. I suppose the problem is like because they are patient use devices, technically we can’t connect them to an SA Health network” (Hunter, Technologist). Maintaining connectivity between multiple organisations can be very challenging. Internet-based networks are considered insecure. In some cases, such as in Queensland, therefore, organisations have built their own networks, which other healthcare organisations cannot use. Since the internal networks of health services, if they exist at all, connect facilities owned by that organisation, cross-organisational communication supporting telehealth services becomes difficult because “once you go outside of the digital telehealth they’re going to try and bridge into those other networks over the open internet it is just hopeless. It was. It drove me crazy of trying to do it. Connection problems” (Liam, Cardiology specialist). Secondly, the case for the use of information technology in healthcare is based on the proposition that within a healthcare organisation, automation of health records and processes, such as ordering examinations and medications, will improve the efficiency, reduce costs and ensure safe healthcare. Coiera (2013) questioned this proposition on the grounds that the design of health information systems at the level of clinical practice is different from the requirements of large-scale systems because: We are often told that national e-health projects must first lay down basic technical infrastructure and that high-value clinical systems will naturally follow, in the same way that laying railway lines is a precursor to delivering transport services. But railways can be too expensive, over-engineered, or not take us anywhere particularly useful — unless there is a destination on which we can all agree. (p. 178)

The implication of Coiera’s point is that priorities for healthcare and the design of automated health information systems are determined according to organisational boundaries. Unless those priorities include the interconnection of organisations, electronic health information systems may not prove to be particularly useful.

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In reality, the cost of building multiple place-based health information systems is large and efficiency benefits have been slow to accrue. According to the Queensland Audit Office (2018), “The consistent view expressed by stakeholders is that the electronic medical record is an investment in quality and safety of patient care … it will take longer and cost far more to realise the expected benefits than the department forecast”. A telehealth service manager observed that, as a consequence, “We’re now faced with how we operate in an environment where there are siloed implementations of [an electronic record]. It’s going to be a significant amount of time until we’re on a state-wide electronic medical record” (Robin, Health service manager). In principle, interoperable systems can provide access to health information such as patient records from distant locations, but many telehealth services still rely on older communications technology that requires manual intervention, such as email, text messaging, postal services and dedicated devices such as facsimile machines. One Australian doctor highlighted the “bizarre situation where in the 21st century we’re doing this fancy telehealth thing, but we’re still faxing clinical records back and forward” (Max, Trauma specialist). Interoperability of video-based telehealth services depends on devices, applications and networks which are often specific to an organisation and supplier, and do not interoperate with other systems. In one Australian state, the lack of any state-based guideline or power to enforce interoperability guidelines on independent health services meant that: people … go off and use Jabber, in La Trobe and Cisco hardware in Loddon Valley they can’t say that’s not, that won’t work within your region … you know Bendigo goes “Come in here”, and we will sit you in front of a Cisco piece of hardware and I go “that’s really not going to work with what I have”. I mean I have Polycom which does connect but not in the right places. (Elena, Telehealth manager)

Nevertheless, some organisations do try to interoperate with partners. In South Australia, a primary health organisation indicated that “the infrastructure that SA Health use for their DTN (Digital Telehealth Network) was a key consideration in our selection of technology” (Ryan, Primary health manager).

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In this chapter we have seen how three key processes have historically contributed to the current organisational contexts for telehealth services. These processes were organising of healthcare to improve the availability of care; structuring healthcare organisations and models of care across organisations; and automating healthcare information and sharing of health records across organisations. When care is shared across organisations, professional practices have to adjust. In the next chapter I consider what happens to professional practices when care is separated, the sociotechnical codes or norms of medical practice that are inherent in these practices and the control of technology used to support separated care.

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Department of Health and Ageing. (2012). State of corporatisation. Commonwealth of Australia. https://www.health.gov.au/internet/main/publishing.nsf/Content/foi-­disc-­log-­2012-­13/$File/222-­1213%20Doc%20 6%20State%20of%20Corporatisation%20Report%20-­%20February%20 2012.pdf Fleury, S. (2011). Brazil’s health-care reform: Social movements and civil society. The Lancet, 377(9779), 1724–1725. https://doi.org/10.1016/ S0140-­6736(11)60318-­8 Gonçalves, M. R., Umpierre, R. N., D’Avila, O. P., Katz, N., Mengue, S. S., Siqueira, A.  C. S., Carrard, V.  C., Schmitz, C.  A. A., Molina-Bastos, C. G., Rados, D. V., Agostinho, M. R., Oliveira, E. B., Roman, R., Basso, J., Pfeil, J.  N., Mendonça, M.  V. A., Moro, R.  G., Frank, T., Stürmer, P.  L., & Harzheim, E. (2017). Expanding primary care access: A telehealth success story. Annals of Family Medicine, 15(4), 383. https://doi. org/10.1370/afm.2086 Government of South Australia. (2015). Transforming health: Delivering transforming health – Our next steps. http://transforminghealth.sa.gov.au/resources/ useful-­documents/ Guanais, F. C., & Macinko, J. (2009). The health effects of decentralizing primary care in Brazil. Health Affairs, 28(4), 1127–1135. https://doi. org/10.1377/hlthaff.28.4.1127 Maldonado, J. M. S. de V., Marques, A. B., & Cruz, A. (2016). Telemedicine: Challenges to dissemination in Brazil. Cadernos de Saúde Pública, 32(suppl 2). https://doi.org/10.1590/0102-­311X00155615 McDonald, K. (2015). Why is e-health interoperability so hard? Pulse IT.  Retrieved from https://www.pulseitmagazine.com.au/news/ australian-ehealth/2271-why-is-ehealth-interoperability-so-hard Mitchell, J. (1999). From telehealth to e-health: The unstoppable rise of e-health. Federal Australian Department of Communications, Information Technology and the Arts. http://pandora.nla.gov.au/pan/12789/20131205-­1637/www. archive.dcita.gov.au/1999/09/rise.html Moura, L.  A. (2016). The need for a strategy for telehealth. Journal of the International Society for Telemedicine and eHealth, 4(0), e2 (1–7). Nicolini, D. (2007). Stretching out and expanding work practices in time and space: The case of telemedicine. Human Relations, 60(6), 889–920. https:// doi.org/10.1177/0018726707080080 Paim, J., Travassos, C., Almeida, C., Bahia, L., & Macinko, J. (2011). The Brazilian health system: History, advances, and challenges. Lancet (London,

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England), 377(9779), 1778–1797. https://doi.org/10.1016/S0140-­6736(11) 60054-­8 Perkovic, V., Turnbull, F., & Wilson, A. (2014). Is it time for medi-change? The Medical Journal of Australia, 200(10), 566–567. https://doi.org/10.5694/ mja14.00427 Queensland Audit Office. (2018). Digitising public hospitals (No. 10). https:// www.qao.qld.gov.au/reports-­parliament/digitising-­public-­hospitals Sabesan, S., Kelly, J., Evans, R., & Larkins, S. (2014). A teleoncology model replacing face-to-face specialist cancer care: Perspectives of patients in North Queensland. Journal of Telemedicine and Telecare, 20(4), 207–211. https:// doi.org/10.1177/1357633X14529237 Savage, B. (2009). Automation in hospitals and healthcare. In S. Y. Nof (Ed.), Springer handbook of automation (pp. 1379–1396). Springer. https://doi. org/10.1007/978-­3-­540-­78831-­7_77 Shaw, J., Gray, C.  S., Baker, G.  R., Denis, J.-L., Breton, M., Gutberg, J., Embuldeniya, G., Carswell, P., Dunham, A., McKillop, A., Kenealy, T., Sheridan, N., & Wodchis, W. (2018). Mechanisms, contexts and points of contention: Operationalizing realist-informed research for complex health interventions. BMC Medical Research Methodology, 18(1), 178. https://doi. org/10.1186/s12874-­018-­0641-­4 Telessaúde-UFRGS. (2018). Revisão do Protocolo de Neurologia Adulto. TelessaúdeRS-UFRGS. https://www.ufrgs.br/telessauders/noticias/ revisao-­do-­protocolo-­de-­neurologia-­adulto/ Thatcher, M. P. (2016). A framework of information technology governance controls in acute healthcare (Doctoral dissertation). Queensland University of Technology, Brisbane, Australia. https://eprints.qut.edu.au/96213/1/ Malcolm_Thatcher_Thesis.pdf Tudor-Hart, J. (2000). In a market-driven society, where can justice grow? Medicine and Humanity, 2001, 31–40. Viana, A. L. d’Ávila, da Silva, H. P., & Yi, I. (2017). Universalizing health care in Brazil: Opportunities and challenges. In I.  Yi (Ed.), Towards universal health care in emerging economies (pp. 181–211). Palgrave Macmillan UK. https://doi.org/10.1057/978-­1-­137-­53377-­7_7 Wade, V.  A. (2014). Uptake of telehealth services funded by Medicare in Australia. Australian Health Review, 38(5), 528–532. https://doi. org/10.1071/AH14090

7 Contested Professional Practices When Care Is Separated

Abstract  This chapter discusses how the management of care changes when care is separated. Changes to accommodate separated care impact the way appointments, examinations, procedures, administration and record keeping are managed. In professional contexts, practitioners are confronted with sometimes conflicting and sometimes complementary norms, processes and practices which taken together, function as sociotechnical codes. Conflicts can arise when choices have to be made between providing patient-centred care at home or reliance on established practices and patient pathways. Competition arises between information technologists, management and clinicians, collectively and individually, for control of the technology used by telehealth services. Disputes over healthcare and technology, based in competing sociotechnical codes, and the splitting of care between two or more places, require the active involvement of human actors to reconnect separated care.

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 A. Taylor, Healthcare Technology in Context, https://doi.org/10.1007/978-981-16-4075-9_7

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For more than a century, the place where interactions between health practitioners and patients take place has shaped the development of healthcare practices. This chapter is concerned with the way changes to accommodate separated care affect the practice of healthcare such as management of appointments, examinations, procedures, administration and record-keeping. Healthcare practices are encapsulated in the sociotechnical codes of healthcare adopted by health professionals working within their professional contexts. Professional contexts contain the interactions between people over the norms, processes, practices and the codes of telehealth services. In professional contexts, changes to medical practice mean that practitioners are confronted with sometimes conflicting and sometimes complementary norms, processes and practices. For instance, conflicts can arise when choosing between providing patient-centred care at home or relying on established practices and patient pathways; or when chronic disease care needs to be a cooperative integrated effort, but in practice medical professionals are siloed according to speciality. It is, therefore, not surprising that the health professionals I interviewed perceived medical practice as being resistant to change. Associated conflicts arise from the competition among information technologists, management and clinicians, collectively and individually, for control of the technology used by telehealth services. Understanding the nature of these conflicts requires an understanding of who controls healthcare. Is it management, clinicians or technologists who drive contemporary healthcare? The prime concern of clinicians is to retain control over practice, including technical elements pertaining to practice, such as information and communications systems. Managers, however, including managers of telehealth services, look to technological solutions to improve system efficiency, while technologists control the management systems of healthcare organisations using their accumulated institutional power, which is sometimes perceived to hinder clinical practice. In the midst of these conflicts, how are telehealth services being aligned with existing practice? My conclusion is that disputes over control of care and technology, competing sociotechnical codes and the splitting of the care role between two or more places take time to resolve and require the active involvement of human actors to reconnect care that has been separated using technology.

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7.1 S  eparation of Care: Challenging Usual Practice Separated care is not a new feature of medical practice. According to Ramos (2010), as long ago as 1764, William Cullen in Edinburgh, Scotland, engaged in: a flourishing mail order practice.… Cullen wrote approximately 20 consultation letters per year. This number jumped markedly to almost 200 a year from 1774 till his death in 1790. He had used an amanuensis (a dictation assistant) and an early version of a copying machine to make it quicker and easier for him to respond. If he did not know the condition well, he cautiously avoided making a diagnosis. For the acutely ill, he preferred hospital admission and personal care. (p. 2)

Despite huge changes in technological capabilities since 1774, more than a century of accumulated interactions between health practitioners and patients have become normalised in the form of personal face-to-face consultations in the place of care. Consequently, the splitting of the care role between two places and its reconnection using telehealth technologies requires a reworking of practice. This is necessary because the usual placebased practices used to collect information and assess a patient’s condition have to be performed at a distance. Any change to practice raises questions about the possible risks to the quality of patient management. In this study, clinicians were concerned about whether the information available to them using a telehealth service was sufficient for appropriate management of patients, and indicated to me that this judgement depended on the clinical context. An Australian GP recalled how she adapted to using video consultations for mental health consultations: a lot of what I did was gather up the evidence and say look there is evidence that you can conduct a mental health assessment as accurately by video consultation as you can in person. And then I would say however I need to tell you from my clinical experience and from watching lots of people do this, there are some situations where it doesn’t work so well and these are those, you know kind of things. So I guess what I’d give to them is the confidence that someone knows what they’re talking about. (Olivia, GP)

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When a video consultation replaced an in-person consultation, clinicians adapted their methods of eliciting clinical information. An orthopaedic surgeon commented: “I can say hi give me a high five please, he’ll give me a high five with the unbroken arm but I’ll then say no I want the other one” (Luke, Orthopaedic specialist). Where video technology has replaced telephone conversations, information quality has improved. A service which had previously relied on the telephone to provide advice to Queensland emergency departments moved to using video. This change occurred because clinicians felt that “what someone is describing on the phone and what you walk around the corner and see as a clinician are two very different things” (Isabel, Telehealth coordinator). The assessment of information quality is influenced by the purpose of the examination. A plastic surgeon had the view that video-based consultations: will never be as good as an in-person consultation. Because it will never quite give you the ability to look at a lesion on a head or a face or something like that with exactly the same clarity as you might have as if I got up and had a look at the thing on the cheek. (Lachlan, Plastic surgeon)

Some health professionals were more comfortable with remote consultations when another health professional was available to assist at the distal end, because “somebody has to take their blood pressure, feel their belly, listen to their chest” (Maya, Endocrinologist). Others insisted on “seeing the patient for the first time face to face and then doing the follow up or subsequent appointments by telehealth” (Kerry, Telehealth manager). Such changes in practice have not proved easy. In telerehabilitation, where interactions between a therapist and the patient are extremely important, there have been changes in the practice of separated care over the years: 10–15 years ago when people would have a proctor at the other end of the … you know you have someone sitting at the other end with the patient. It will be a clinician-to-clinician experience it wasn’t a clinician-to-patient experience. So they got very nervous when we were saying well there’s no one at the other end, it is just the patient and you are going to be doing that. (Sasha, Physiotherapist)

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Clinicians who relied on diagnostic test results to provide information rather than a physical examination of the patient tended to find the use of video consultations with patients easier. For instance, a cardiac specialist felt that not much had changed “apart from the fact that I can’t examine them. But that’s why we do the ECG and we do the basic observations” (Liam, Cardiology specialist). When a healthcare activity is mediated by any type of technology, a reworking of the etiquette used between health professionals and patients is required. For instance, introductions between doctors and patients using video conferencing technology become “a bit more formal and you can’t actually shake hands but you shake hands as such verbally and I always spend perhaps a few more minutes settling the patient and making them feel comfortable, explaining the technology” (Oscar, Mental health specialist). A study by Green et al. (2016) demonstrated how telehealth service providers in Queensland adapted their interactions with patients because of issues “around depersonalization … (and) how aspects of intangibility (such as loss of touch) are negotiated” (p. 488). Even when patients are co-located with clinicians in the same room, the presence of technology has to be considered: we had to change where people sit in the room because now we had two screens and the doctors need to type because generally if you’ve got notes on the desk you can write this way but you can’t do that so I had a barrage of complaints for about eight or nine months.… The doctor didn’t look at me. They didn’t talk to me! (Abigail, Nurse manager)

Because the majority of existing practice is place-based, the separation of care between places and its reconnection using telehealth services requires changes to workflows. Place-based healthcare requires the patient to attend at a physical facility which maintains its own workflow for managing activities for that patient. When care is provided at more than one place the management of patients and scheduling of appointments will differ. Scheduling appointments can be “a bit tricky sometimes, we try and embed telehealth as just part of the normal process just part of the normal clinic” (Isabel, Telehealth coordinator). Halford et al. (2010) showed how the organisation of work in Norwegian hospitals was disrupted because

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logistical and scheduling complications arose when telehealth services were used alongside place-based service provision, in part because a telehealth appointment or service requires a second workflow to be created at the other “end” of a telehealth service. A telehealth coordinator in Queensland summed up this issue and explained how he and his colleagues had reallocated clinical time to manage workloads: We have departments who perceive telehealth as a wholly different kind of service delivery and requiring a great deal of administrative time over and above what they’re already doing. And so they look at their administrative load … and think we just can’t do telehealth. It would be great for the patient but we just can’t do it because I can’t pull the doctor away from what they’re doing now … so they have agreed to essentially use the substitution model of telehealth where instead of doing a face-to-face clinic they’ll take that block of time the consultant will use that time to see patients. (Jacob, Telehealth coordinator)

Tensions between the established practices of in-person care and separated care represent contests between opposing sets of sociotechnical codes. Resolution of these tensions requires considerable work. As a physiotherapist recalled, it took time “to get our heads around it and to understand and to know what process worked and what didn’t” (Sasha, Physiotherapist).

7.2 Practice at a Distance: Adapting Norms Hitherto, most medical practice has been place-based and undertaken within the confines of a health facility. The expectations of, and rules learnt by, health professionals are based on accumulated experience of in-person interactions with patients within a facility. Therefore, the extent to which patients should be seen in person remains a concern for clinicians. While this concern was not expressed often by practitioners of telehealth, it is certainly of concern to the wider medical profession, although perceptions do seem to be changing as younger doctors enter the workforce. According to a Queensland telehealth coordinator:

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The staff physician’s not keen on telehealth. Much prefers to sit in with the patient, see the patient, touch the patient and prefers to do outreach and go and visit the outlying sites, as opposed to there are patients that could quite easily be seen by telehealth. There’s somebody that we just chip away with. As we get new younger doctors that are very  – they’re not technologically phobic [laughs]  – either, they encourage the older. (Elena, Telehealth manager)

A psychiatrist who had been practising telepsychiatry for many years noted that “there’s no doubt that for 90 percent plus of physicians, high quality practice means having a one-on-one with the patient in some form or other. And that’s what they’ve been brought up with and they genuinely believe” (Fletcher, Psychiatrist). Additionally, the norm of in-person consultations and associated remuneration processes has long influenced the ability of the health profession to control workloads and has remained so for telehealth services. With the advent of the telephone, an editorial from The Lancet of 1883 questioned the wisdom of teleconsultations because: when people can open up a conversation with us for a penny, they will be apt to abuse the privilege, and that to have a dozen telephone consultations in one day, or conversations that might be thought to supersede a consultation, would be a doubtful addition to one’s advantage or repose. (Aronson, 1977, p. 72)

Prior to the COVID-19 pandemic, Brazilian medical associations such as the CFM played a powerful role in resisting telehealth practice: “principally the CFM” (Eduardo, Family physician) are “preoccupied with protecting traditional practice … rather than considering the advent of technology and the need to be closer to people while being separated from them” (João, Health service manager). One of the reasons that Brazilian associations protected the status quo was the existence of a large private sector in which many health professionals owned independent businesses. Consequently, there were fears that Brazilian doctors will earn less through providing telemedicine services than they would in private practice (Felipe, Family physician). According to a primary healthcare manager, this meant that “the last item in the list is to protect the patient … and gynaecologists and paediatricians are very worried about losing employment” (Fábio, Health service manager).

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CFM regulations prohibited direct consultations with patients using technology. Brazilian telehealth services have navigated these restrictions because, as one telehealth coordinator indicated, “if we say teleconsultation, the CFM will close our doors tomorrow” (Marcos, Family physician). Another primary care manager indicated that medical trade unions feared that “you will need fewer dermatologists if this [telemedicine application] is used. We are defenders of the medical class, so we will not let this happen” (Luiz, Cardiologist). Fear of losing income is but one facet of an array of defensive arguments for the existing norms and practices of in-person care when confronted with new sets of sociotechnical codes. In Australia, similar fears were reported by a telehealth call centre manager: the whole project was sabotaged from the start, because of potential we were a threat.… Because if we’d shown that we can replace services currently provided (by) the people currently in those services … they couldn’t see that we weren’t trying to replace the face-to-face service. We were trying to augment the service. (Toby, Health centre manager)

A senior management view of these defences was that “standard power struggles that exist in every sector … our job is to say you’re not going to change that overnight, with an outcome view for patients in mind and understanding that is how cultures have been built over time” (Michael, Health service director). It was only at the end of the last century, that the use of telehealth services to improve patient outcomes was anticipated in a Medical Journal of Australia article, which stated: “by early in the next century, healthcare delivery will emphasise the importance of bringing care to patients rather than bringing patients to the healthcare system and tertiary hospitals, regardless of where patients live” (MacKinnon, 1997, p. 1). Subsequently, the “bringing of care to patients” as a concept has developed into the notion of “patient-centred care” where healthcare services focus on the needs of patients wherever they are located, preventative care has increased importance and multi-morbidities can be managed by a care team. Almeida-Filho (2011) links patient-centred care concepts to a “strong political demand to replace the reductionist, disease-orientated,

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hospital centred, specialisation driven pattern of medical education by one that is more humanistic, health orientated, focused on primary healthcare, and socially committed” (p.  1899). Many people I interviewed made the same connection, arguing that there is a need to reconceptualise healthcare models so that the “health system … would actually say, that’s a really important way to do business that actually meets the consumer or the health person’s needs, rather than them having to fit in with our needs. It’s a really big mind shift” (Australian psychiatrist). Telehealth services can enable healthcare providers to implement a patient-centred care model, but a shift in established cultural norms is then required. According to an Australian telehealth manager: clinicians aren’t known for wanting to do things differently.… For some people it was about a change in clinical practice and being hesitant about changing the way that they actually physically practised. And then for some people it was a personal culture around what’s in it for me as a clinician.… And that’s changed because there’s an overarching culture change in this district around driving a patient-centred service. (Emma, Telehealth coordinator)

Culture is a key component of sociotechnical codes. Parmelli et  al. (2011) observed that organisational culture “pertains to the multiple aspects of what is shared among people within the same organisation: for example, beliefs, values, norms of behaviour, routines, traditions, sensemaking” (p. 1). Cultures are complex, have been acquired over time and become entrenched beliefs and habits. They include tensions and conflicts about the nature of best medical practice, how to respond to patient needs and the role of specialists in team care. Many of the health professionals I spoke to felt that dealing with an unwillingness of clinicians to engage in cultural change led to “battling with clinicians who have always done things one way and not seeing the reason why they would change. And that’s still happening and that’s still the biggest battle” (Sasha, Physiotherapist). Certainly, before the COVID-19 pandemic, scepticism prevailed about the ability of the medical profession to change practice. A Brazilian family doctor felt that:

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we have an extremely conservative medical class, especially the people who are in the position of coordinating the medical councils and such. So we argue, for example, paediatricians who say that a family doctor cannot care for a child. (Fábio, Health service manager)

Similar opinions were expressed by an Australian doctor: “your big problem if you want me to push this … is the conservatism of the medical profession and it’s worse than that. It’s … a threat and it threatens what they’re doing. You know we’ve always done it” (Leo, Physician). The roots of this conservatism are complex. Learned attitudes about medical practice and relationships with patients are but one aspect of medical conservatism according to an emergency medicine specialist: You know the people that go into medicine are different … and they’re not necessarily as a group best communicators they’re very good at what they are which is how they actually get into it. So the idea of making things easy … they’re not too fussed about patients waiting or how they get to see them, as long as you’ve got patients and we’re doing the work. (Lachlan, Plastic surgeon)

Another factor, especially in Brazil, is that “the doctor often finds himself very powerful in some way, knowledgeable, infallible. This is often taught at university, so people think they know everything and often know nothing, or know less than they think they know” (Pedro, Family physician). However, several people I interviewed felt that generational changes were occurring in the medical profession as newly trained doctors with information technology skills entered the workforce: The cohort of doctors certainly that I have in my hospital and the kind of doctors that are coming out now are absolutely IT enabled … so none of my doctors really had problems but we have a fairly young workforce. Our oldest practitioners are in their late 40s, the majority are in their late 30s, early 40s and then younger. (Nicholas, Health service manager)

Many health professionals I met felt that the norms or sociotechnical codes of clinical practice were changing slowly, while acknowledging that this change depended on generational renewal of a conservative medical profession.

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7.3 C  ontrolling Separated Care: Aligning Technology Within professional contexts there are at least three key stakeholder groups interacting with each other and competing for control over separated care: medical professionals; doctors; management; and technologists. These interactions are structured by the role, interests and power of individuals and organisations. At the heart of these interactions is the concern expressed by the health professionals about the use of technology in healthcare. These concerns included a fear of technology, a lack of control over the use of technology and the rise of health information systems as a managerial tool in health organisations, all of which challenge the power of the medical profession. Fear of technology was commented on by many participants as “essentially a fear of the unknown. So a lot of them are fearful that they’ll have to know how to use the technology” (Sasha, Physiotherapist). Added to these concerns is the possibility of doctors “looking foolish and not being able to manage the technology” (Aiden, Acute care specialist). Maintaining the self-esteem of specialists was felt to be important during consultations involving distant GPs because “they feel like they’re being judged or assessed and some don’t like being put on the spot and GPs asking questions they don’t have the answer to, they feel like they’re being undermined” (Owen, Researcher). The use of technology in healthcare has been described by Ulucanlar et al. (2013) as a co-construction process where “diverse influences from the industry, healthcare organisation and practice, health technology assessment and policy interact to produce ‘technology identities’” (p. 95), and by Andreassen et al. (2015) as an organisational management tool for “allocating resources, generating and managing enthusiasm, system correction and aligning local practice and national policies” (p. 62). When technology is used as a management tool, the division of labour changes when new tasks and roles are created. Nicolini (2006) found: a recurrent pattern in the way labor is re-distributed following the introduction of telemedicine. Such redistribution assumes quite often the form

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of the delegation of clinical tasks to non-medical personnel and artefacts. According to my data, this pattern is strictly related to the nature of the technology (telehealth) itself. (p. 2760)

Guise et al. (2014) identified that new tasks and roles arising from the separation of care motivate resistance to the introduction of telehealth services alongside current practice. A simple example of a resistance to a new task was reported by a Brazilian telehealth advice service which found that doctors took the time they needed to use a telehealth service out of “direct patient care, because the computer was consuming more time, but they did not take time out of the coffee break” (Samuel, Physiotherapist). When technology is perceived as a management tool, disputes over control of it materialised in conflict between the institutional power of clinicians and technologists, conflicts which were almost impossible to overcome. According to one former information technology director, “in some cases I’ve lost my job over it … trying not to be a party to either of those sitting there saying it’s got to be done my way or the highway which is rarely successful for either” (Michael, Health service director). In other cases, conflicts between the powers of clinicians and technologists were resolvable. According to a clinician who was insisting on the provision of local technology support being made available for distributed telerehabilitation teams: [W]e had to go to the wall to get a technical person at each of the three sites because … rationally would have had it all centralised.… But I said no. It (has) all got to be down on the sites with the clinicians. (Marion, Rehabilitation specialist)

Expansion of electronic information systems has led to the creation of additional technology design, implementation and support roles. These roles have grown in importance within the public health systems of Australia and Brazil and gained an ability to shape investment programs in health organisations. Naturally, technologists are concerned to maintain control over information systems, so it is inevitable that the information technologists and medical professionals compete for control of this technology. One clinician felt that “IT systems have the feel that they

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constructed for the benefit of an administrator and for the bureaucracy rather than for the benefit of the patient” (Henry, Mental health specialist). The large investment in electronic medical records brings significant power to information technology departments, exercised through control of system design. Clinicians, mainly from Australia, expressed concerns about an inability to control information technology because “there is a massive disconnect between the clinicians and the IT guys” (Hannah, Manager). Clinicians felt that when they ask for help in establishing telehealth services, technologists “don’t really want to know about telehealth too much. So small request like, ‘Can we get wireless for the iPads?’ seems to be met with, ‘It’s a security issue’” (Hudson, Technician) or “Doing something like this will … will increase our risk profile” (Kerry, Telehealth manager). Additionally, the scale of the commitment made to large electronic record systems (EHR) operating in the acute care sector has limited the resources available to telehealth services. In one Queensland hospital, a telehealth coordinator noted that the hospital “is already digital and the rest of … goes digital over the next six months which means that trying to roll out any new telehealth is almost impossible” (Emma, Telehealth coordinator). In another state, a clinician observed that when they met a senior information technology manager, “I saw that it took up all his time … getting EPAS (an EHR) not working. And he was sort of very caught up with that” (Marion, Rehabilitation specialist).  There can be both acceptance and resistance to technology by the health profession (Hage et  al., 2013). However, it would be wrong to place responsibility for adaptation just on health professionals. Technologists have a role in developing acceptance of or creating resistance to telehealth services. For instance, Leverington and Bassa (2019) reported how a South Australia telehealth implementation model was changed to allow technologists to work closely with clinicians through a co-construction design process whereby technologists were physically co-­ located with clinicians. Co-construction entails more than just cooperation during a design process. A review of social practices and the uptake of technology in the healthcare sector by Shaw et al. (2017) argued that “health and care technologies need to be embedded within sociotechnical networks and made

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to work through situated knowledge, personal habits, and collaborative routines” (p. 1). Many researchers argue that telehealth services are most successful when tailored to existing professional practices. Barlow et al. (2003) recommended that telehealth services need to be integrated into the care system. Elbanna and Linderoth (2015) concluded that telehealth should fit with professional identity, institutional traditions, arrangements or work practices. The implication arising from these studies is that telehealth services should be designed to be accommodated to or fit within existing contexts. Why technology-enabled healthcare modalities should be viewed in this way, while other modalities are not, is not always clear, but existing and professional contexts, including clinical practice, authority and roles, clearly exert a powerful influence on the development of telehealth services. Health professionals I interviewed felt that once technology was aligned with clinical routines, initial fears and resistance tended to disappear: “now all of them compete and see how many patients they can bring in” (Owen, Researcher). The process of arriving at the point where splitting the care role between two or more places using telehealth services can be widely adopted by a health service takes time: time to resolve disputes over control of care and technology and time to agree on sociotechnical codes. It also requires the active involvement of health professionals. In the next chapter, I examine the first step in this process: the legitimisation of telehealth services for use in healthcare.

References Almeida-Filho, N. (2011). Higher education and health care in Brazil. The Lancet, 377(9781), 1898–1900. https://doi.org/10.1016/S0140-­6736(11) 60326-­7 Andreassen, H. K., Kjekshus, L. E., & Tjora, A. (2015). Survival of the project: A case study of ICT innovation in health care. Social Science & Medicine, 132, 62–69. https://doi.org/10.1016/j.socscimed.2015.03.016 Aronson, S. H. (1977). The Lancet on the telephone 1876–1975. Medical History, 21(1), 69–87.

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Barlow, J., Bayer, S., & Curry, R. (2003). The design of pilot telecare projects and their integration into mainstream service delivery. Journal of Telemedicine and Telecare, 9(Suppl 1), S1–S3. https://doi.org/10.1258/ 135763303322196132 Elbanna, A., & Linderoth, H. (2015). The formation of technology mental models: The case of voluntary use of technology in organizational setting. Information Systems Frontiers, 17(1), 95–108. https://doi.org/10.1007/ s10796-­014-­9513-­6 Green, T., Hartley, N., & Gillespie, N. (2016). Service provider’s experiences of service separation. Journal of Service Research, 19(4), 477–494. https://doi. org/10.1177/1094670516666674 Guise, V., Anderson, J., & Wiig, S. (2014). Patient safety risks associated with telecare: A systematic review and narrative synthesis of the literature. BMC Health Services Research, 14, 588. https://doi.org/10.1186/s12913-­014-­0588-­z Hage, E., Roo, J. P., van Offenbeek, M. A. G., & Boonstra, A. (2013). Implementation factors and their effect on e-health service adoption in rural communities: A systematic literature review. BMC Health Services Research, 13, 19. https://doi.org/10.1186/1472-­6963-­13-­19 Halford, S., Lotherington, A. T., Obstfelder, A., & Dyb, K. (2010). Getting the whole picture? New information and communication technologies in healthcare work and organization. Information, Communication & Society, 13(3), 442–465. https://doi.org/10.1080/13691180903095856 Leverington, S., & Bassa, A. R. (2019). A state-wide telerehabilitation service for South Australia. Australian telehealth conference, Brisbane. https://www.hisa. org.au/slides/atc19/ScottLeverington.pdf MacKinnon, M. (1997). Information technology in medicine. The Medical Journal of Australia, 167, 574–574. Nicolini, D. (2006). The work to make telemedicine work: A social and articulative view. Social Science & Medicine, 62, 2754–2767. https://doi. org/10.1016/j.socscimed.2005.11.001 Parmelli, E., Flodgren, G., Beyer, F., Baillie, N., Schaafsma, M. E., & Eccles, M. P. (2011). The effectiveness of strategies to change organisational culture to improve healthcare performance: A systematic review. Implementation Science, 6, 33. https://doi.org/10.1186/1748-­5908-­6-­33 Ramos, V. (2010). Contributions to the history of telemedicine of the TICs. 2010 Second Region 8 IEEE Conference on the History of Communications, 1–5. https://doi.org/10.1109/HISTELCON.2010.5735269

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Shaw, J., Shaw, S., Wherton, J., Hughes, G., & Greenhalgh, T. (2017). Studying scale-up and spread as social practice: Theoretical introduction and empirical case study. Journal of Medical Internet Research, 19(7), e244. https://doi. org/10.2196/jmir.7482 Ulucanlar, S., Faulkner, A., Peirce, S., & Elwyn, G. (2013). Technology identity: The role of sociotechnical representations in the adoption of medical devices. Social Science & Medicine, 98, 95–105. https://doi.org/10.1016/j. socscimed.2013.09.008

8 Legitimising Telehealth Services

Abstract  When care is separated, new practices must be legitimised. Guidelines defining the healthcare processes, codes of practice, ethical principles, work instructions and protocols and models of care which manage the risks of separated care are discussed. Strategies, guidelines and regulations, form the sociotechnical codes that health professionals rely on in their practice of separated care. Legitimisation of separated care occurs through  a socially interactive process within organisations and stakeholder groups which encapsulate norms of practice into organisational sociotechnical codes  which mitigate the risks to the safety of patients and the liabilities of clinicians. This chapter explores how the practice of separated care becomes legitimised. The questions that arise are whether organisational strategies, guidelines and regulations shape practice norms and how organisations adapt to and exploit the potential of telehealth services to improve access to healthcare.

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 A. Taylor, Healthcare Technology in Context, https://doi.org/10.1007/978-981-16-4075-9_8

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Clinical practices and processes have to take account of organisational strategies, norms, processes and the preferences of individual clinicians or teams to develop models of care for telehealth services. What, then, is the role of guidelines in defining healthcare processes, codes of practice, ethical principles, work instructions and protocols, and models of care? Guidelines in themselves may have limited influence, but when they are incorporated into administrative, financial, technological or clinical regulations shared by actors across a health system, they define the clinical processes to be undertaken (Bradford et al., 2016). Strategies, guidelines and regulations, whether explicitly stated or implicitly practised in clinical routines, become an integral part of the sociotechnical codes which inform professional health practice. I argue that legitimisation of separated care occurs when a norm is backed by and agreed to by social groups. Regulatory norms are agreed on at a political, governmental or organisational level and require that conflicts between stakeholder groups be resolved. My research shows that the development of strategies, guidelines and regulations is a socially interactive process which defines organisational norms. These norms, processes and practices used by organisations form the sociotechnical codes for telehealth services. As will be shown, adoption of these sociotechnical codes by social groups mitigates the risks to the safety of patients and the liabilities of clinicians.

8.1 Organisational Strategies Shape Norms Formal organisational strategies to encourage the use of telehealth services could be expected to lead to change in organisational practice. However, whether strategies are effective change agents is open to question. In a systematic review of the effectiveness of strategies in two North American health organisations, Parmelli et al. (2011) concluded, “current available evidence does not identify any effective, generalisable strategies to change organisational culture” (p.  1). The evidence from the interviews I conducted was that strategies are an effective tool, but cannot act in isolation: other measures are needed to supplement them.

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Telehealth strategies have been influential in the state of Queensland, a state where the large regional population stands to benefit from improved access to healthcare. The telehealth unit within Queensland Health has maintained a strategic plan since at least 2006, even though the main strategic focus of the organisation at that time was the development of patient information systems. A detailed policy statement (Queensland Government, 2012) on rural and remote health services widely promoted telehealth options and promised additional funding. Telehealth coordinators were employed to support telehealth service delivery models. For instance, a Telehealth Emergency Management Support Unit was created to provide emergency management advice for rural and remote communities. The latest Queensland strategy has taken a long-term view of health system directions. It aims to reduce “the need for face-to-face visits and opportunities exist to increase the scope and reach of telehealth services to include aged care and hospital in the home” by 2026 (Queensland Health, 2017, Goal 4). This policy seems to be filtering down to regional health services. A nurse telehealth coordinator in central Queensland welcomed strategic change resulting from the appointment of a new chief executive: “[A] new CEO … has really given us good direction … so everyone knows this is the direction we are going and telehealth is a very important part of it in the rural area” (Olive, Nurse). Strategies may be articulated indirectly through legislation and regulations. For instance, in South Australia, a new mental health act required faster access to consultant psychiatrists for general reviews and assessments. This led to infrastructure upgrades and the creation of the South Australian Digital Telehealth Network (which I mentioned in Chap. 5), as high-quality video consultations were thought to reduce the medico-­ legal risk to psychiatrists (Newman et al., 2016). Strategies and visions have been seen as key components of promoting organisational change (Todnem By, 2005). When organisational direction or strategy was absent, Australian and Brazilian professionals complained that the implementation of telehealth services became more difficult (Moura, 2016; Yellowlees, 2001). In the absence of supportive strategies for telehealth services, there was a flow-on effect to clinical practice. A Queensland clinician observed:

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[T]he most major barrier has been there is no strategic approach to driving telehealth within clinical departments, so there may be a contract between Queensland Health and the CEOs, but I don’t see any agenda items at operational levels about reporting on telehealth. (Flynn, Oncologist)

In Australia, strategies for telehealth services at the state level were developed without active national support. This reflects the more limited focus in Australia on improving access to state-based hospital outpatient services for regional populations by supplementing existing services. In contrast with Australia, Brazil has taken a strategic national approach, linking telehealth services to national policy aimed at improving primary healthcare. The Brazilian primary healthcare sector is large, with more than 45,000 primary healthcare facilities and 33,000 family health teams. The establishment of the Brazilian Telehealth Networks program is a prime example of a comprehensive national, social and political strategy aiming to educate and support primary healthcare workers. The conditions for this strategy were laid when a progressive federal government led by President “Lula” gained power in 2003 and commenced making significant investments in health and education services. Extensive national discussions on the potential for telehealth began in 2005, and the federal telehealth program was launched in 2007 (Messina & Filho, 2013; Silva, 2018). I interviewed one of the key architects of the policies developed during this period, who described how they had taken a holistic approach to changing the culture of the health system: We had a set of strategies for working in undergraduate courses, we had some strategies for professional education, technical vocational education, because in my department there was also the issue of professional technical education – 60% of our workforce in the Sistema Único de Saúde is of professionals of technical level, so we have to educate these professionals … we had to change undergraduate courses and have strategies to work with the professionals who were already in service… These policies had more or less three important parts. The first part is the concept of the health and disease process, including social determinants, so an enlarged and not simply a biological and pathological view of disease, as the philosophy behind all this policy.

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The second part was to use health services, as the setting for the training processes, integrating education and work for both undergraduate students and in-service health professionals, that is, involving the university and the health sector in developing capabilities together. And the third part was the use of active teaching and learning methodologies for working with the students – we used Paulo Freire a lot – discussed with him, working for projects, working in groups with flatter interactions and applying information and communication technologies. It was within this vision that one of the programs that we developed was the Brazilian national telehealth program. (Jakinda, Specialist)

As part of the Brazilian Telehealth Networks Program, states such as Rio Grande do Sul and Santa Catarina developed health service strategies which included telehealth services. These states now have well-developed, relatively large-scale services (Gonçalves et  al., 2017; Nobre & Von Wangenheim, 2012). In contrast, the most affluent state in Brazil, São Paulo, was unable to develop its own strategy, and its telehealth services are currently low volume and fragmented. Unfortunately, twelve years later in 2018, despite the existence of a national telehealth program, the political context of healthcare in Brazil had changed, and many healthcare workers were becoming concerned about the possible impacts of changes to the universal healthcare system (SUS) on telehealth services: We have a very strong threat to the SUS. Given the size of the threat, I do not know if Telehealth is going to be a priority, you know? There is a very strong threat to dismantle SUS. We have a Federal Government now that thinks that SUS is not possible to maintain and needs to be replaced with private health plans and this would dismantle the system. (Patricia, Telehealth coordinator)

Strategies by themselves may not support organisational change. Research in the UK noted a “gap between the enthusiasm of policymakers and technologists for telehealth and telecare and their more limited uptake in practice” (Greenhalgh et al., 2012, p. 11). Also, organisational strategies may not filter throughout organisations or result in changed investment priorities. When I asked a Brazilian technologist about the existence of ICT strategies in the state health sector, he replied: “If there are clear strategies … nothing that has been published or is publicly accessible,

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at least” (Miguel, Technologist). It is important to note that strategies require other measures to be taken such as the allocation or reallocation of resources to become effective. A senior Australian manager complained about: [the] utter lack of investment in change or systemic change.… You have lots of politicians, lots of health service managers all saying in one form or another telehealth or hospital in my home or integrated care or patient-centred care is the way of the future and then I step back from that. And say out of a hundred billion year to year how much have you invested systemically over a period of X years to actually look at doing this differently? (Michael, Health service director)

This last comment illustrates that while strategies may set organisational priorities, changes to clinical practice require additional measures to help legitimise them.

8.2 Guidelines and Regulations Shape Practices Guidelines legitimise telehealth services by prescribing their design and establishing new operational practices. In Chap. 2, I demonstrated that guidelines are written to improve quality and safety, to ensure responsibility for patients, to minimise professional liability and risk exposure and to provide advice on patient privacy and confidentiality and consent procedures. Written guidelines may not be a prerequisite for the implementation of new telehealth services: Clinicians rely on their clinical experiences, implicit knowledge and routines to guide their day-to-day work and refer to formal guidelines infrequently. Clinicians, especially in Australia, often extended their own established practices, for instance, triaging criteria into telehealth practice, without creating new written guidelines. However, where explicit guidelines existed, they were valued for the credibility, authority and protection provided against criticism or possible legal processes arising from adverse clinical events.

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There are many forms of guidelines. Guidelines can document procedures or work instructions which support the continued operation of services: “If I go on leave or the coordinator goes on leave and someone has to jump into our spots then those people have no idea what they’re doing. So we have to do the I guess the administrative type instruction set” (Emily, Oncologist). Guidelines can be quite comprehensive and have national applicability; for example, many health professionals relied on the Brazilian Telehealth Manual for Primary Care (Ministério da Saúde & Universidade Federal do Rio Grande do Sul, 2012) and the ACRRM Telehealth Handbook (ACRRM, 2017). Other types of guidelines are also important. Technical guidelines which inform technology design shape the user experience: “we feel that we roll out video conferencing equipment to … video conferencing industry standards” (Austin, Telehealth manager). Procedural guidelines documented instructions for the operation of technology: “a 2 pager, one side is the pre-consult and the other is the technical steps in actually creating a call” (Ryan, Primary health manager). A researcher in the field of telehealth summed up the impact of guidelines: Having some protocols or procedures I think are very useful to ensure appropriateness and also to streamline the process. If you’re going to be triaging cases for example, having a protocol that helps you identify what type of patients and with what conditions and what requirements would help kind of make sure that you’ve got the most appropriate person being seen at the appropriate time. (Owen, Researcher)

Flowcharts and operating procedures also provide guidelines that help to resolve conflict and mitigate risks. This type of guideline is a good example of the use of guidelines to add credibility, standardise approaches and reduce liability. For example, a trauma service operating in Queensland created a standard set of operating procedures where: the algorithms are all documented, there is almost like a book on the computer. Call from X goes to Y and they are all different. the focus has always been on what is it like for the person on the other end making the call. It is about making it as simple for them as possible, and if that means that our guys have to navigate a few different things to do it, it doesn’t matter, it is about providing a service to someone who is on their own, feeling scared. (Jake, Trauma specialist)

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One Australian telehealth coordinator relied on a guideline that mapped out “the very beginning of a telehealth consult all the way through to the end. The requirements of the nurses and requirements of the patients. It’s also included in our consent form that when patients come on to our service” (Alice, Telehealth coordinator). Not everyone agrees that the existence of guidelines is a prerequisite to successful implementation of new services. According to Bosse et  al. (2006), “systematic reviews of strategies for changing professional behaviour show that passive interventional methods of disseminating and implementing guidelines, such as their publication in professional journals, rarely lead to changes in professional behaviour” (p. 392). An allied health professional observed, “I think that the background of all the documents all the policies procedures and stuff can be done but I don’t think that that needs to be all organised and done before we actually provide the service” (Sasha, Physiotherapist). Many of the providers I met indicated that they made minimal or no use of any form of written guidelines. In this context, the limitations of guidelines were made clear by an Australian telehealth manager: a number of people have asked me for a list of things that are safe to do via telehealth and a list of things that aren’t in any kind of a rule book and I just keep going back to people who say we can’t do away with individual clinical reasoning in the context of the individual consumer. (Amelia, Health service manager)

Many doctors I met felt that their telehealth practice was “based on experience, based on the fact that every consultation case is seen either by myself or by … both of us are senior consultants who have done the job for decades” (Archie, Dermatologist). Others felt that guidelines in “the early stages they’re fairly important but the end goal would be that it just becomes no different to – it just becomes part of practice and that you don’t need them after a while” (Hannah, Manager) or they were “not necessary because (practice) is identical to in person, (and) does not change because I work by talking” (Specialist, Brazil). This last perspective illustrates the view that decision-making should be retained in the hands of clinicians rather than codified as practice in regulations or guidelines.

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We have seen that there is resistance to guidelines on the part of some clinicians. To overcome this resistance, regulations based in governmental or organisational authority are used as tools to maintain the status quo and to force change in existing clinical practice. Government legislation and regulations can limit or enable new forms of healthcare practice. Regulations can provide or deny permission to provide telehealth services and limit the scope of services through funding and reimbursement rules. Australian telehealth services are regulated through advisory guidelines prepared by health organisations and professional associations. Important regulatory reform occurred in Australia when national registration of health professionals was introduced in 2010 by federal legislation (Australian Health Ministers’ Advisory Council, 2018). National health practitioner regulation enables all registered health practitioners to practise across state borders; previously, such practice was difficult and limited the coverage of some telehealth services. Regulations have also had the effect of creating financial borders which circumscribe the delivery of telehealth services. Before the COVID-19 pandemic, with a few exceptions, Australian telehealth services were only able to claim government (MBS) subsidies for patients living in certain regional areas and residing more than 15 km distant from the provider, and then only for a limited number of procedures. One intent of these regulations was to protect regional medical practices from competition from metropolitan-based clinics and areas. The other intention was to ensure that government expenditure was protected from a then unknown increase in payments to meet an expansion in overall service use if a wider range of telehealth services was subsidised. Hence, in practice, the MBS rules defined geographical borders limiting the delivery of telehealth services. Brazilian telehealth services are no longer regulated by geography. Prior to the pandemic, they were highly regulated according to the type of technology that could be used, and direct consultations between clinicians and patients were not allowed. The Brazilian body that assumed authority over medical practice, the CFM, issued a number of regulations governing the activities of physicians, including the practice of telemedicine. Although these regulations did not technically have the force of legislation, they were interpreted as rules to be obeyed (Botrugno et al.,

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2019). Interpretation of these rules varied, and there have been consistent efforts to change them. Only after the advent of the COVID-19 pandemic did the national government pass legislation overriding these restrictions (see Chap. 1). While remote consultations with patients in Brazil have only been permitted recently, other forms of telehealth services such as physician-to-­ physician advice (second opinions or teleconsultorias in Portuguese) have been permissible for many years. The CFM last discussed revision of telehealth regulations in 2018. After a storm of criticism, those proposals were withdrawn. Two factors were behind the criticisms. Firstly, medical trade unions felt they had not been fully consulted and that continued employment of their members was threatened. One medical union stated its opposition to telemedicine because “to defend public access to quality public health … implies conditions for the exercise of good medical practices, from the adequate remuneration of the doctor … respect for professional ethics and life. Therefore, we cannot support on-line medical consultation” (Federação Médica Brasileira, 2019). Secondly, the timing of the proposed revisions to regulations was unfortunate because they were circulated during the national elections in late 2018. Groups operating on social media opposed to the “socialisation” of healthcare were able to link telemedicine to an opposition political figure who happened to have been a leading figure in the promotion of telehealth services under the previous government. These groups cast the CFM proposals as a coup against the status quo and went on to attack “the wife of the (unsuccessful ex-­ presidential candidate) who was behind the telemedicine coup” (Cardoso, 2019). Regulatory definition of telehealth services also occurs at the state level in Brazil. Regulations issued by commissions of municipal and state representatives coordinate patient management across the municipal and state levels of the health system, with the aid of the Federal Government (Sousa et al., 2019). From 2015 onwards, many states began to use these commissions to approve protocols or regulamentos (regulations) requiring treating doctors to follow state-wide referral protocols which require them, in some cases, to obtain advice from telehealth advice services, either online or via the  telephone. For instance, in the state of Santa Catarina, the teleadvice service “implemented mandatory teleconsulting for

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access to specialists. So, before a referral to the orthopaedic specialty, we implemented mandatory telehealth advice. So, in this way, we generated significant improvement” (Juliana, Health service manager). A mandatory referral protocol for dermatology (Piccoli et al., 2015) was implemented in 2013 because “things at least here in Brazil work if you have a clear process. So the way to force staff to make this referral through Telemedicine has been by creating this regulation” (Lucas, Dermatologist). Regulations were seen by Brazilian doctors as an important strategy forcing change in existing routine practice, because “we have to create a compulsory trigger for the use of teleconsultorias, so that it becomes a routine in the process of a doctor’s work, and that he is forced to update himself, forced to learn” (Emanuel, Telehealth coordinator). As a result, in some states these regulations led to a large increase in the use of telehealth services (Von Wangenheim & Nunes, 2018) and to significant reduction in unnecessary referral of patients to specialists.

8.3 Social Interactions Influence Practice While guidelines and regulations may appear to influence clinical practice directly, it is actually the interactions between individuals and groups of individuals adopting new models of care which act as the causal mechanism for practice change. A specialist I interviewed felt that guideline development required collective social activity to “show to people that is a credible group of people. So you got to do (guidelines) with organisations. So we did it through the Oncology Society of Australia and the College of Physicians” (Flynn, Oncologist). New telehealth models of care tend to be built on known, existing relationships, processes and technology, but their implementation can be difficult when contradictory practices exist, such as place-based appointment systems, unregulated patient entry points, siloed medical records or disincentives to collaborate with fellow practitioners. It is for this reason that Krupinski et  al. (2011) recommended that site coordinators of telehealth programs should have “strong organizational skills and the ability to work with other health care providers” (p. 1280), thereby illustrating the importance of social relationships and interactions in implementing telehealth services.

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Any new models of care require additional work to create new practice norms. When care is separated and then reconnected using video consultations, patients at a distant end need to be booked into a videoconferencing system and, in many cases, booked into a room in a distant health facility. An Australian specialist indicated: You know there’s all this sort of extra work that needs to be done. So despite the fact that we might be there hooking in for one hour seeing four or five patients what will happen to prepare for that hour is a couple of other hours work. We also have admin staff here doing our other paperwork here and making sure our letters and charts and everything are okay for our end. (Maya, Endocrinologist)

Separated care also requires additional work to standardise the social interactions occurring during patient referral to other doctors. A specialist practice in Queensland reported that “We just done like flow sheets and things like to send out to doctors this is what you need to do to do the referral” (Madeleine, Nurse). Scheduling of appointments for these referrals was a particularly difficult problem raised by Australian participants, because “liaising between our doctors the GP and the patient and getting that all lined up at a set day a set time that suits everyone is incredibly difficult” (Zara, Cardiologist). Changes to medical practice inevitably require changes to schedules and routines. For example, an Australian telehealth coordinator built a flowchart to map the processes required by telehealth clinics to: make sure everybody from medical officer to nursing to midwives to admin, to allied health are across … multiple people across all sides. So we need to make sure everybody knows the process, everybody knows what’s going on and there’s multiple telehealth clinics with each site … everybody knows that you do this clinic you do this, this clinic you do this, so that when they have a temporary staff member come in or a medical officer or admin come in, it does not matter if you just say look this is what you do, get the flowchart, follow this. (Isabel, Telehealth coordinator)

It is mainly the nurses and administrative staff who do this additional work of patching existing place-based systems that cannot facilitate cross-­ facility bookings or give access to shared patient records.

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Tensions over what is considered normal or additional work occur when pathways for separated patient care have not yet been mapped into existing practice norms. Ultimately, tensions over changes in practice and technology, and the risks of separated care are resolved through developing social relationships. As I discussed in Chap. 3, social relationships work within social groups or “norm circles” to encode new practices into explicit and implicit strategies, guidelines and regulations, which I have described as sociotechnical codes. Sociotechnical codes influence the use of technology in practice and help to build confidence, as I show in the next chapter on the building of confidence in telehealth practices.

References ACRRM. (2017). Handbook for the telehealth online education module. http:// www.acrrm.org.au/docs/default-­s ource/documents/rural-­a nd-­r emote-­ medicine-­resources/handbook-­for-­telehealth-­online-­education-­module-­ final.pdf?sfvrsn=0 Australian Health Ministers’ Advisory Council. (2018). Regulation of Australia’s health professions: Keeping the national law up to date and fit for purpose. https://www.coaghealthcouncil.gov.au/Portals/0/Regulation%20of%20 Australias%20health%20professions_Keeping%20the%20National%20 Law%20up%20to%20date%20and%20fit%20for%20purpose%20 FINAL.pdf Bosse, G., Breuer, J., & Spies, C. (2006). The resistance to changing guidelines – What are the challenges and how to meet them. Bailliere’s Best Practice in Clinical Anesthesiology, 20(3), 379. https://doi.org/10.1016/j. bpa.2006.02.005 Botrugno, C., Goldim, J. R., & Fernandes, M. S. (2019). O telessaúde Brasil redes: Um sistema tecnologico “socialmente engajado.” Latin American Journal of Telehealth. http://cetes.medicina.ufmg.br/revista/index.php/rlat/ article/view/271 Bradford, N., Caffery, L., & Smith, A. (2016). Telehealth services in rural and remote Australia: A systematic review of models of care and factors influencing success and sustainability. Rural and Remote Health, 16(4), 4268. Cardoso, F. (2019). Caneta Desesquerdizadora da Saúde – Posts. https://www. facebook.com/pg/CanetaDesesquerdizadoradaSaúde/posts/

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Federação Médica Brasileira. (2019). Sindicato dos Médicos publica carta contra telemedicina. Federação Médica Brasileira. http://portalfmb.org. br/2019/02/06/al-­sindicato-­dos-­medicos-­publica-­carta-­contra-­telemedicina/ Gonçalves, M. R., Umpierre, R. N., D’Avila, O. P., Katz, N., Mengue, S. S., Siqueira, A. C. S., Carrard, V. C., Schmitz, C. A. A., Molina-Bastos, C. G., Rados, D. V., Agostinho, M. R., Oliveira, E. B., Roman, R., Basso, J., Pfeil, J.  N., Mendonça, M.  V. A., Moro, R.  G., Frank, T., Stürmer, P.  L., & Harzheim, E. (2017). Expanding primary care access: A telehealth success story. Annals of Family Medicine, 15(4), 383. https://doi.org/10.1370/afm.2086 Greenhalgh, T., Procter, R., Wherton, J., Sugarhood, P., & Shaw, S. (2012). The organising vision for telehealth and telecare: Discourse analysis. BMJ Open, 2(4), e001574. https://doi.org/10.1136/bmjopen-­2012-­001574 Krupinski, E. A., Patterson, T., Norman, C. D., Roth, Y., ElNasser, Z., Abdeen, Z., Noyek, A., Sriharan, A., Ignatieff, A., Black, S., & Freedman, M. (2011). Successful models for telehealth. Otolaryngologic Clinics of North America, 44, 1275–1288. https://doi.org/10.1016/j.otc.2011.08.004 Messina, L. A., & Filho, J. L. R. (Eds.). (2013). Impactos da Rede Universitária de Telemedicina, Phase 1 2006–2009. E-papers Serviços Editoriais. http:// www.e-­papers.com.br Ministério da Saúde & Universidade Federal do Rio Grande do Sul. (2012). Manual of telehealth for primary health care. http://189.28.128.100/dab/ docs/portaldab/publicacoes/manual_telessaude.pdf Moura, L.  A. (2016). The need for a strategy for telehealth. Journal of the International Society for Telemedicine and eHealth, 4(0), e2 (1–7). Newman, L., Bidargaddi, N., & Schrader, G. (2016). Service providers’ experiences of using a telehealth network 12 months after digitisation of a large Australian rural mental health service. International Journal of Medical Informatics, 94, 8–20. https://doi.org/10.1016/j.ijmedinf.2016.05.006 Nobre, L. F., & Von Wangenheim, A. (2012). Development and implementation of a statewide telemedicine/telehealth system in the State of Santa Catarina, Brazil. In K. Ho, S. Jarvis-Selinger, H. Novak Lauscher, J. Cordeiro, & R.  Scott (Eds.), Technology enabled knowledge translation for ehealth: Principles and practice (pp. 379–400). Springer. Parmelli, E., Flodgren, G., Beyer, F., Baillie, N., Schaafsma, M. E., & Eccles, M. P. (2011). The effectiveness of strategies to change organisational culture to improve healthcare performance: A systematic review. Implementation Science, 6, 33. https://doi.org/10.1186/1748-­5908-­6-­33

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Piccoli, M. F., Amorim, B. D. B., Wagner, H. M., & Nunes, D. H. (2015). Teledermatology protocol for screening of skin cancer. Anais Brasileiros de Dermatologia, 90(2), 202–210. https://doi.org/10.1590/ abd1806-­4841.20153163 Queensland Government. (2012). Better health for the bush. https://www.health. qld.gov.au/__data/assets/pdf_file/0027/436815/better-­health-­bush.pdf Queensland Health. (2017). Digital health strategic vision for Queensland 2026. Queensland Government. https://www.health.qld.gov.au/__data/assets/pdf_ file/0016/645010/digital-­health-­strat-­vision.pdf Silva, E. A. da. (2018). Análise dos Impactos da Telessaúde na Formação dos Profissionais da Atenção Básica de Saúde. Latin American Journal of Telehealth. http://cetes.medicina.ufmg.br/revista/index.php/rlat/article/view/266 Sousa, N. L., Macedo, K. P. S., Martins, J. V. F., & Galvão, M. L. dos S. (2019). Integração do telessaúde com a central de regulação ambulatorial no estado no Ceará: Um relato de experiência. Latin American Journal of Telehealth. http://cetes.medicina.ufmg.br/revista/index.php/rlat/article/view/273 Todnem By, R. (2005). Organisational change management: A critical review. Journal of Change Management, 5(4), 369–380. https://doi. org/10.1080/14697010500359250 Von Wangenheim, A., & Nunes, D.  H. (2018). Direct impact on costs of the teledermatology-centered patient triage in the State of Santa Catarina analysis of the 2014–2018 data. Instituto Nacional para Convergência Digital. https:// doi.org/10.13140/RG.2.2.20044.92807 Yellowlees, P. (2001). An analysis of why telehealth systems in Australia have not always succeeded. Journal of Telemedicine and Telecare, 7(suppl 2), 29–31. https://doi.org/10.1258/1357633011937056

9 Building Confidence in Telehealth Practices

Abstract  For telehealth services, acceptance of the technology was the first step in building confidence. Triaging of patients for clinical condition and suitability for participation in telehealth services were seen as a key process to control the perceived  risks of separated care. Management of the risks and the development of trust combined to reduce conflicts over the limitations of telehealth services. The establishment of trust changes behaviour at the individual level and group level, assisted by interactions with implicit and explicit sociotechnical codes that inform practices, habits, mental models and routines supporting separated care. This chapter discusses how confidence in separated care is built, how the technology supporting separated care becomes accepted and how the risks of practice are negotiated. In exploring how confidence is built, my interviews in Australia and Brazil revealed that acceptance of telehealth

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services was seen as related to the skill base or digital literacy of physicians, the training received, and the usability of the technology, all of which evolved over time. For telehealth services, acceptance of the technology was just the first step in building confidence. The next step was to manage the perceived risks of separated care. Triaging of patients for clinical condition and suitability for participation in telehealth services was seen as a key process to control risk. Management of the risk and the development of trust combine to reduce conflicts over the limitations of telehealth services. Risk management and trust building by health professionals support confidence in the ongoing use of telehealth services. Risk can be managed through using guidelines to build trust between groups using risk mitigation strategies (Taylor, 2015). Trust building changes behaviour at the individual level (clinicians) and group level (organisations), assisted by interactions with implicit and explicit sociotechnical codes held as practices, habits, routines and mental models. Confidence in separated care increased when sociotechnical codes supported modified procedures and routines. By implementing routines to choose (triage) patients who could be easily cared for at a distance, and by managing a range of risks, health professionals were able to build trust in the practices of separated healthcare.

9.1 Accepting Technology in Practice The use and acceptance of telehealth services by health professionals and patients has been studied from the perspectives of the technology acceptance model (TAM) and the theory of planned behaviour (TPB). These perspectives are derived from behavioural psychology models (Davis, 1989) and psychometric research into the use of information technology. As I showed in Chap. 3, these techniques can inform the study of technology acceptance by providing evidence of correlations between variables, but lack a multidimensional analysis of human behaviour. Porpora (2015) remarked, “even in the rigorous form of a regression equation [they] cannot serve as an explanation” (p. 62). Health professionals in Australia and Brazil revealed that acceptance of telehealth services was related to the skill base or digital literacy of

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physicians, the training received and the usability of the technology. The Organisation for Economic Co-operation and Development (OECD, 2020) confirmed that digital literacy among health professionals is an issue because: Around one third of health workers in the OECD report not being accustomed to using digital solutions due to gaps in knowledge and skills in data analytics. Some countries are working towards developing clinical informatics skills and improving digital literacy among health care workers… However, none of the policies and initiatives reported involve bottom-up and coordinated approaches across the education, health and ICT sectors. (p. 31)

I observed that the digital literacy of health workers using telehealth services varied according to education and was determined in part by generationally acquired skills. Digital literacy, in particular among physicians, was seen as important, especially for older physicians, whereas younger doctors were already using mobile devices and video applications. An Australian telehealth manager felt that “people are more resistant to technology change still because we have still got lots of people in the workforce who are not digitally confident” (Elena, Telehealth manager). Digital literacy was also related to the experience of physicians. Shulver et  al. (2016) found that being a more experienced physician could also confer more confidence in the management of clinical risks when using telehealth services. Prior to the COVID-19 pandemic, incentives to use technology were limited and, according to a nurse, “it took a long time and it took some harsh conversations” (Alice, Telehealth coordinator) for clinicians to start using telehealth services. The major mechanism for increasing the use of telehealth technologies seemed to result from professional interactions. In small teams, there was a snowball effect, as another nurse observed: “all of a sudden RN (Registered Nurse) Y will use it and all of a sudden it will be RN X and RN Y. So once people use it it’s there and they think about it” (Blake, Nurse). A researcher who had been trying to encourage the use of telehealth services for some time observed that:

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amongst the surgeons who simply refused to do it and said there’s just no way we’re doing it – there were half a dozen of them – went to the stage of eventually one said that he’d give it a try and then the second person saw that person and became competitive and all of them have started doing it. (Owen, Researcher)

Training to improve the digital literacy of physicians is a recommendation found in many Australian telehealth guidelines. Training can be seen as a more formalised form of professional interaction, often undertaken in the workplace. For instance, when supporting emergency medicine, training was “a very large component of what we do. I’m doing some training this afternoon with one of the rural sites.… But definitely education and training is just ongoing. We see it as bread and butter work for us” (Blake, Nurse). Formal training also takes place in some university medical courses. An Australian professor told me, “we actually we put it into all our exams now … everyone had to go online and do the you know the telehealth group [ACRRM] … they’ve got this online course for clinicians” (Marion, Rehabilitation specialist). All the Brazilian telehealth centres I visited explicitly promoted education and training as a key activity because “to teach is to do. This is the philosophy that created telehealth” (Rod, Telehealth centre manager). Many telehealth practitioners I interviewed argued that the acceptability of telehealth services could be improved by employing “digital” consumer devices with which people were already familiar. The rationale for this argument was that consumer devices, such as a mobile phone, were easier to use. This finding can be related to the concept of sociotechnical codes if we remember that users of consumer devices learn the sociotechnical codes for these devices outside their professional lives. The design of consumer devices when used for healthcare activities, therefore, matches existing mental models. The alignment of users’ existing experiences, knowledge and skills (their sociotechnical codes) with the operating assumptions designed into new technology can be achieved through education to improve “digital literacy”. Alternatively, it can be achieved by designing the technology to be compatible with existing competences, thereby incorporating pre-­ existing sociotechnical codes into the technology. According to one

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technologist, this matching of design with existing models could be achieved through co-design activities: [W]e actually did a design team that involved two clinicians embedded and actually co-located with the development team so that there was an immediacy of feedback of does this work and getting that and 1) the actual delivery time I would say it was halved and 2) there was absolute engagement from the end users … when they hear that two clinicians had designed this. (Ali, Technologist)

The work to align sociotechnical codes plays a role in acceptance of technology, but there are perceptions that there is additional work required to change practice. For instance, in North Queensland, practice changes were seen as generating additional work: I think with old school doctors you walk into clinic, see a patient face to face and that’s it. Some of them see it as extra work: having to log on, dial in and see that patient in Charters Towers or wherever when patients could just come in and be part of the clinic. (Annabelle, Telehealth coordinator)

But when that additional work was done by Annabelle with “an initial appointment organised for them by our team, their whole mindset changes and then they realised it’s really good. Once you get over that mindset that it is something extra that I have to do”. This additional work linked to practice change can be viewed through different lenses. On the one hand, patient waiting lists can be reduced by introducing new practices in primary care. For instance, when a patient with high blood pressure and diabetes “goes to a health post and says that ‘the cardiologist said that I have to see an endocrinologist’. And I say ‘no, I can treat diabetes. It is not necessary’. And there is conflict” (Pedro, Family physician). On the other hand, in a small clinic: at 3 o’clock in the morning and you’ve got three assistant-in-nursing on with one registered nurse, the easiest thing for them to do from a resourcing perspective is to say you need to go to a hospital and you need to go. They don’t want to be a video conference with an ED [Emergency Department] physician telling

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them that they need to give fluids, start antibiotics, whatever the management plan may be. (Robin, Health service manager)

Reluctance to undertake the additional work required to access telehealth advice services was explained by a Brazilian technologist as because “many professionals do not want to sit at a computer, they do not want to spend time, to do that” (Eloá, Telehealth centre manager). Use of a computer was seen by some doctors as an additional task which should be done outside of working hours. According to a family doctor, “the doctor goes home, thinking of an unresolved patient case … at 08:30 at night he accesses the platform and says: ‘Look, I have a problem’. But ideally he could do this while he works” (Gustavo, Family physician). This viewpoint was echoed by a specialist quoting the example of the adoption of electronic medical records in Queensland: “the (electronic medical record) … imagine you left it to the clinicians and we will let you decide to use it. It would never have happened” (Flynn, Oncologist). Although the work to align old and new practice is a burden for some health professionals, for others the potential to change practice provided an opportunity to improve healthcare. Shulver et al. (2016) found that the clinicians most willing to practise telehealth services “were focussed on the potential for telehealth to achieve better outcomes for patients, and were willing to re-think and adjust their practice to provide distance healthcare” (p. 10).

9.2 Managing Risks of Practice The transition from old to new practice requires confidence in the new mode of service delivery. For technology-based services, acceptance of the technology was the first step in building confidence in new telehealth services. The next step is to manage the perceived risks of the new service. Estimation of risk is a well-established process in industry, for example, for quantitative measurement of component failure rates, or for qualitative assignment of risks to indicate the degree of risk which may be incurred by organisations (ISO, 2018) during their business activities. Risk assessment in healthcare is well developed, especially in acute and

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trauma care (Cameron et  al., 2014) where risk assessment coordinates care by triaging patients for the most appropriate treatment. Triaging in telehealth services at the acute level is, therefore, an important component of telehealth services in Australia. Kyle et al. (2012) describe how: coordination ensures that high level clinical advice is available prior to and during transport, that expensive transport and clinical retrieval services are used safely and efficiently, and that the patient is directed in a timely manner to the most appropriate receiving facility. (p. 147)

Returning to the example of the Scottish doctor who managed patients via the postal service given in Chap. 7, we can see how he retained control over his practice by establishing triaging processes to choose the patients he wished to take on, and how his role as a doctor subsequently expanded to include letter writing to patients. Many telehealth services that I encountered had put in place risk management rules in the form of clinical processes (triaging) to determine which patients could safely be managed using telehealth services. Modifications to patient triaging rules for subsequent referral, for remote management or for immediate in-person treatment were the most important practice changes made when telehealth services were adopted. Brazilian referral systems and telehealth advice centres regulate the application of triaging protocols derived from evidence-based medical knowledge for referral of patients to specialists (known as regulamentos). As a result, Brazilian telehealth services have made the provision of evidence-­ based advice and education for primary healthcare practitioners a centrepiece for their services, and the benefits of evidence-based practice are at the centre of a struggle challenging the pre-existing norms of practice. As I outlined in Chap. 8, use of triaging guidelines for participation of patients in telehealth services, based on their clinical condition, is the principal process employed to manage the inherent risks or limitations of telehealth services. Triaging of patients for telehealth services extends existing triage practices (both implicit and explicit) with the addition of criteria for urgency and the distance (and hence travel time) involved for the patient or clinician for a physical appointment. Clinicians triaging patients often compared prior practice (face-to-face appointments) with

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appointments via telehealth services and looked for equivalent levels of risk when justifying their practice. Risk management rules are discipline-­ specific and context-dependent: elemental safety plans have been described by Luxton et al. (2010), and telecardiology risk management in South Australia has been discussed by Wade and Stocks (2017). A South Australian mental health service which has developed over more than 20 years attributed its continued existence to a number of factors, including co-location of teams and use of triaging protocols (Hyde & Fielke, 2009). In my study, both doctors and nurses reported undertaking triaging in this service where “a set of senior nurses … do a triaging, (a) sort of brief intervention whatever if they think a psychiatrist needs to come in then they organise it” (Henry, Mental health specialist). Triaging of patients for suitability to participate in telehealth services was seen as a key process to control for risk by all the clinicians I interviewed. A variety of triaging methods and criteria were evident. In Brazil, where telehealth services focus on primary healthcare, Pfeil (2018) documented how triaging systems or processes play an important role in managing patient referral to specialists using agreed protocols or regulations. In the USA, Bashshur et al. (2020) recommended that “ideally, the triaging system would be implemented state wide or region wide for maximal efficiency” (p. 572). Brazilian telehealth services use exactly this type of state-wide, formal process of triaging to regulate and reduce waiting lists for specialist treatment. In Brazil, central state- or municipality-wide units examine the information provided by referring primary health doctors. On the basis of that information, patients are allocated a place in the waiting list, or the referring doctor is asked to provide further information. The decision to refer a patient always rests with the primary health doctor. Telehealth advice lines provide assistance to primary health doctors during this referral process which has successfully reduced the waiting lists in many specialities. According to one doctor from Rio Grande do Sul, the impact of triaging and telehealth services reduced the waiting list from 190,000 people in July 2014 to 97,000 people in May 2016. We have seen good results. For every three patients we triage, we are able to treat two in primary healthcare … because when we elaborate the triaging protocol,

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we look at waiting lists and establish protocols that take account of 80 to 85% of problems. (Emanuel, Telehealth coordinator)

Decisions to use triaging processes have to weigh the risks of separated care against the risks of delaying an intervention until a place-based appointment can be organised. Australian telehealth services triage patients on a variety of criteria, including the distance the patient has to travel: “It is generally because they are most isolated that we choose them, because they can’t get in all the time and so you offer them that solution” (Diane, Nurse). Triaging can give priority to high-acuity patients: “I’ve seen patients for the first time. I have. It’s not my preferred way again because I should be able to examine the patient and I can’t. So these are the emergency visits” (Emily, Oncologist). Adaptation of the current state (in this case, place-based consultations perceived as having low or known risks) to a new state (where separated care is delivered at a distance) brings tensions over potential new risks. It could therefore be expected, given widespread societal concerns about the privacy of information held or transmitted on electronic platforms, that this would be of concern to practitioners of telehealth services. Yet, privacy issues arising from the separation of care did not feature strongly in the views of the health professionals that I interviewed. The health professionals I met who expressed concerns about possible breaches of patient confidentiality had either put in place processes to protect information, “we instruct professionals to delete photos” (Valentina, Health service manager), or relied on safeguards in the technology platform: “you need to make sure that your video conferencing platform is secure” (Sasha, Physiotherapistt). Legal or ethical risks arising from the use of telehealth services were discussed by some health professionals. Responsibility for the patient is one such issue, because care across places introduces more than one medical professional into the care process; for instance, “there are cases that went wrong by telehealth where there was a problem with who was really responsible” (Marion, Rehabilitation specialist). For clinicians, judgement of clinical risks was clearly more important than privacy, legal or ethical concerns.

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Some, such as an intensive care specialist, felt that “the truth of the matter is most people couldn’t give a stuff (about privacy)” (Lachlan, Plastic surgeon). A manager compared the security of telehealth technologies to established technologies because “we’re still using fax machines in hospitals to transfer very significant clinical documentation. Why? Because that’s what we trust and that’s what the system is built around” (Robin, Health service manager); a mental health professional pointed out, “the irony is I guess a telephone conversation or a fax machine can be intercepted by phone more easily than video material” (Chloe, Pain specialist). Privacy risks arising from the use of devices were seen as controllable, and clinicians were able to make judgements about the possible privacy risks when using technologies for healthcare activities. According to an Australian researcher working with GPs: most GPs didn’t, the first time they picked up a mobile phone, decide they’d take photos of all of their patient records and carry them around with them. They actually developed an ongoing sense of what’s appropriate, what’s not? I’m willing to talk to my patient online, I’m willing to get an email from them – those sorts of things. (Georgia, Palliative care researcher)

Clinicians also formed their own independent judgements on the risks of using different technologies even when technologists gave advice that a particular technology (such as Skype) should not be used. “I don’t know what the rules are actually. It’s not official policy but we certainly use it [Skype]” (Darcy, Paediatrician).

9.3 Creating Trust in Practice Trust can be interpreted as the acceptance of a risk after steps have been taken to reduce a risk, or as the absence of unresolved concerns, conflicts and contradictions. Changes to roles, re-division of work and threats to established interests are examples of risks that can lead to conflict. Relationships change when care is separated because tasks and roles previously undertaken by one provider (e.g., the consultant) are taken over by a provider (nurse or GP) who is co-located with the patient. When roles

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change, relationships and levels of trust between people in those roles change. Whitten et  al. (2000) proposed trust as a factor in technology adoption in emergency medicine, and an Australian researcher felt that when roles changed, “the risk perception is higher because you don’t – in some way you pass some sense of the decision making – not the total decision making, but some part of the decision process to people that you trust to actually be able to understand and have the expertise” (Georgia, Palliative care researcher). Having confidence in the care provided via telehealth services was based on three components of trust that the participants identified: firstly, knowing fellow professionals, specifically other clinicians, and thus having confidence in their skills; secondly, having confidence to apply new processes and technology; and thirdly, becoming familiar with and having confidence in the functioning of technology and systems. Echoing the importance of trust, in a systematic scoping review of change management practices used for telemedicine service implementations, Kho et al. (2020) found that the building of trusting relationships was linked to increased confidence in the technologies used in telemedicine: Trust was relevant in multiple referents including in the technology being used, the trusting relationships amongst those providing the service, as well as trust of users and patients in the service.… Similarly, meetings with management, clinical and evaluation staff to address concerns and issues about the change were also useful practices to gain acceptance, trust and buy-in.… As confidence and familiarity was gained with the system, providers and patients were more likely to accept telemedicine as another modality for clinical consultations. (p. 10)

The social relationship between people and organisations in healthcare activities is a determining factor in the use and adoption of technology. Trust is one of the factors that persuaded paediatricians (Maiga & Namagembe, 2012) and emergency medicine practitioners (Whitten et al., 2007) to adopt technology. The participants in my study also confirmed the important role of trust between clinicians practising through technology. For clinicians, as Mair et al. (2007) noted, perceptions of risk in the use of telemedicine services are also related to concerns about total dependence on a technology, in the case of failure.

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Perceptions of risk and trust are related. On the one hand, there is the status quo of place-based care, trusted and perceived as being low risk. On the other hand, there is the new telehealth service facilitating separated care, which is not trusted and brings new risks. There are two facets of trust in separated care: trust between people and trust in the technology that connects the separated healthcare activities. The threat of a technology or practice failing is a risk that can be managed through the creation of guidelines and routines that build confidence in the reliability of a technology or clinical process. Many telehealth services, especially in Australia, have built support processes which rely on technical and administrative staff to ensure process continuity when using technology. Participants in my research felt they were able to bridge physical distances when they could rely on colleagues, technologists or patients in whom they could trust or develop confidence. A strong implicit belief in the value of a pre-existing relationship between health professionals who work together while separated by distance emerged from my interviews. Not knowing the person, according to a nurse in Queensland, raised doubts: [It] is also about the trust in the person at the other end. So you’re asking a clinician at the other end to provide you potentially with clinical information but you don’t know that person and you don’t know that you can trust their clinical ability so that can often be deemed risky. (Emma, Telehealth coordinator)

Health professionals built confidence in new practice through “knowing” the people, both patients and fellow professionals. Having physically met with a person at some time in the past was considered important to clinicians: “you probably know that trust is a lot about how the human world works. So some of the sort of tactics I used to try and help people get trust in me is to have met me face to face” (Lincoln, Psychiatrist). Clinicians who “don’t have relationships with referring doctors or other sites … find it very difficult to, without any rapport and knowing who they’re talking to at the other end” (Owen, Researcher). However, a Brazilian doctor explained that, as time passes, “people get to know the teleconsultants” (Eduardo, Family physician). An Australian nurse suggested that trust was easy to develop with new doctors:

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for me we just move on. Like if that geriatrician leaves, the first couple of consults that you see the next one, you see how they work and what their focus is on, and you just adjust the way you provide the information, or kind of just read what they’re going to be looking for and you pre-empt it. (Millie, Telehealth coordinator)

Trust is linked to decisions based on inductive inferences which a person believes to be reliably based on previous experiences. Hence, trust is linked to acquired confidence in a future outcome based on experiences. Building trust is influenced by the relationships between professional roles and requires accommodations to be made by the parties involved in separated healthcare activities: one of the things that can be tricky in the roles is that GPs who join into a consult with a specialist, they are actually quite intimidated and it’s quite scary for them to take part in a consult with the specialist and usually they are in a position of power and superiority with their patient and suddenly they are taking a back seat and that’s quite a shift. (Jessica, Telehealth manager)

A Brazilian doctor described this process of accommodation as demonstrating a degree of professional insecurity, because “the fact that I am connected to a colleague to discuss a case, in some way shows some weakness of mine, something I don’t know, some difficulty that I have” (Pedro, Family physician). An extreme example of insecurity reported by a Brazilian telehealth coordinator was of doctors who “are frightened to ask questions, write, or ask clear questions” (Arlette, Researcher). Brazilian nurses had the same difficulties in using telehealth services, exacerbated by a feeling of professional inferiority compared with doctors, because nurses “feel a little more uncertain about using telehealth because initially it was something that doctors used” (Pedro, Family physician). However, an Australian specialist felt that a positive outcome of working with other doctors at a distance was that “I would rather see a patient on telemedicine in the primary care clinic with their primary care … than see them by myself in my own office. I think there’s no doubt I practice better” (Fletcher, Psychiatrist). Building confidence in new practices, the technology and the systems upon which practice depends requires the acquisition of knowledge and

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experience of the performance of a technology or system. The threat of a technology or practice failing or performing in an unexpected manner is a risk that has to be managed through the creation of documented guidelines and routines. The importance of routines was highlighted by Lehoux et al. (2002) who argued that actors’ actions tend to reduce their anxiety and raise their self-esteem through the establishment of social routines. Actors observe, monitor and reflect upon their own conduct and that of others. In the course of time, through this reflexivity, they gradually develop more comfortable, routine social practices. Establishment of social routines to reduce anxiety about the performance of technology also requires technical and administrative processes to aid the building of trust in telehealth services. These processes need to be able to respond to the needs of clinical practice, as a physiotherapist reflected: You know one of our criteria one of our things was we need to have IT people in the teams embedded … we could not have worked with help desk model … you can’t have a job locked and … you know if you’ve got a patient in front of you need someone there who can troubleshoot to deal with it because it’s a clinical situation. (Sasha, Physiotherapist)

A manager of an established telehealth service recalled, “the IT help desk that has been supported for many years now. Where we can just pick up a phone talk to someone and within 5 minutes the problem is sorted. Which does not happen for other IT things” (Emily, Oncologist). An Australian specialist commented that once the telehealth service was embedded: from a retrieval perspective I think we have what we need in terms of a support network. I suppose it is about continuing to enable the clinicians to use technology in a way that supports practitioners and patients. We have sold the concept, it is now an accepted model of care. (Jake, Trauma specialist)

Once confidence in the functioning of processes and practices has been acquired, mental models change. A physician reported changes in how they felt about their practice after adopting telehealth services: “before it was kind of like … I’d check that I had my shirt buttoned up and I’d remember everybody’s name, whereas now it’s just another way of human

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communication … I think the big change has been myself” (Lincoln, Psychiatrist). Having confidence in processes and practices changes risk perceptions. As a result, many health professionals came to share the view of a telehealth coordinator that their telehealth service was “just a modality now. It’s nothing special … it’s just our day-to-day routine” (Lara, Telehealth coordinator). In this chapter we discussed how building confidence in telehealth practices is related to trusting technology and systems, where systems have been framed as processes that support clinical activities. In Chap. 3, we recognised that processes and practices are built on the interactions between human actors within organisational and professional contexts. Chapter 8 discussed the role of sociotechnical codes when adopted by social groups in mitigating the risks of separated care. The importance of interactions and relationships in social groups was highlighted by Whitten et al. (2000) who suggested that trust comes “through relationship building, shared constructions of hierarchies and power structures, the development of trust between providers that enables telemedicine activity to actually occur, and the creation of expectations that guide the norms and membership roles” (p. 129). In the following chapter, I investigate how the building of relationships within social groups underpins telehealth services.

References Bashshur, R., Doarn, C.  R., Frenk, J.  M., Kvedar, J.  C., & Woolliscroft, J.  O. (2020). Telemedicine and the COVID-19 pandemic, lessons for the future. Telemedicine and E-Health, 26(5), 571–573. https://doi.org/10.1089/ tmj.2020.29040.rb Cameron, P. A., Gabbe, B. J., Smith, K., & Mitra, B. (2014). Triaging the right patient to the right place in the shortest time. BJA: British Journal of Anaesthesia, 113(2), 226–233. https://doi.org/10.1093/bja/aeu231 Davis, F. D. (1989). Perceived usefulness, perceived ease of use, and user acceptance. MIS Quarterly, 13(3), 319. Hashiguchi, T. C. O. (2020). Bringing health care to the patient: An overview of the use of telemedicine in OECD countries (OECD Health working papers No. 116). https://doi.org/10.1787/8e56ede7-­en

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Hyde, G., & Fielke, K. (2009). Sustainable tele-psychiatry: Walking the talk. Australian and New Zealand Journal of Psychiatry, 43(s1), A3–A4. ISO. (2018). ISO 31000 risk management. http://www.iso.org/cms/render/live/ en/sites/isoorg/home/standards/popular-­s tandards/iso-­3 1000-­r isk-­ management.html Kho, J., Gillespie, N., & Martin-Khan, M. (2020). A systematic scoping review of change management practices used for telemedicine service implementations. BMC Health Services Research, 20(1), 815. https://doi.org/10.1186/ s12913-­020-­05657-­w Kyle, E., Aitken, P., Elcock, M., & Barneveld, M. (2012). Use of telehealth for patients referred to a retrieval service: Timing, destination, mode of transport, escort level and patient care. Journal of Telemedicine and Telecare, 18(3), 147–150. https://doi.org/10.1258/jtt.2012.SFT106 Lehoux, P., Sicotte, C., Denis, J. L., Berg, M., & Lacroix, A. (2002). The theory of use behind telemedicine: How compatible with physicians’ clinical routines? Social Science & Medicine (1982), 54(6), 889–904. Luxton, D., Sirotin, P., & Mishkind, M. (2010). Safety of telemental healthcare. Telemedicine and E-Health, 16(6), 705–711. Maiga, G., & Namagembe, F. (2012). A user based model for adoption of telemedicine by pediatricians in resource constrained environments. Makerere University. http://hdl.handle.net/10570/2015 Mair, F., Finch, T., May, C., Hiscock, J., Beaton, S., Goldstein, P., & McQuillan, S. (2007). Perceptions of risk as a barrier to the use of telemedicine. Journal of Telemedicine and Telecare, 13(suppl 1), 38–39. https://doi. org/10.1258/135763307781645158 Pfeil, J. N. (2018). Avaliação da regulação de consultas médicas especializadas baseada em protocolo teleconsultoria [Federal University of Rio Grande do Sul]. https://lume.ufrgs.br/handle/10183/179789 Porpora, D.  V. (2015). Reconstructing sociology: The critical realist approach. Cambridge University Press. Shulver, W., Killington, M., & Crotty, M. (2016). ‘Massive Potential’ or ‘Safety Risk’? Health worker views on telehealth in the care of older people and implications for successful normalization. BMC Medical Informatics and Decision Making, 16(131). https://doi.org/10.1186/s12911-­016-­0373-­5 Taylor, A. (2015). Applying international guidelines for telehealth services – A case study. In A. Maeder & J. Warren (Eds.), Proceedings of the. 8th Australasian workshop on health informatics and knowledge management (HIKM 2015) (pp. 87–95). https://doi.org/10.13140/RG.2.2.13263.69286

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Wade, V., & Stocks, N. (2017). The use of telehealth to reduce inequalities in cardiovascular outcomes in Australia and New Zealand: A critical review. Heart, Lung and Circulation, 26(4), 331–337. https://doi.org/10.1016/j. hlc.2016.10.013 Whitten, P., Sypher, B.  D., & Patterson, J.  D. (2000). Transcending the technology of telemedicine: An analysis of telemedicine in North Carolina. Health Communication, 12(2), 109–135. https://doi. org/10.1207/S15327027HC1202_1 Whitten, P., Johannessen, L., Soerensen, T., Gammon, D., & Mackert, M. (2007). A systematic review of research methodology in telemedicine studies. Journal of Telemedicine and Telecare, 13(5), 230–235.

10 Building Relationships to Underpin Telehealth Practices

Abstract  In this chapter, I explore how collaboration establishes relationships, how conflicts are resolved and whether leadership matters. Collaboration and relationships between health professionals is an integral part of the culture of healthcare. Building support for separated care requires communities to collaborate on the norms, processes and practices which form the sociotechnical codes of telehealth services. When group interests did not coincide, conflict became visible, especially in regard to information technology, clinical practice, and workloads. Leaders can develop relationships and collaborations spanning provider boundaries to resolve these conflicts. The power of leaders stems from their interactions within various groups, within and external to organisations. Social relationships are the fabric of the cultural structures that underpin healthcare. In this chapter, I explore how collaboration establishes relationships, how conflicts between different interest groups are resolved through collaboration, and whether leadership matters. All of the health professionals I interviewed emphasised that collaborations between © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 A. Taylor, Healthcare Technology in Context, https://doi.org/10.1007/978-981-16-4075-9_10

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health professionals and the personal relations supporting collaboration are an integral part of the culture of healthcare. Personal relationships take time and human agency to build. Building of support for separated care using telehealth services requires clinical, managerial and technology communities to reach agreement on the aims and practices to pursue and to collaborate on achieving these. When interests did not coincide, conflict arose, especially with regard to information technology, clinical practice and workloads. When care is separated, relationships between clinicians can change. Care that is dependent on other providers, management and technical support can become difficult to control. What underlies these observations about changing relationships when care is separated? Consideration of the ability of organisations and workers to control healthcare activities can help us answer this question. Linderoth (2014) offers a starting point through his observation that when implementing a telehealth service, “suddenly hospital care would become a service provider to primary care, which would be a radical re-thinking of roles and relationships” (p. 7). Key actors in resolving these conflicts are the leaders who are able to develop relationships and collaborations which span provider boundaries. The value and power of leaders stems from their interactions among various groups within and external to organisations, which build relationships. Relationship building facilitates the creation and operation of norms, processes and practices, thereby forming the sociotechnical codes of telehealth services.

10.1 Collaboration Establishes Relationships Collaboration and teamwork have always been important in healthcare. In a study of eHealth projects, Petersen et al. (2013) concluded that collaboration has been a particular catalyst in telehealth services. From my own experience, I know that “effective collaboration between clinical and technical stakeholders and further workforce education in telehealth can be key enablers for the transition of face-to-face care to a telehealth mode of delivery” (Taylor et al., 2015, p. 1). Collaboration is established when, according to Cho et al. (2009), there are “dynamic interactions between

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diverse external forces and internal interests and motives” (p. 354). Many studies have shown that negotiation, building of alliances (van Offenbeek et al., 2013), teamwork (Obstfelder et al., 2007) and cohesive relationships among practitioners (Wade et al., 2014) are important when healthcare activities are divided by place and separated by distance. Examples of collaboration that I encountered during my research were found in cooperation within and between small groups, across facilities, within states and between government departments. For example, a Brazilian family health team comprised “a physician, a nurse, two health technicians and six community health workers. We established a WhatsApp group” (Gustavo, Family physician). An Australian telehealth service had “clinicians sitting in on every session … a community mental health nurse, the patient’s case manager or it may be a hospital registered nurse if it’s an inpatient. So we do really maintain close links with the nursing teams” (Oscar, Mental health specialist). Collaboration is based on understandings, alliances, agreements and contracts between health professionals, organisations and loose associations based on common interests such as communities of practice. Communities of practice were observed to promote collaboration across organisational and geographic boundaries. In South Australia, a telehealth service established: communities of practice within each discipline or profession. So within allied health we split them up into a speech pathologist who has their own community of practice, physio, an exercise physiologist, … social work, … and they are given an opportunity to have an open forum to trouble shoot to talk about challenges to talk about any issues and experiences that they’re going through using the technology. (Amelia, Health service manager)

In Brazil, de Lima Verde Brito et al. (2018) analysed the connections made between collaborative Special Interest Groups (SIGs) on telehealth using the Brazilian academic network (RUTE). His analysis found that the “RUTE network and its SIGs provide an example of innovation in scientific collaboration, which enabled the development of collaborative health groups in university hospitals, with the involvement of researchers from all regions of the country and abroad” (p. 8). The Brazilian SIGs

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illustrate the value of cooperation at a national scale between the education and health sectors and educational institutions: Eleven years ago we did not have a body of health information technology involved in telehealth … now we have matured. We produce knowledge, we have people involved who believe in the tools, but when we started it was a small group. (Jakinda, Specialist)

Collaboration, when formalised, results in partnerships between organisations, as is the case with Brazilian SIGs, and becomes a powerful lever for change. In some Brazilian states, relationships have been built between health departments and state government supporting sustained commitments to telehealth services. Formal collaboration takes time: in the state of Santa Catarina, guidelines for dermatology were developed between 2012 and 2013 among multiple stakeholders (Von Wangenheim & Nunes, 2018). A Brazilian researcher described how the development of these guidelines depended on multiple relationships and partnerships: [It goes] beyond simple top-down, managerial-level decisions, it has to be performed together with all involved players. In our case, we sat together with state and municipal decision-makers and defined processes, workflows, and rules. Afterwards we officiated these rules in the State Health Committee, in practice turning them into law. (Fabrício, Researcher)

Partnerships underpinned the early years of the Brazilian Telehealth Networks Program when a tripartite commission comprising representatives from federal government, the states and municipal governments was formed to manage its implementation (as I outlined in Chap. 5). This edited vignette is an account of how the central characters of Julian, Antônio, Flores and Christine (real names are not used) worked to establish Brazilian telehealth centres. And the only other person who understood what we were talking about how to model this service and … was, Christine. And also Flores from the Ministry of Health.… But finally, they understood a little and having understood a little,

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they made contact with us after the meeting, more particularly with me. They called and told me and they had realised that only Julian and I understood what the need was, and they had the resources. So they wanted us to continue participating, in a second meeting … I went to look for Julian because I noticed how he and I were in great agreement, and said “Julian, I got this call, I want you and me to decide together where this project will be based, so we can do everything together”.… So I informed the Ministry of Health that we would accept receiving this project and we would coordinate it together … Between me and Julian that year, I had little more time, so I did the literature review … I read all that in English. I do not like reading English so much, but I read it all. Every week I met with Julian and said, “Look, there is nothing new” or “this week one of the articles has a very important point”. I did that entire year of 2006. In that year we created the role of the teleregulator which at that time did not exist in the literature. So the role of a family medicine teleregulator would respond to the problems of primary care doctors and determine who can answer those questions. Meanwhile Flores had been promoted in the hierarchy of the Ministry of Health … she asked me to write a draft of a national regulation which all telehealth centres would adopt and she approved the regulation. (Antônio, Family physician)

This relationship between two doctors defined the form that Brazilian telehealth services would take into the future. Their review of the role telehealth services could play in healthcare led to the creation of a unique function within Brazilian telehealth services of a “teleregulator” in family health who would respond to the problems of primary care doctors. Such vignettes of relationships in action are not unique; similar constructive relationships have been key to building telehealth services elsewhere in Brazil and in Australia. When collaboration becomes formalised into organisational partnerships, it becomes a powerful lever for systemic change. The Brazilian Telehealth Networks program described in Chap. 5 is a good example of collaboration at the national and state levels. In the Brazilian case, collaboration between the Ministry of Education and the Ministry of Health was key to improving the work of the family health teams where “Brazilian telehealth on one hand the Open University of the Universal Health System [UNA-SUS] and the National Telehealth University

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Network [RUTE] where three joint initiatives … responded to public policy demands” (Jakinda, Specialist). Considering the role of partnerships in the Australian context, a report by National ICT Australia (2010) recommended that a coordinated strategy should be developed for eHealth trials across the new Australian NBN and testing of the telemedicine technologies. Subsequently, a partnership between the Australian Government Departments of Health and Communications established the Telehealth Pilots Program between 2012 and 2014 (Taylor, 2015). This program, described in Chap. 5, is an example of a cross-sector collaboration supporting telehealth services. However, after the Telehealth Pilots Program was completed, national cross-sector collaboration in telehealth has appeared to stall, whereas in Brazil, national collaboration has continued, albeit with increasing difficulties due to financial constraints. When national stimuli are absent, telehealth collaboration has shifted to the state level. In some states, it proved possible for leaders to build relationships between health departments and state governments resulting in sustained commitments to telehealth. A doctor in the state of Santa Catarina commented as follows: I think it’s this partnership between the university and the state health department … let’s say, it was a happy coincidence that these two … and at the time that Telemedicine was implanted there was a superintendent here and he had a progressive vision, he had a vision that Telemedicine was something very good. (Felipe, Family physician)

The work of creating and maintaining relationships is a significant task. The value of established relationships is the credibility they bring to telehealth initiatives. Underpinning collaboration within organisational networks are personal relations. Specialists delivering telehealth services into regional Australia reported that they made a point of forming personal relationships with physicians in these localities. According to a hospital-based clinician, “collaboration works well when there are good relationships and co-operative structures between the GPs and ourselves. So you know and there’s got to be willingness on both ends to work out systems that work” (Marcos, Technician). When this willingness does not exist or the

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system context discourages collaboration, telehealth services are particularly difficult to establish. One physician noted: the Department of Health has very little influence over the running of a hospital system. It’s all very individual network based, so there’s no driver to make it more efficient because the … districts compete with each other, compete with each other for work to whatever may be, and have no interest in cooperating because it’s not what we’re about. (Nate, Cardiologist)

All of the health professionals I interviewed emphasised that collaboration between health professionals is underpinned by personal relationships and collaborations. These relationships sustained the operation of telehealth services and enabled clinicians to resolve the problems they encountered when extending place-based practice to work at a distance.

10.2 R  elationships Provide a Means of Resolving Conflicts Use of telehealth services does not come about as an inevitable consequence of technology availability or organisational reform. Resistance to reform and technology-based interventions and the ensuing conflicts may be as important as acceptance (van Offenbeek et al., 2013) and arise from different group interests. Orlikowski and Gash (1994) suggested that “where the technological frames of key groups in organizations— such as managers, technologists, and users—are significantly different, difficulties and conflict around the development, use, and change of technology may result” (p.  174). For these writers, a key proposition was that: Managers, system, developers, and users, at a minimum, will be key actors, and by dint of their membership in particular social groups and the different roles and relationships they have with technology, will tend to share their group’s technological frame. (p. 179)

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I also observed that clinicians, managers and technologists all tried to exercise power and thereby control clinical practices, resources and information technology. Networks acted as bridges between these groups: “I think one of the purposes of our telehealth support unit team is we are kind of the glue in between all of those groups like we are the conduit” (Technologist, Australia). Telehealth managers used networks as: an enabler for me to get to clinical leaders to discuss opportunities and all barriers around telehealth adoption. So having a broader profile does enable me access to a very wide range of specialist providers and their steering committees and their broader networks. (Robin, Health service manager)

Networks between organisations and people are a more formal expression of collaborative relationships. Networks can take various forms including committees, commissions, communities of practice and deliberate tearoom conversations. Networks are key to the operation of telehealth services. When formalised within existing governance structures, “clinical networks actually have formed sub committees specifically around ‘Okay for our specialty, let’s talk all things telehealth’” (Austin, Telehealth manager). Because Brazilian health services are decentralised to the level of municipalities, they depend on formal networks to agree on joint initiatives within each state. As a counterpoint to the impact of decentralisation in Brazil, various forms of collaboration across organisational boundaries emerged, often supported by state health departments. These networks in the form of Bilateral Management Commissions, in several states, agreed on the protocols for triaging patients for specialist treatment using telehealth services in order to manage waiting lists. In the state of Santa Catarina, “(because) there are few large municipalities that manage to resolve their own problems by themselves. The majority depend on the state to coordinate (healthcare) regionally” (Pedrina, Telehealth coordinator). Consequently, collaborative governance evolved to coordinate care and telehealth services. For instance, in Santa Catarina, Pedrina told me that “a meeting between state and municipal managers decided that in several specialities the referral of patients would be regulated through the (telehealth) network”.

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Many health professionals felt that existing relationships between clinicians determined the implicit rules and codes governing referral of patients to specialists. When those relationships do not exist, according to an Australian cardiology specialist, “patients … do a lot of travel they need not do just because there’s no one there who realises that they don’t need to refer them to a big centre, they can just refer to a telehealth review” (Nate, Cardiologist), whereas in other areas, Nate told me that referral pathways are “working very well. I find they’re very well established. We have a very well-established relationship, they refer cardiology issues to me … even their acute presentations, they will just give me a phone call rather than anyone else”. State-wide governance mechanisms in Australia have played an important role in supporting telehealth services within state boundaries. In South Australia, it was felt that a “governance committee and the communities that practice … helps to influence that what can be most effectively and efficiently done state wide” (Amelia, Health service manager). In Queensland, the state health department has been successful in keeping: telehealth as a state-wide technology. The technology and the infrastructure, keeping that as a state-wide service and a state-wide support, bandwidth is still managed from a state-wide perspective … I think is one of the major factors that’s keeping us you know with the trend of increasing telehealth. (Austin, Telehealth manager)

When group interests did not coincide, conflict became visible, especially in regard to information technology, clinical practice and workloads. As Chap. 7 outlined, conflict over technology occurs when practices, devices, networks and applications have not been designed and built for delivering healthcare across boundaries, or when there are difficulties in interoperating and facilitating the sharing of information between health professionals. Additionally, conflict between sectional interests based on professional boundaries can rise to the surface when changed practices require additional work. For instance, in Australia, the AMA suggested that incentive payments were necessary for telehealth consultations involving video, telephone or email consultations and the associated additional

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administration, broadband, equipment, support and training costs (AMA, 2011). Conflict also arises when professional status and employment prospects are perceived as being threatened by telehealth services. In Brazil, medical associations used their position as a medical authority to limit changes in established medical practice (Melo, 2019) due to fears that telehealth services would threaten the viability of their businesses. Reform proposals in 2018 from the Brazilian CFM for more extensive liberalisation of the use of communications technologies in patient care proved controversial for these reasons (Silva et al., 2020). These proposals would have removed restrictions limiting telehealth services in Brazil to providing second opinions from a doctor or specialist to the treating doctor and would have enabled direct consultations to occur between doctors and their patients, thereby increasing the ability of patients to sue the services of different specialists. In the Australian context, medical associations have been more willing to support telehealth services as long as their members’ business model is not threatened. The RDAA (2014) stated that “the use of telehealth in primary care should only be viewed as an adjunct to rural general practice and not as an alternative to face-to-face consultations” (p. 2). The concern was that rural doctors could be undercut by metropolitan-based telehealth services. This issue remains a key concern of the federal government’s policymaking for telehealth services and demonstrates that “organised medicine remains politically skilful in steering and modifying government policies” (Willis, 2006, p. 428). While conflicts over sectional interests may restrict relationship building, the work of creating and maintaining relationships within an organisation is also important. One telehealth coordinator recounted how she “had to form working relationships or reasonable relationships with all the directors.… There are probably in my work sphere about 300 or so people that require active relationship maintenance” (Abigail, Nurse manager). Some specialist telehealth services into regional Australia made a point of forming relationships with physicians in these localities: In Roma, we flew out to meet the GPs face to face. In Mt Isa I never met them face to face ever and in Mackay I never met them face to face but definitely in

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the public hospital we took the trouble to fly to Roma to meet all the GP and nurses face to face before we set up the telehealth service. (Jordan, Psychiatrist)

Established relationships are seen as particularly useful: “my contact with the Secretary of State goes back years, so it was easy to agree common objectives and make partnerships because of that previous relationship” (Pedrina, Telehealth coordinator). Established relationships bring with them credibility: We knew each other and there was credibility and respect that had been earned over a period of time. You can’t just go in and say … I’m really good at telehealth, this is what we are going to do. It is about having a relationship there already having worked with somebody in the trenches, spoken to them about a certain patient, they know they can rely on you. (Jake, Trauma specialist)

We can see from this discussion that individuals performing the roles of technologists, clinicians and managers (including coordinators of telehealth services) have different, but overlapping, interests (norms), and each group exercises some degree of power and control in each of the organisational units. Elder-Vass (2010) attributed the power of individuals and groups to influence events to the relationships formed within interest groups, communities of collaboration and networks. According to Elder-Vaas, relationships generate the casual power “to increase conformity of its members to the norm” (p. 124); that is, to affect the behaviour of individuals. Elder-Vass suggested that these groups function as “norm circles” where: a norm circle is the group of people who are committed to endorsing and enforcing a particular norm. Such groups are social entities with people as their parts, and because of the ways in which the members of such groups interact (a mechanism) they have the causal power to produce a tendency in individuals to follow standardised practices. (p. 22)

Applying Elder-Vass’s (2012) concept of norm circles, it can be seen that each group involved in telehealth service (clinicians, managers, technologists, etc.) belongs to a different circle, with different norms, which

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sometimes coincide because they are all members of an organisational norm circle (the health service). When the norms held by each group are different, then conflicts over overlapping interests (such as services provided to patients or business interests) occur. According to T. Williams et al. (2003), resolution of such conflicts occurs when norm circles succeed in “normalising the use of technology in clinical practice, through convincing a wider professional audience of the value of the technology” (p. 52).

10.3 L eadership Develops Relationships Across Boundaries Because telehealth services span geographical, organisational and professional boundaries, actors in these services must develop relationships across wide audiences in order to become effective service providers. Geographical boundaries have in the past controlled the accreditation of physicians in many countries, particularly those with federal structures such as the USA (Siwicki, 1999), and still directly influence where and by whom patients are cared for. Boundaries can take diverse forms. It is important to recognise that boundaries which impact telehealth services—and healthcare more broadly—need to be seen as more than geographical ones; they can also manifest in organisational, professional and technological forms. As I discussed in Chap. 6, boundaries can be conceptualised as “political, geographical, technological, cultural, and economic borders” (Whitten & Cornacchione, 2010, p. 215). Organisational borders are a case in point. The scope of telehealth services delivery has always been constrained by the boundaries of the organisational structures, and boundaries between acute- and primary care organisations continue to impede integrated care for patients. Leaders contribute to enabling telehealth services to operate across all these types of boundaries. Leaders, colloquially known as “champions” of telehealth services, have a crucial role to develop relationships, as one manager indicated:

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From my perspective working in here and me reporting to the DDG [Deputy Director General] and having a relationship with the DG [Director General] and her office has been pivotal in ensuring this works. More just being able to influence things and at the right time, chuck things in about telehealth. Telehealth has always had the support of, has always had a focus in Queensland, as you know it has the biggest, best network. (Jake, Trauma specialist)

A Brazilian telehealth leader felt that: A culture and a champion are needed. There has to be someone who will promote the plan. Champions are not always in a position to coordinate. It is an internal political question. Our first 19 institutions were chosen in this way … were chosen as champion institutions. And certainly in the champion institutions there were champions. (Gustavo, Family physician)

Important characteristics of successful leadership are being able to bring people together, to break down obstacles and to build bridges across boundaries. In doing so, these leaders often become known as telehealth champions (Al-Qirim, 2007; DuBose-Morris, 2014; Ellis, 2005; Wade & Eliott, 2012), especially in Australia. The obvious question is then: Is “the existence of effective champions for telehealth a result of personal characteristics, organisational policies or are they just people in the right place at the right time?” (DuBose-Morris, 2014, p. 126). Evidence from my research points in both directions, but, crucially, shows that champions need supportive management and organisational networks to be effective. Given the right support and networks, collaboration can create political support and relationships and mobilise resources for telehealth services. Individuals who are able to develop these relationships have been described as “boundary spanners” by P.  Williams (2002). A telehealth coordinator in a Brazilian state recalled how “I convinced the health secretary, and we convinced the governor, directly the governor and the governor gave us carte blanche as well and so a contract was made between the Health Secretary and the federal university in the state” (Izabel, Orthodontist). This initial support allowed the Santa Catarina Telehealth Centre:

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[to] open channels to all municipal governments, [to] talk to them convince them that this was a good thing for them. It was much better than horse trading for ambulance places. And these channels never close at least not with the small cities. [We] are at liberty to call the Mayor of all these small cities and talk to them or her if necessary. The political support of the small cities is important for the State Government. (Fabrício, Researcher)

Navigation of these boundaries and interests required conscious agential work on the part of champions, particularly the work required to convince people to adapt their practice: “you have to have change champions people that are just going to doggedly pursue something that they think it’s going to work and hopefully bring people along with them” (Sasha, Physiotherapist). In simple terms, a trauma physician likened this process to “the CPR of consistency, persistent, resilience” (Jake, Trauma specialist). Champions can have different ways of working: “If you’ve got a champion who quietly goes about setting up a pilot and then gradually rolling it out, endeavouring to do it with the least moving parts. And endeavouring to do it within budget. It will work” (Samuel, Physiotherapist). But having a champion does not always lead to sustainable telehealth services: And then they got a new doctor in who’d come up from Melbourne and she used to do telehealth there and her first thing is why aren’t we doing this. So she started and then slowly it’s starting to expand.… On the other hand we had … departments [where] we’ve had one champion there for many years … but until recently the rest of the department have been … been completely disinterested. (Emma, Telehealth coordinator)

Sometimes it was necessary for a champion to stand back: “Well I think that was actually a liability during the rollout.… It was sort of being seen as my pet project that I would roll their eyes on the implementation committee. So I kind of pulled right back” (Marion, Rehabilitation specialist). The ability to span organisational boundaries was particularly important for workers in telehealth service coordination roles. For instance, an Australian telehealth coordinator was described as “a bit of a bridge to … the arms of health within the SA government to … build some of these relationships … so he is influencing the culture of the way that we use ICT in health” (Amelia, Health service manager). Telehealth coordinators were able to:

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make things happen and … very good at knocking down barriers. And in particular in country where you know you’d have a region or a hospital or a hospital manager say oh no, I can’t have my staff doing this and he would just get on the phone and make it happen. (Samuel, Physiotherapist)

Telehealth leaders, when acting as boundary spanners, navigate the boundaries of different groups exercising power and control over information technology, existing clinical practices, employment and resources in order to normalise telehealth services within healthcare. Leaders who were adept at forming relationships were able to establish collaborations through which they could obtain the resources needed by telehealth services. I turn my attention to these needs in Chap. 11.

References Al-Qirim, N. (2007). Championing telemedicine adoption and utilization in healthcare organizations in New Zealand. International Journal of Medical Informatics, 76(1), 42–54. https://doi.org/10.1016/j.ijmedinf.2006.02.001 AMA. (2011). AMA submission on connecting health services with the future: Modernising Medicare by providing rebates for online consultations. https:// ama.com.au/submission/submission-­connecting-­health-­services-­future­modernising-­medicare-­providing-­rebates Cho, S., Mathiassen, L., & Gallivan, M. (2009). Crossing the diffusion chasm: From invention to penetration of a telehealth innovation. Information Technology & People, 22(4), 351–366. https://doi.org/10.1108/ 09593840911002450 de Lima Verde Brito, T. D., Baptista, R. S., de Lima Lopes, P. R., Taylor, A., Haddad, A. E., Messina, L. A., & Pisa, I. T. (2018). Collaboration between medical professionals: Special interest groups in the Brazilian telemedicine university network (RUTE). Telemedicine and E-Health. https://doi. org/10.1089/tmj.2018.0075 DuBose-Morris, R. (2014). An interpretative phenomenological analysis of telehealth champions. CEC theses and dissertations. http://nsuworks.nova.edu/ gscis_etd/140 Elder-Vass, D. (2010). The causal power of social structures. Cambridge University Press.

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Elder-Vass, D. (2012). The reality of social construction. https://www.academia. edu/2366759/The_reality_of_social_construction Ellis, I. (2005). The clinical champion role in the development of a successful telehealth wound care project for remote Australia. Journal of Telemedicine and Telecare, 11, 26–28. Linderoth, H. (2014). The role of technological frames of reference and institutional logics in the Use of ICT. Proceedings of the 25th Australasian conference on information systems, 8th–10th December, Auckland, New Zealand, 2014. http://hdl.handle.net/10292/8079 Melo, I. (2019). Entidades pedem revisão de resolução do CFM sobre telemedicina e defendem ampliação do debate. GaúchaZH. https://gauchazh. clicrbs.com.br/saude/noticia/2019/02/entidades-­p edem-­r evisao-­d e-­ resolucao-­do-­cfm-­sobre-­telemedicina-­e-­defendem-­ampliacao-­do-­debate-­ cjrsermr4013s01td7wsxuci5.html National ICT Australia. (2010). Telemedicine in the context of the National Broadband Network. Australian Government. https://www.nicta.com.au/ content/uploads/2015/02/TelehealthNBN.pdf Obstfelder, A., Engeseth, K., & Wynn, R. (2007). Characteristics of successfully implemented telemedical applications. Implementation Science, 2, 11. https:// doi.org/10.1186/1748-­5908-­2-­25 Orlikowski, W. J., & Gash, D. C. (1994). Technological frames: Making sense of information technology in organizations. ACM Transactions on Information Systems (TOIS), 12(2), 174–207. https://doi.org/10.1145/196734.196745 Petersen, L. S., Bertelsen, P., & Bjørnes, C. (2013). Cooperation and communication challenges in small-scale eHealth development projects. International Journal of Medical Informatics, 82(12), e375–e385. https://doi.org/10.1016/j. ijmedinf.2013.03.008 Rural Doctors Association of Australia. (2014). Telehealth key principles. Rural Doctors Association; Rural Doctors Association. http://www.rdaa.com.au/ sites/default/files/public/Telehealth%2520PUBLICATION%2520DR AFT_20150514114116.pdf Silva, A. B., da Silva, R. M., & Ribeiro, G. da R., Guedes, A. C. C. M., Santos, D. L., Nepomuceno, C. C., & Caetano, R. (2020). Three decades of telemedicine in Brazil: Mapping the regulatory framework from 1990 to 2018. PLoS One, 15(11), e0242869. https://doi.org/10.1371/journal. pone.0242869 Siwicki, B. (1999). Telemedicine providers’ progress impeded at the border. The need for physicians to obtain a medical license in every state in which they practice slows the growth of telemedicine. Health Data Management, 7(5), 94–98.

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Taylor, A. (2015). Applying International Guidelines for Telehealth Services – A Case Study. In A.  Maeder & J.  Warren (Eds.), Proceedings of the 8th Australasian workshop on health informatics and knowledge management (HIKM 2015) (pp. 87–95). https://doi.org/10.13140/RG.2.2.13263.69286 Taylor, A., Wade, V., Morris, G., Pech, J., Rechter, S., Kidd, M., & Carati, C. (2015). Technology support to a telehealth in the home service: Qualitative observations. Journal of Telemedicine and Telecare. https://doi. org/10.1177/1357633X15601523 van Offenbeek, M., Boonstra, A., & Seo, D. (2013). Towards integrating acceptance and resistance research: Evidence from a telecare case study. European Journal of Information Systems, 22(4), 434–454. https://doi.org/10.1057/ ejis.2012.29 Von Wangenheim, A., & Nunes, D. H. (2018). Creating a web infrastructure for the support of clinical protocols and clinical management: An example in teledermatology. Telemedicine and E-Health. https://doi.org/10.1089/ tmj.2018.0197 Wade, V. A., & Eliott, J. (2012). The role of the champion in telehealth service development: A qualitative analysis. Journal of Telemedicine and Telecare, 18, 490–492. https://doi.org/10.1258/jtt.2012.GTH115 Wade, V. A., Eliott, J. A., & Hiller, J. E. (2014). Clinician acceptance is the key factor for sustainable telehealth services. Qualitative Health Research, 24(5), 682–694. https://doi.org/10.1177/1049732314528809 Whitten, P., & Cornacchione, J. (2010). The multiple contexts of borders that impact telemedicine as a healthcare delivery solution. Journal of Borderlands Studies, 25(3–4), 206–218. https://doi.org/10.1080/08865655.2010.9695782 Williams, P. (2002). The competent boundary spanner. Public Administration, 80(1), 103–124. https://doi.org/10.1111/1467-­9299.00296 Williams, T., May, C., Mair, F., Mort, M., & Gask, L. (2003). Normative models of health technology assessment and the social production of evidence about telehealth care. Health Policy, 64(1), 39–54. https://doi.org/10.1016/ S0168-­8510(02)00179-­3 Willis, E. (2006). Introduction: Taking stock of medical dominance. Health Sociology Review, 15(5), 421–431.

11 Applying Resources to Telehealth Services

Abstract  This chapter considers how the differential  distribution and availability of resources including infrastructure, staffing, education, training and financing of healthcare shape the development of telehealth services. The distributions of funding, workforce and infrastructure available to rural, remote and regional health services and populations compared with metropolitan areas were the principal concern of health professionals in Australia and Brazil. Funding healthcare has has always challenged governments because the benefits of improved health partially accrue outside of the health system. Consequently, resourcing the sustainable operation of telehealth services is inextricably linked with wider contexts. The uneven distribution of resources for healthcare is at the very heart of the rationale for telehealth services. The use of telehealth services to improve access to healthcare is a consequence of the differential distribution of healthcare resources within sections of imperfect universal healthcare systems. This chapter will consider how the distribution and

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availability of resources, staffing, training and financing of healthcare shape the development of telehealth services. Resources can take many forms including the infrastructure and staff that support services, training, education for staff and funding for services. Healthcare resources have two dimensions: the resources available to health organisations and the resources available to care recipients. Patients also require access to infrastructure such as clinic buildings, transport, computers and communications. Patients need to understand how to use those resources and gain that capability through experience, education and training, including digital “competencies”. Patients have limited income to pay for resources, be it transport costs or mobile phones and internet access. Uneven distribution of the health workforce, particularly specialists, is associated with differential access to health services and infrastructure for the general population. In both Australia and Brazil, staff cannot be retained in regional locations. Infrastructure for telehealth services relies on ICT, staff and training of staff to maintain and use technology, without which the infrastructure becomes useless. The physical infrastructure of health facilities determines their ability to host telehealth services. Private consulting rooms, air-conditioning, lighting, power supplies, computers, mobile devices and internet connections are essential. These resources are not equally available to all organisations and populations. The resources available to rural, remote and regional health services compared to metropolitan services were the principal concern of the health professionals I interviewed for my research. Funding healthcare resources has always been a policy challenge for governments because the benefits of improved health partially accrue outside of the health system; telehealth services are no exception. Many of the costs and benefits of telehealth services reside outside of the health organisations that provide these services. Evaluations of telehealth services face the same problem. Health interventions can be evaluated for cost, efficiency, utilisation and quality, but holistic, societal-wide evaluations are difficult to undertake, resulting in many evaluations of telehealth services restricting their assessment of the impact of telehealth services to those outcomes which accrue within the health system.

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11.1 Distribution of Resources Government policies can change over time. Governmental priorities for healthcare influence the available funding for healthcare and telehealth services. We have seen how in Brazil, from 2006 until 2015, according to a seminal history by Haddad et al. (2016), there was significant federal support for the Brazilian Telehealth Networks program. Subsequently, that support fell away when a change of government led to the replacement of Ministry of Health staff and to changes in health policies. One manager observed that at that time: [W]hen the government changed from Lula1 to Dilma,2 they completely changed the health department … for example the person that became the coordinator for primary care prohibited mention of the previous coordinator’s name. (Marcos, Family physician)

When economic influences reduce government funding for healthcare, telehealth services can be severely impacted. For instance, in 2011, austerity measures in Queensland resulted in “a major cost cutting phase … so as soon as you do anything … deemed to be an added workload for them we get knocked back”. Massuda et al. (2018) documented the impact of austerity measures from 2015 on Brazilian healthcare. Brazilian telehealth centre workers felt that the impact of these measures was “so great that telehealth is just another service that will be dismantled and to fight, you will fight for other things … in the context that we live today, that is a threat to the system” (Patricia, Telehealth coordinator). In political contexts, health professionals and managers recognise the importance of gaining political support for the resources they need and have learnt to attract political attention when bidding for resources. A South Australian clinician recounted that: the election was new wins. Yes state elections in February. So everybody knew that we had to have the project up and running this year … the Minister liked it so he understood it. He liked it and he kept talking about it. (Marion, Rehabilitation specialist)  Luiz Inácio Lula da Silva, popularly known as Lula, was president of Brazil from 2003 to 2010.  Dilma Vana Rousseff was president of Brazil from 2011 until 2016.

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The need to maintain political support for recurrent funding was acutely felt by health professionals. When there was a change in state government, health professionals played an active role in arguing for the prioritisation of funding for telehealth services, and a Brazilian telehealth centre leader explained how they succeeded in renewing their funding by inviting the new health minister to see the operations of the centre at first-hand. Despite the erosion of Medicare reimbursements for patients in Australia and the difficulties of accessing timely public healthcare in Brazil, equitable, universal access to health services is still perceived as an important design principle for public health systems. Within these systems, the distribution of resources that support telehealth services was a common concern of everyone I talked to in Australia and Brazil. Resources—human, technological, and financial—act as clearly visible mechanisms supporting or inhibiting the operation of telehealth services. In Chaps. 4 and 5, I have shown how the resources available for health services and telehealth services (physical, human and financial) are unevenly distributed in Australia and Brazil despite the improvements made over the last 20 years. At one level of social analysis, the availability of resources to telehealth services is just a very obvious empirical observation. However, underlying the uneven availability of healthcare resources are political, governmental and economic priorities. In turn, at a deeper level of reality, there are other influences, such as the place-based structure of healthcare; the accounting problems posed by payments for separated care; conflicts between groups for control of resources and relationships with decision-makers who decide the allocation of resources. Dalkin et al. (2015) have proposed that when resources are introduced into a context, for instance, as funds for a project or as enabling technology, there is a “change in reasoning … (which) alters the behaviour of participants, which leads to outcomes” (p. 4). Elaborating on this proposition, it is logical to infer that the absence of resources can also lead to outcomes. Two simple examples demonstrate the operation of this type of reverse mechanism. Firstly, in Brazil, the creation of telehealth services was intended to support an under-resourced primary healthcare system as a means of extending universal healthcare. Secondly, in Queensland, Australia, the funding for telehealth services was politically important due to the relatively large numbers of people who live outside

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metropolitan areas. Avoidance of patient travel to centres of care in metropolitan areas then became a key aim for telehealth services. Concerns with the availability of infrastructure were particularly expressed by telehealth coordinators, managers and physicians in states which had resourced telehealth services for some time (Queensland, Santa Catarina and Rio Grande do Sul). In these states the distribution of financial resources for health services across geographic zones had not met the needs of regional populations. It should be noted that the geographical distribution of resources can significantly shape the telehealth services that can be offered in different areas. As Wade (2013) pointed out, “the decision of the Australian Government to remove outer metropolitan areas from eligibility for Medicare rebates for telehealth from 1 January 2013 (and) since then, there has been a 29% drop in the number of video consultations” (p. 594). Broader economic pressures can compound the need for patients to travel. One hospital-based telehealth coordinator observed that “the patient travel was increasing because people are getting sicker as the private health is increasing in price. People are getting out of it and therefore there’s more demand on public services” (Penelope, Telehealth coordinator). Even when travel is subsidised, a clinician reported that for rural patients travelling into the city for treatment: [T]here’s no nostalgia at all much out west for getting on that train, bus or private car and coming to the city and then being put up. Even if it was all at the expense of the state, they weren’t coming here and then taking advantage of going [shopping]. (Lincoln, Psychiatrist)

Geographic isolation is not the only influence on access to healthcare. Health services are not homogenous organisations, but are divided on the basis of professional speciality. Such divisions can result in patients with many health conditions (who require integrated care) having to access different health services in different locations because not all health services offer access to the same range of specialities. A telehealth coordinator observed that: within the health service each service each is like lots of different businesses. So you have got your hospitals your paediatrics hospital and your oncology hospital

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and then within that you have the division of medicine division of surgery and then you have your neurology and neurosurgery and they all do their own thing and somehow vaguely crossover in some parts, sometimes. (Jessica, Telehealth manager)

Because integrated models of care cross professional and practice boundaries and organisational borders, in the Australian activity-based funding system (which only pays for individual patient sessions) integrated care has proved difficult to fund. Bradford et al. (2016) noted “a considerable number of services provided by allied health and multidisciplinary teams that are not eligible for MBS reimbursement” (p.  8). Integrated care also challenges the existing practices of medical specialities. Within an Australian tertiary hospital, a nurse observed: We get a lot more response and support from the chronic disease or the medical area than we do from the surgical area because it is very old school, it’s very paternalistic. The way that surgery is run, it’s very acute … we’ve got chronic issues and we need to be dealing with a different strategy than what we are doing with the bring them in, cut them open, cut it out and get rid of them client approach which doesn’t work. (Abigail, Nurse manager)

In Chaps. 6 and 7, I outlined the importance of understanding how care is spatially embedded in organisational contexts and how separated care can challenge usual professional practice. When different professions work within an integrated care team, professional categories are challenged. A Brazilian dentist felt that the policies of professional medical associations did not help because: they think that only a doctor can work with a doctor or a nurse with a nurse or a dentist with a dentist [whereas integrated care] enables work within a team, learning the limits of their knowledge, because the nurse is alongside [the doctor], the dentist technician and technician is there. (Kaci, Dentist)

Two contextual forces appear to call for the provision of telehealth services. Firstly, when the spatial distribution of population does not align with the available resources for healthcare, telehealth services can assist with the redistribution of services. Secondly, when practice boundaries

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need to be overcome, telehealth services can facilitate inter-professional dialogue. In both cases, infrastructure, workforce and funding mechanisms then become important.

11.2 Availability of Infrastructure Infrastructure (technology, physical facilities), human resources and medical education form the foundation of existing health and telehealth services. Within the Australian and Brazilian systems there are clear disparities in the availability of resources, particularly physical infrastructure and human resources. For instance, during my research in Brazil, I visited a private hospital in São Paulo which runs a valet parking services for its clients and an elite telehealth service for private health insurance customers. In the same city, I spent time in a small community health clinic in an outlying suburb where only a handful of old computers were available for patient registration. In Brazil and Australia, capital investment by municipalities and health organisations tends to prioritise building and environmental upgrades— the visible public face of healthcare—rather than communications and information technology which could support telehealth services. Given the historically low level of investment in the Brazilian public sector, the physical environments of many health facilities provide poor conditions for patients. Consequently, in many Brazilian states, “the major state investment has been in physical care units … which was a priority” (Carla, Telehealth service manager). In some states such as Santa Catarina, “Today our infrastructure is much better. All our health posts are air-­ conditioned. Of 59 facilities more than 30 are totally adequate from a sanitary perspective and all have disabled access” (Juliana, Health service manager). Australian clinicians were also concerned about the availability of physical facilities and technology for telehealth consultations. Although the Australian Government funded a Broadband for Health program until 2009 to improve information technology availability (Communio, 2009), Australian health professionals still felt that technology was a constraint on improving telehealth services. The neglect of information

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technology provision within some health facilities provoked comments from Australian health workers that “Wi-Fi in every single facility would be very helpful” (Isabel, Telehealth coordinator) and “in all the aged care facilities their Wi-Fi infrastructure was terrible and needed technical improvement” (Olivia, GP). Australian clinicians were concerned about “rooms and also which room (patients are) going to go into and which room has telehealth capability and which doesn’t, who’s going to be there, which nurse is going to attend” (Indiana, Cardiologist). Although communication technology availability has increased over the past 20  years, doctors were particularly concerned about internet capacity, because connection speeds may not meet the needs of the applications used for telehealth (which primarily uses synchronous video technology). I think it really though depends on a high-quality consultation/connection. Occasionally, and this is one of the reasons why I haven’t been overly keen on going out to GP or patient clinics is that often the broadband connection into those places is poor and once you start dealing with a poor audio signal it really makes the consultation difficult. (Felix, Endocrinologist)

Another doctor felt that “it is getting better now but occasionally it is really hard for them to see me and me to see them because the packets are not big enough, whatever you call those things” (Jude, Respiratory specialist). In contrast, Brazilian telehealth services were consciously designed to operate over asynchronous technology using historically lower connection speeds, and communications coverage remains uneven outside metropolitan areas. An early pioneer of these services recalled that, because in 2005 they were limited to a slow 300 kbps connection: I thought at the time this is not an efficient way of doing it because synchronous teleconsulting has the problem that…. You are taking a specialist, an expert and he’s committed to you for this one hour. You were not efficiently using the expertise. So I proposed here for our telehealth people an asynchronous model. (Fabrício, Researcher)

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Currently, internet availability continues to be a problem in Brazil. A survey of the use of information technology in Brazilian health facilities illustrated large variations in the availability of computing and communications infrastructure between urban and rural, public and private, and richer and poorer regions (Martinhão, 2017), limiting the availability of telehealth services.

11.3 W  orkforce Distribution, Training and Education Palozzi et al. (2020), in a literature review of telemedicine employment in rural areas, argue that “telemedicine infrastructures, the quality of care in rural areas could be improved also by supplying training to local providers; this allows sharing of ‘evidence-based’ best practices” (p.  22). Infrastructure for telemedicine relies on ICT, staff and training of those staff, without which the infrastructure becomes useless. Wakerman and Humphreys (2012) argued that in rural Australian healthcare, a systematic approach to staffing, training and education is required: “ensuring adequate funding, infrastructure, effective management and governance, community participation, and professional development opportunities has been shown to minimise recruitment problems and result in workforce stabilisation” (p. 22). Uneven distribution of the health workforce, particularly specialists, is associated with differential access to health services and facilities for patients in Australia (National Rural Health Alliance, 2013) and in Brazil (Scheffer, 2018). For example, in Brazil, the need to travel for medical treatment has major implications for people living in inland cities and settlements who may have to travel more than 500 km to reach a medical facility, particularly hospitals, in many cases using patient transport services provided by the Brazilian universal healthcare system (Alonso et al., 2017). A health manager related that his motivation for becoming involved in the provision of telehealth serves came about because:

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What convinced me was travelling round the state seeing all the poverty, minimal access to healthcare. I saw one patient travel 500 km by taxi, nine or 10 patients in a taxi, like tinned sardines, to have cancer treatment in Florianópolis, chemotherapy and on the way home they had to stop five or six times so people could … [be sick]. (Gabriel, Government manager)

Australian telehealth models attempt to reduce patient travel to specialist centres by diverting patients to peripheral facilities which then provide staff to host remote consultations. Remotely delivered telehealth services may simply change the mix of staff skills applied to care in both the peripheral and central centres. An Australian physician commented: I think that the biggest impediment to the roll out is the resourcing of the peripheral centre in terms of having an administration officer and a person to sit in on the consultation to take notes. So that actually involves resources and to an extent you don’t really need it. The only reason why you need an [administrator] making the appointment up there is because they’re [the patient] actually physically coming into the hospital. (Felix, Endocrinologist)

The Brazilian telehealth model described in Chap. 5 reduces patient travel to specialist centres by retaining patients in primary health facilities and providing advice to local clinicians on how to manage conditions, thereby avoiding the need for additional administration or nursing time directly linked to a remote consultation. In both Australia and Brazil, when staff cannot be retained in regional locations, the difficulty of managing or treating regional patients is compounded because “you get a good relationship going with somebody … particularly remote sites, and that person then leaves because no one stays in remote sites terribly long … and suddenly it all falls apart with no links anymore” (Nate, Cardiologist). There are also contradictory implications for telehealth services providing services into regional health facilities. On the one hand, telehealth services can extend healthcare to areas lacking certain specialities; on the other, even remotely delivered care requires staff in peripheral centres to administer and supervise patients, and additional staff in central locations to provide care. In both Australia and Brazil, the difficulty of managing or treating regional patients is

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compounded by the difficulties of retaining staff. In the Brazilian state of Santa Catarina, there are: very few dermatologists wanting to work in the public health sector with SUS [the Brazilian universal healthcare system], because it pays a lot less and we absolutely don’t find dermatologists who want to go upstate because there is so much patients in the big cities. So the only way you can take dermatology upstate is by doing teledermatology. (Fabrício, Researcher)

For those health professionals working in rural and remote communities, there is limited education, training and support. Questions of isolation, professional development, personal security and salary all play a part in high staff turnover, particularly of family doctors: “sometimes salaries are more attractive in other municipalities. Frequently it is a question of vulnerability” (Manuel, Telehealth coordinator). In 1995 the Project for Rural Health Communications and Information Technology report acknowledged that “the majority of healthcare providers feel professionally isolated in their work location” (Australian Rural Health Research Institute, 1996). Twenty years later, an Australian nurse was still able to comment, “So really these young doctors have got nobody to support them. They are learning off each other but now we have got the telehealth they feel reassured” (Olive, Nurse). It is difficult to avoid the conclusion that staff retention and recruitment are key to the improvement of care and access to care, whether that care is provided remotely or not. Education of health professionals is seen a means of improving staff retention. Green (2016) recommended that confidence in the new practices of separated care can be acquired by doctors through “training and self-education to understand the modifications to clinical practice of healthcare across different medical specialties as a result of service separation” (p. 183). In Brazil, the need to develop the knowledge base of medical professionals was at the core of development of the telehealth services, and this need has been met through the creation of SIGs, hosted by the Brazilian RUTE network. Medical education is particularly important for Brazil. A coordinator of a telehealth centre outlined the educational philosophy used as being one of “Permanent education. Our teleeducation is rooted in

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the idea of problem solving. We have emphasised this approach and try to support workplace needs. Our educational philosophy is to identify the needs and put in place the required support” (Patricia, Telehealth coordinator). However, conflicts were reported to me about the difficulties of allocating time for on-the-job education when management was reported to have told a family physician “we want fully qualified doctors … if a doctor takes time to study he will see fewer patients” (Gustavo, Family physician). The competence of health professionals to use information technology devices and applications was frequently cited as in need of improvement. Overall, within the Australian and Brazilian workforces, there was a collective sentiment that that there were people “resistant to technology change still because we have still got lots of people in the workforce who are not digitally confident” (Elena, Telehealth manager). Older professionals looked at entrants to the professions as being better equipped to understand these practice changes. Reservations about this expectation existed because the implication is that, eventually, as a younger generation rises through the education system and workforce, they will “increasingly becoming accustomed to video conferencing, web conferencing, and that young people now begin to take disciplines of telemedicine in medical courses … (but) it is not easy to change this culture from day to night” (Gilberto, Technologist). Behavioural changes, when new technology is adopted for personal use, may not extend to professional domains. For instance, a family doctor observed that doctors used a smartphone for WhatsApp, Facebook, contacting colleagues and consulting the internet to find medication information, but when using the employer electronic health records, “if he does not have a [computer] terminal in the room, or if there is a fault with the systems he stops using ah, ‘this sucks, it’s no good’” (Gustavo, Family physician). Some of this behaviour can be linked back to management policy to prioritise patient volumes and efficiency, which ultimately is determined by funding.

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11.4 Availability of Funding Funding was seen as an enabler for telehealth services, without which most services felt they could not operate. Funding issues related to the amount, stability and methods of funding. Financial challenges to telehealth service provision were reported by one nurse because “I just saw the benefit for the clients and I just … that was fantastic. But management was looking at the bottom line. The money” (Chelsea, Nurse). In the early years of telehealth, between 1995 and 2005, funding for pilot telehealth projects was raised from multiple sources including international, federal and state organisations and health, education and research bodies, as I described in Chap. 5. In Brazil, federal funding for the Brazilian Telehealth Networks program, telehealth centres and the University Telemedicine network began in 2007, expanded in 2012, and has continued, albeit with some interruptions (2017–2018), to the present day, although the current funding situation remains uncertain. Stability of funding represents a major problem for telehealth services, especially in Brazil. In both countries, telehealth services have to work within existing funding arrangements. Budgets that are determined on an annual basis, tied to specific projects and subject to continuous renegotiation do not provide the financial stability for long-term planning. When federal government funding has not been available, some states stepped in and implemented telehealth services to improve access to healthcare for regional communities. Queensland (2001), South Australia (2010), Santa Catarina (2005) and Rio Grande do Sul (2004), which funded telehealth services in the earlier years, now have the most developed telehealth services. In comparison, state funding in São Paulo (Brazil) did not occur until much later, and telehealth services there have yet to achieve widespread service coverage. Telehealth centres in Australia and Brazil benefitted from government funding. There are many examples, but in a prominent initiative in Australia, the Telehealth Pilots Program provided $20.6 million in funding between 2013 and 2015 to nine projects across the country using broadband services to support healthcare. Queensland and South Australia provided capital injections and support for running costs of

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telehealth video services. For instance, Queensland provided $30.9 million over 4 years from 2013 to 2017 (Bryett, 2015). Australian telehealth services have mainly been funded from within the budgets of state health services, so they receive annual block grants. State funding consists of combinations of block funding grants for projects or telehealth centres, incentive funding linked to the number of telehealth episodes and activity funding arising from unitised payments for health episodes. All these arrangements present problems for new services. Block grants are normally time-limited; incentive payments generate expectations that the incentive will be maintained indefinitely; and activity funding is based on unitised payments which do not always represent true costs. Within some Australian state health sectors, incentive payments to services offered from hospitals encouraged a greater range of telehealth services, but these incentive payments were only temporary arrangements. Payment of incentives to healthcare providers to undertake work seen as additional to traditional face-to-face consultations has been a feature of healthcare funding and telehealth service funding in Australia at the federal and state levels for some time. The intention of incentive funding is to increase the availability of telehealth services by encouraging more health professionals to use them. Some state governments, such as that of Queensland, provided selective incentive payments within their state health systems for telehealth activity in the belief that travel costs for patients and professionals would be contained and clinical outcomes improved if patients could be serviced closer to their place of residence (Queensland Health, 2019). Otherwise, telehealth activity attracted no additional funding, which meant that practitioners who see telehealth as requiring extra work are reluctant to provide telehealth services. A manager observed, “[T]here’s only funding built into the model for outpatient not-admitted activity. We have an incentive around emergency, we have an incentive around admitted patient, an incentive around store-forward”. (Robin, Health service manager). The limitations of incentive and activity-based payments became clear in January 2021 when it was uncertain as to how many GPs would find it financially viable to participate in the COVID-19 vaccination campaign (Woodley, 2021).

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Research and development funding have also been important. Researchers at the University of Queensland Centre for Online Health received about $5 million of funding from the National Health and Medical Research Council between 2013 and 2018 (National Health and Medical Research Council, 2019). Between 2007 and 2012, the Brazilian Ministry of Health funded nine universities to provide teleconsulting, telediagnosis and second opinions. The telehealth centre in Santa Catarina received about 3 million Reis (about $1 million Australian dollars) annually in the period 2011–2017 to provide teleadvice services (Silva et al., 2015). Rio Grande do Sul has received about 85 million Reis since 2009 for a number of project and services. Block funding of university-based telehealth centres in Brazil has not always been targeted at centres that have the required expertise or needs, and it has been an unreliable funding source. According to Marcos, a family physician, “In 2012 we had an initiative in Brazil to open new telehealth centres, including in localities that did not want a telehealth centre, but felt obliged to participate because funding was available”. Many of the smaller Brazilian centres did not survive and “there was the weakening of several university-based telehealth centres although some were able to grow, as in the case of Rio Grande do Sul” (Carla, Telehealth service manager). Dependence on one source of funding, subject to national political and economic considerations, has created cash flow problems for most telehealth centres. Additionally, federal funds could only be used for the specified purposes, constraining federal universities’ partnership options with the private sector. Cash flow problems included delays in agreeing contracts with the Ministry of Health or late payments of contractual instalments. During 2018 and 2019, many centres had yet to finalise agreements and had received indications that their funding would be substantially reduced. One telehealth manager complained, “the government has cut our funding … we will have to stop everything on the 22nd, because we have no money” (Arlette, Researcher). In an effort to diversify sources of funding, Brazilian and Australian telehealth centres have negotiated once-off agreements or partnership with state governments. These agreements provided equipment, in-kind support or financial contributions enabling them to maintain services. For instance, “with 1 million Reis from the state health department we

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established a [teleradiology] project to support 80 municipalities … the department adopted the project and commenced to fund this form of care. And until now we support 800 municipalities” (Juan, National manager). Paradoxically, although Brazilian telehealth services improve patient access to healthcare, municipal governments are not obliged to contribute to their respective telehealth centres even though they benefit most from reductions in patient travel expenses. Another funding source has been federal governments. Like Australia, Brazil has a table of rates payable for different procedures in the health system although the rates do not reflect actual costs. One manager observed, “[F]or ECG [electrocardiograph] exams the payment has not changed for 20 years…. For example R$5.15 [about $1.50 Australian] is the amount SUS [the Brazilian health system] pays for an electrocardiogram” (Rod, Telehealth centre manager). In the main, these payments benefitted telehealth services providing diagnostic services and excluded telehealth advice services. At the federal Australian government level, some specialist telehealth consultation fees began to be subsidised through the MBS from 2011, and about $28 million per  annum was provided in 2017 for telehealth specialist consultations over a limited range of specialities and procedures (Australian Government Department of Health, 2019a). Activity payments from the Australian Federal Government accrue to the healthcare provider or the organisation for which they work. Activity payments subsidise the price charged by private specialist and primary healthcare providers. Payments are at a higher rate than standard consultations. Prior to the COVID-19 pandemic, the fee-for-service payments of Australian healthcare were a limiting structure for telehealth services. For instance, in the funding for patient to GP telehealth treatment prior to the pandemic, only GPs in the remotest regions of Australia received incentive funding for telehealth services (Australian Government Department of Health, 2019b). This restriction was based on fears that GPs operating in metropolitan areas could undercut rural GPs if they were allowed to offer telehealth services. Changes in processes and practices arising from the separation of care are often perceived or used by professional organisations as a justification for financial compensation. For instance, the AMA has suggested that

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incentive payments were necessary for telehealth consultations involving video, telephone or email, and for associated additional administration, broadband, equipment, support and training costs (AMA, 2011). Other Australian associations, including the Australian Nursing Federation, Australian Psychological Society, National Rural Health Alliance, National Stroke Foundation and Royal Australian and New Zealand College of Psychiatrists, echoed this demand. Critical events can trigger changes to the availability of funding. For instance, changes were made to allow Australian GPs to claim for mental health consultations (Australian Government Department of Health, 2020) following severe bushfires which ravaged many communities. But it is worth noting that, prior to the COVID-19 pandemic, these payments were made only for consultations using video conferencing; federal MBS activity-based payments were not expanded to cover a broader range of clinical activity due to budgetary concerns.

11.5 Sustainability of Funding Funding healthcare has always been a policy challenge for governments because the benefits of improved health partially accrue outside of the health system. Telehealth services are no exception because, as described by Liddy et al. (2018) in their review of specialist services, many of their costs and benefits reside outside of the health organisations that provide these services. Evaluations of telehealth services face the same problem. While the World Health Organization (2016) has proposed that digital health interventions should be evaluated for cost, efficiency, utilisation, and quality, holistic, societal-wide evaluations are difficult to undertake, resulting in many evaluations of telehealth services restricting their scope to impacts within the health system. By restricting the scope of evaluation to organisations it becomes more feasible to provide a defined context within which economic assessments of telehealth services can be undertaken. Snoswell et al. (2017), in a study of the international literature on the cost effectiveness, minimisation and utility of telehealth services, concluded that telehealth:

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demonstrated great potential for productivity gains arising from health system redesign; however, under the Australian activity-based funding, it is unlikely that these gains will result in cost savings. Secondary care use mitigation is an area of promise for telehealth; however, many studies have not demonstrated overall cost savings due to the cost of administering and monitoring telehealth systems. (p. 1)

This conclusion illustrates that within an organisation, telehealth services may cost less than transferring a patient by helicopter, but when considered from a wider perspective, a more complex set of variables such as cost of fuel, carbon pollution, jobs, aviation services and the support of regional communities require economic assessment. The embedding of telehealth services in mainstream healthcare was seen to be dependent on reductions in system costs and improvements in system efficiency. Many of the health professionals I interviewed who commented on the costs and benefits of telehealth services contended, or quoted data to show, that telehealth services were able to reduce costs and improve efficiency. In the main, they spoke from the perspective of their own clinical contexts; for instance, telehealth “drops the consult time from 25 minutes down to about 17 or 18 minutes. It sounds like a very small margin for us but we see about 170 patients through here a day with 14 rooms” (Abigail, Nurse manager). Noticeably, managers tended to take a broader view of costs and benefits: So what we see is telehealth activity increasing 40–50% annually year on year for a number of years and we continue to see that [patient travel] spend go up. So telehealth is probably in some instances meeting unmet demand and in other instances via the provision of a new telehealth service, it’s identifying a broader cohort or a broader range of patients that can have some interaction via telehealth that need to travel for other parts of their care. So we’re not seeing the return on investment from a financial cost saving point of view. (Robin, Health service manager)

Telehealth services can result in expenditure being delayed or shifted within the system: “it looks like it saves money over a 1-month period. Certainly in the community. But then someone ends up might end up in hospital although that’s okay because it’s spending somebody else’s pool of money”

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(Chloe, Pain specialist). In some cases, a telehealth service improves efficiency because it “allows you to do more with the same money. So it’s not necessarily saving money but it’s stopping you from spending more. And you’re seeing more cases and we did see that very convincingly” (Marion, Rehabilitation specialist). One of the difficulties that telehealth services face when considering service development is that healthcare organisations may not be funded to provide infrastructure. Responsibility for building construction or communications links can reside across organisational boundaries with other departments and organisations. As a result, many of the assessments of telehealth services have not included information technology costs (Caffery et al., 2017), demonstrating that assessments of funding requirements and benefits are influenced by the scope and context in which they are undertaken. Clearly, a broad assessment of activity within the health system is important. However, even when these costs are included, it is difficult to cost use of shared infrastructure funded using different formulae such as buildings, telephone systems, electronic health records, networks, computer rooms, administration, maintenance and support. Telehealth service infrastructure comes at a cost: We’ve got four techs, two customer service officers and two specialised level three techs and then myself. Cost of labour is about a million dollars. Total cost of services when you include stationary computers, the accommodation costs. That’s our second biggest obviously. It’s about $1.6 million [AU] a year. Then we have lifecycle management which costs me somewhere around 4 to 6 million [AU] a year which is replacing old devices. (Leon, Technology manager)

Ultimately, many costs are placed in the category of “overheads” which are necessary for the operation of health services but cannot be attributed to any one health service and often represent costs external to the health system. Transport costs are one such overhead, motivating a Brazilian telehealth manager to say, “when we started the project I wanted to show them how much money they were throwing out of the window. But that’s what you call here ambulance therapy” (Fabrício, Researcher). In a review of models of care and factors influencing the sustainability of telehealth services in rural Australia, Bradford et al. (2016) argued that

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for “telehealth to become integrated into the health system there needs to be a clear understanding of how services are funded, from what budget source, where the savings are generated, and how they are distributed back into the health system” (p. 8). Australian interviewees agreed that existing funding arrangements for telehealth services are not working, but clinicians often took a pragmatic view of funding because they felt they are always likely to see a patient at some point in time. According to an Australian telehealth coordinator: we’ve got a number of hospitals who are mainly our provider sites for…. They don’t see that as an issue because they’d be seeing the patients anyways, particularly patients coming from rural areas where you don’t have those specialties. So whether they see them face to face or telehealth it’s not going to really blow out the numbers. (Penelope, Telehealth coordinator)

One of the main reasons expressed for caution about the sustainability of telehealth services was the instability of funding. Brazilian telehealth centres in São Paulo and Santa Catarina had to suspend operations while waiting for federal government payments; the national telephone advice line operating out of the Rio Grande do Sul Telehealth Centre also had to reduce operations for a similar reason. One of the principal reasons for this instability was that many Brazilian telehealth centres are not recognised in “state policies … if there were state policies, no minister can remove resources, do you understand? The problem is that it is project and being project, the minister [can say] ‘ah … That’s expensive, I’m going to cut it’” (Salvador, Surgeon). In this chapter we have seen how the way in which resources are distributed in Australian and Brazilian healthcare systems has both enabled and inhibited their respective telehealth services. Resourcing the sustainable operation of telehealth services is inextricably linked to wider contexts. In the following chapter I will show how both contexts and mechanisms operating within contexts have influenced and continue to influence telehealth services.

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12 How Contexts and Mechanisms Influence Telehealth Services

Abstract  Does the technology used in telehealth services shape our healthcare, or do we, collectively, change and shape the technology and services used in healthcare? Drawing on the research presented in this book, I develop a meta-theoretical model which suggests that the development of telehealth services is better explained as a process of contextual adaptation, the resolution of differing sociotechnical codes and the influence of social mechanisms. My model has two major components: organisational contexts and professional contexts, within which historical and contemporary processes shape telehealth services. The operation of macro-mechanisms and secondary or  contributory mechanisms influence the extent of mutual adaptation between contexts and telehealth services. The outcome arising from these complex interactions is not normalisation or sustainability, but a new contextual state, or new normal, marking the beginning of a new adaptation cycle.

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 A. Taylor, Healthcare Technology in Context, https://doi.org/10.1007/978-981-16-4075-9_12

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In the preceding chapters I explored the different trajectories taken by telehealth services in Australia and Brazil and summarised the experiences of the health professionals that I talked with during my journey across these vast territories. In Chap. 1 of this book, I indicated that I would analyse the operation of telehealth services through a critical realist lens. In Chap. 2, I outlined some of the perceptions and practices of telehealth services from organisational and professional perspectives. In Chap. 3, I introduced the concept of sociotechnical codes which make it possible to study the social and technological changes associated with telehealth services without implying the dominance of the social or the technical. I have applied realist methodologies to the examination of the health system contexts of Australia and Brazil (Chap. 4), charting the developmental stages of telehealth services over time (Chap. 5) and identifying the major interactions that influence telehealth programs (Chaps. 8, 9, 10 and 11) within organisational and professional contexts (Chaps. 6 and 7). In this chapter, I use a meta-theoretical model to show how contexts and mechanisms influence telehealth services, particularly organisational contexts and professional contexts. In each of these, historical processes shaped and continue to shape telehealth services. Within these contexts, an ongoing process of mutual adaptation of organisational contexts and professional contexts to telehealth services has been influenced by macro-­ mechanisms operating at the group or societal level. The aim of this journey was to contribute answers to the broader question that I posed at the beginning of this book: Does the technology used in telehealth services shape our healthcare or do we, collectively, change and shape the technology and services used in healthcare? Before we can finally answer this question, it is necessary to reach an understanding of how contexts and mechanisms shape the operation of telehealth services over time.

12.1 A  re Telehealth Services Sustainable Over Time? The problem I faced in the research for this book was how to explain the sustainability and development of telehealth services, over time and between organisational and professional contexts. This question was

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predicated on the idea that the continued development of telehealth services—their sustainability over time or their inclusion into “normal” care—could be related to the contexts within which they operate. Implicit in my question was the proposition that telehealth services will develop and become a stable, normal and sustainable feature of mainstream healthcare over time. In turning to the literature for guidance, I found very different conceptual views of sustainability and normalisation. For instance, Bashshur et al. (2013) view a sustainable service as “a mainstream service fully integrated into the institutional portfolio of services provided by the health system” (p. 343). Other authors have discussed the concept of sustainability, such as Gundim (2018) and Wade et al. (2010), to name just two of the many contributions, who suggested that many factors influence the sustainability of services. Another long-standing approach to the sustainability of new technology, by Rogers (1971), employs a diffusion conceptual model in which the “diffusion effect is the cumulatively increasing degree of influence over time upon an individual to adopt or reject an innovation” (p. 161). Rogers acknowledged the relevance of social mechanisms in bringing about change. However, subsequent commentators, such as advocates of Gartner’s “Hype Cycle for Emerging Technologies” (2016), have neglected social mechanisms and suggested that the successful adoption of a technology is naturally a cumulative process, largely independent of contexts which, driven by the competitive advantage, a new technology may offer. Accepting that structural change in healthcare occurs over time affects our understanding of sustainability and normalisation. Many researchers base their analysis of sustainability on the work of May (2006) which I outlined in Chap. 3. Subsequently, May (2013) proposed that the “embedding of an innovation is a state that occurs when these agentic contributions lead to appropriate normative restructuring, the reworking of relational conventions and group processes, the enacting of practices, and their projection into the future” (p. 32). The theoretical perspectives proposed by May (2013), Bashshur et al. (2013) and Rogers (1971) all assume that sustainability is achieved when a new service or use of a technology becomes routine practice, or is embedded or normalised. Their perspective reflects a tendency in the literature to view organisational and

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professional contexts as a given, rather than subject to change. The implication of this approach is that technology needs to adapt to a given context in order to be adopted or to be successfully diffused through social structures. Further implications are that the process of normalisation of new telehealth practices requires time; and the extent to which contexts influence the development of telehealth services, or to which telehealth services change existing healthcare contexts, requires more attention. If contexts were in fact dynamic, then a more reasonable proposition would be that social processes operating over time are responsible for changes to both healthcare contexts and telehealth services. My research shows that telehealth services commenced more than 15 years ago in Brazil, 20 years ago in Queensland and 25 years ago in South Australia. However, before the advent of the COVID-19 pandemic they had not achieved significant patient volumes compared with place-based procedures. The evidence shows that prior to the pandemic, only a few telehealth services were becoming routine or normalised in healthcare practice. However, even the largest telehealth services in Queensland and Rio Grande do Sul were hesitant to claim that the majority of their services were completely normalised or were operating at significant volumes. This situation completely changed during the COVID-19 pandemic, especially in Australia. The Australian Minister of Health stated: One thing that has come from COVID is the fact that we have skipped a decade and jumped from 2030 to 2020 for the delivery of telehealth for all Australians. Universal, whole-of-population telehealth and it will now be permanent. (Australian Government Department of Health, 2020)

My research suggests that enactment of modified practices takes time, much more than the duration of a pandemic; that the viability of many services is uncertain; and that only a minority of telehealth services could claim to be fully embedded and normalised into mainstream healthcare. Research from New Zealand reported that use of telehealth services during the pandemic “was not generally embedded permanently and so, with notable innovative exceptions, has now largely reverted to in-person care due to COVID risk decreasing” (New Zealand Ministry of Health,

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2020). Therefore, the explanations for the sustainability or non-­ sustainability of telehealth services must be sought in an understanding of the interactions of telehealth services with organisational and professional contexts.

12.2 Contexts Are Moments in History A fundamental proposition of critical realism is that contexts change over time as a result of social interactions. In Chap. 3, expanding on Pawson and Tilley (1997), I defined context as: the spatial and institutional locations of social structures and their material parts, together with the norms, processes, practices, and inter-relationships found in them (i.e., the cultural structures) which condition the potential interactions between social or cultural structures and individual or collective agency. (Author’s adaption of Pawson & Tilley, 1997, p. 216)

In this book I have referred to organisational contexts as providing the structural conditions for telehealth services, such as resources, management and technology. Professional contexts represent the interactions between people over the norms, processes, practices and the codes of telehealth services. To date, the work of Greenhalgh et al. (2017) is the one contribution which has examined the adaptation of telehealth services over time within a whole of health system context. Greenhalgh et al. classified context into multilayered domains comprising: the condition or illness, the technology, the value proposition, the adopter system (comprising professional staff, patient, and lay caregivers), the organization(s), the wider (institutional and societal) context, and the interaction and mutual adaptation between all these domains over time. (p. e367)

The findings from my research support and extend the work of Greenhalgh by showing that organisational and professional contexts, that is, the social and cultural structures of healthcare, have influenced the nature of

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telehealth services over time. In this chapter, I hope to deepen an understanding of these issues by specifically identifying the social mechanisms which interact with and within organisational and professional contexts to produce outcomes that dynamically change contexts. My analysis starts from the premise that the physical and social worlds are complex and multilayered. In social science, investigation into these worlds may occur in individual or group behaviour, social interventions or organisational or country-wide phenomena. Two problems are faced by all researchers. Firstly, which layer of reality—individual behaviour, social interventions or organisational dynamics—should be investigated? Secondly, should the investigation be restricted to the duration of an intervention or attempt a historical analysis over an extended period of time? Investigators following the realist tradition of social research have tended to focus their attention on social programs or organisations using time-limited case studies. Two methods of investigation have been used by researchers operating within realist traditions to address these problems: firstly, analysis of the relationships between contexts, mechanisms and outcomes of social programs, and, secondly, morphogenetic analysis of organisational change over time. In the first method, researchers aim to find answers to the question, “what works for whom in what circumstances?” (Pawson, 2003, p. 474). This investigative tradition seeks to uncover the causal mechanisms introduced into a particular context by an intervention which produces observed outcomes. In shorthand nomenclature, this investigative process is labelled CMO, representing C (Context) + M (Mechanism) = O (Outcomes).1 An elaboration of this process by Archer (1995) explains: [R]ealism itself is committed to an explanatory framework which acknowledges and incorporates (a) pre-existent structures as generative mechanisms, (b) their interplay with other objects possessing causal powers and liabilities proper to them in what is a stratified social world, and (c) non-­ predictable but none the less explicable outcomes arising from interactions between the above, which take place in the open system that is society. (p. 159)  The C + M = O analogue need not be unique. Complex interventions will depend on multiple mechanisms. For a discussion of complexity in realist theory, see Clark (2013) for a useful taxonomy for analysing the mechanisms of complex interventions. 1

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In the second method, morphogenetic analysis proposed by Archer (1995) links explanation of the social world with her ontological conceptions of structure, culture and agency. Morphogenetic cycles simply posit that change takes place over time and in stages. This conception of phased social change is not new; for instance, Rogers (1971) also described innovation as “the process by which alteration occurs in the structure and function of a social system” (p. 38). Archer argued that in a first stage, structural conditioning sets the conditions for human agency. In the second stage, social interactions occur, followed by structural change, when agents transform structures (morphogenesis) or, in the case of maintenance of the status quo, morphostasis. According to Archer, morphogenetic cycle(s) exists for both social structures and culture. Implicit in this concept of phased social change is the assumption that human agency undergoes a cycle of group conditioning, group interaction and group elaboration (when groups bring about changes in structures). Realist evaluation has most often been applied in program evaluations. For instance, Collier et  al. (2016) used a realist evaluation approach to explore clinicians’ perspectives on their experiences of integrating a telehealth model into a specialist community palliative care program. Morphogenetic analysis has been applied in intensive case studies such as the review by Horrocks (2009) of information systems’ development and organisational change in British local government during the 1990s. Both methodologies recognise that contexts and mechanisms interact with human agents to generate underlying social forces. Realist evaluation enables us to look for the mechanisms associated with changes in healthcare delivery enabled by telehealth services, and morphogenetic analysis reveals the stages in which change has taken place. The mechanisms that I outline later in this chapter act within the contexts of telehealth programs to bring about structural, morphogenetic changes in health systems and to produce outcomes that support separated care. The interaction of historical contexts with these mechanisms which leads to contextual changes over time is the subject of the following section.

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12.3 Contextual Influences on Telehealth Services In Chap. 3, my review of the practices and perceptions of technology-­ supported healthcare found three broad explanations for the development of telehealth services: Firstly, on technology acceptance by users; secondly, on organisational impact of technology; and thirdly, on adoption of technologies by users and organisations within broad social contexts. The dominant discourses in these explanations concerned the factors leading to acceptance of telehealth technology by users and were based on various empirical psychometric models. Less dominant discourses were related to socially constructed normalisation processes and diffusion models for innovative practices. Each of these discourses is shaped by contexts. Acknowledgement of the role of context in accommodating innovation was made in a systematic review by Fleuren et al. (2004) who found that the determinants of innovation were “divided into four categories: characteristics of the environment, characteristics of the organization, characteristics of the user (health professional), and characteristics of the innovation” (p. 107). My empirical research outlined in Chap. 6 found that the most important contextual influences on telehealth services from an organisational perspective have been the organisation of care and its priorities, how healthcare organisations were structured and bounded and the drive for increased use of ICT to automate healthcare processes. In Australia and Brazil, healthcare has been organised to be delivered by universal healthcare systems, where care is (mostly) free of charge at the point of care. Nevertheless, inequities and disparities in the healthcare provided by these systems exist, largely delineated by whether a patient lives in a metropolitan conurbation or in a regional area. Telehealth services have been seen as a way to provide healthcare to underserved populations across geographical and organisation boundaries. Consequently, the rationale for telehealth services has been inherently political and inextricably linked with the notion that healthcare should be universally available as a democratic right. The degree to which telehealth services are supported by governments therefore reflects the

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prevailing priorities for care. In both Australia and Brazil, the priority given to telehealth services has waxed and waned as governments changed. How the advent of the COVID-19 pandemic is altering these priorities, and the rationale for telehealth services, will be discussed in Chap. 13. Decentralisation has been one of the most significant reforms to the legal and geographical boundaries of healthcare organisations in Australia and Brazil over the last 20 years. Decentralisation of healthcare, which took place in Australia from 2010 onwards and in Brazil between 1990 and 2001, aimed at strengthening local democratic control of healthcare organisations, particularly in Brazil. Spatial and institutional boundaries profoundly shaped the distribution of resources and relationships between healthcare providers. Geographical and political boundaries determining where patients are treated are an obvious example. Telehealth services are constrained by these boundaries, even when the services are technically able to operate across them. Spatial distribution of communications infrastructure and human resources has been described as a key constraint for telehealth services, while at the same time providing a rationale for their provision. Geographical decentralisation has accentuated pressures on the organisational capacity of smaller units. In an attempt to relieve these pressures, electronic information systems have been employed to connect smaller organisations into larger organisational networks. The drive to automate healthcare processes using electronic information systems during the last 20 years is another structural process which has greatly influenced the organisational context for telehealth services. Although telehealth services depend on ICT, paradoxically, they struggled to obtain even a small proportion of the funding allocated to health information systems. Although health information systems were not a focus in my interviews, health professionals who were directly responsible for the delivery of telehealth services felt frustrated by current efforts to automate healthcare processes. Many regarded electronic information systems as immature, in part because they had been unable to incorporate the many sociotechnical codes of healthcare practice to the satisfaction of clinicians. Health professionals reported that telehealth services relying on technology to deliver healthcare were conditioned by systems which were designed to meet the needs of a single organisation in the first place, and only subsequently did they consider the needs of other organisations.

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When the specific needs of an organisation or health professionals are neglected, new technology-based initiatives can face resistance. A review of social practices and the uptake of technology in the healthcare sector by Shaw et al. (2017) argued that “health and care technologies need to be embedded within sociotechnical networks and made to work through situated knowledge, personal habits, and collaborative routines” (p. 1). When situated knowledge is ignored and unaccounted for within new telehealth service interventions, then professional contexts, in particular, become sites for conflict over pre-existing place-based sociotechnical codes and modified codes that support separated care. The place where healthcare delivery takes place has been central to the way health professionals manage care. Appointments, examinations, procedures, administration and record-keeping have been developed through more than a century of accumulated experience of interactions between health practitioners and patients in a place of care. My analysis found that splitting the care role between two or more places and its reconnection using technologies resulted, with a few exceptions, in changes to these established processes, medical practices and routines. In professional contexts, medical practice is influenced by several, sometimes conflicting and sometimes complementary, norms, processes and practices (sociotechnical codes), such as calls to base practice on evidence while simultaneously relying on accumulated experience to guide practice. Conflicts arise between new and older sociotechnical codes: Should patient management be patient-centred or be determined by established practices and patient pathways; or can chronic disease care needs be met through a cooperative integrated effort when the medical profession is siloed according to speciality? It is, therefore, unsurprising that place-based medical practices were reported, in Chap. 7, as being resistant to the changing practices required when care is separated. Professional silos can fertilise competition between information technologists, management and clinicians, collectively and individually, for control of healthcare. Conflict over which group should control health information technology was evident. I found that the prime concern of clinicians was to retain control over practice, including any technical elements of practice, such as information and communications systems. Managers, including managers of telehealth services, looked to

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technological solutions to improve health system efficiency with the potential to change the nature of established care. At the centre of these interactions over these concerns, information technologists have accumulated significant institutional power which clinicians felt hinders their right to determine clinical practice. Thus, the development of telehealth services in Australia and Brazil can be seen as contingent on interactions within organisational healthcare contexts and professional healthcare contexts. The key mechanisms influencing these interactions are discussed later in this chapter.

12.4 Mechanisms as Social Forces In the introduction to this book, I outlined how the basic concept of a mechanism fits within realist paradigms. According to Archer (1995), mechanisms cause or influence the state of a context comprised of material and cultural structures. Mechanisms arise from interactions between human agents and may not be directly observable. An example would be the mechanisms associated with conflict, such as managerial control, which may not be openly discussed by health workers. Such interactions, while they may not be immediately evident, “do” work. Mechanisms can be seen as being “what it is about a program which makes it work”. Mechanisms have also been described as processes, theories and explanations for particular outcomes. Westhorp (2018) has described mechanisms as processes with multiple inputs interacting with social actors to produce changes in social (and physical) contexts; that is, they have powers that produce change. In this sense, mechanisms are interactions defined by relationships between people that can do work to change something and have social power. Westhorp (2018) describes mechanisms as having inherent powers and liabilities, as being able to act as forces, as being the result of interactions, as processes and as consisting of reasoning and resources. She argues that: any construct of mechanism can be right so long as it is consistent with the fundamental realist conception of mechanisms: that they are causal forces or processes which operate at a different level of the system than the out-

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come that they generate; that they are not observable using the same observational tools or methods that “work” at the level of the outcome they generate; and that they involve description of at least three things: the necessary components of the system, the necessary relationships between those components and the processes (or interactions) through which those components and relationships generate the outcomes that they do. (p. 53)

Implicit in these debates are assumptions about the nature of reality. Linked to the proposition that reality is stratified is the suggestion that mechanisms are not observable “using the same observational tools or methods that ‘work’ at the level of the outcome they generate” (Westhorp, 2018, p. 53). In the research for this book, I sought to understand reality, which is “hidden”, by “digging” down through “hidden” levels of stratified reality extending from the empirical observational level to a deeper level of reality. If reality is stratified into levels or compartments, then it is logical to propose different categories of mechanisms and different levels of mechanisms operating in different parts of reality over different timescales. For example, mechanisms have been proposed to operate at the micro-social level (individuals), the meso-social level (groups) and the macro-social (societal) level (Blom & Morén, 2011). If reality is complex, then multiple mechanisms can exist, or may have existed in the past, and may have different effects. Shaw et  al. (2018) pointed out that the diversity of understandings of mechanisms arises because “a researcher’s definition of mechanism will depend on his or her underlying beliefs and interests in the analytically relevant units of analysis and components of the empirical case” (p. 4). Because mechanisms change and have changed contexts over time, it can be difficult to determine whether a particular mechanism is actually active in a contemporary context or if it is a historical mechanism which has changed a context in the past. Some mechanisms may well be mistaken for static contextual elements without any powers of influence until the accumulated outcome of their interactions reaches a critical threshold and they become visible, potentially triggering other mechanisms.

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12.5 Critical Events Trigger Mechanisms In social theory, causal powers are viewed as already inherent in the “social relationships or structures that people build” (Danermark, 2002, p. 54). Much of this discussion of the powers possessed by the relationships and structures which contribute to social mechanisms is based on a very limited understanding of, and a comparison with, the physical sciences, for instance, the ability of copper to conduct electricity (Pawson, 2013). In the case of the natural sciences, copper has inherent properties giving it the ability to conduct electricity; the reality is that unless an event occurs as the result of natural or human agency, such as the connection of a battery, no electricity will be conducted. The evolution of the NBN project in Australia illustrates this point. The rollout of the NBN was the critical event resulting from work involving more than a decade of debate, lobbying, proposals to government, definition of policies, reports and relationship building that argued the case for improved broadband network services to support health and education. The NBN has now been largely completed, having been announced in 2007 by a new government. Now, in 2021, the NBN can be regarded as part of the physical context that supported a 500% increase in the number of video-based specialist consultations during the COVID-19 pandemic (Snoswell et al., 2021), and a doubling of general traffic (National Broadband Network, 2020). The social agency of the movement to improve broadband certainly had causal power. However, until that critical trigger event occurred, the movement lacked power to transform the Australian context. Critical events indicate points at which transformations occur in contexts, described by Elder-Vass (2010) as a type of “macro-event” of a collective or historical nature, built on other smaller events. The identification of critical historical events can reveal “substantive changes in the structure, or the broader organizational environment, as perceived by the primary actors” (Williams & Karahanna, 2013, p. 939), helping to connect changes that have occurred in different contexts. Dobson et al. (2013) applied an earlier version of this methodology in their examination of the adoption of broadband technology in a regional Australian town. Their

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research linked specific mechanisms and outcomes to sequential or phased change during a project’s morphogenetic cycle. Hitherto, analysis of phased change within contexts has been limited to time-bound case studies where detailed information was obtained on the interactions taking place within organisations. For example, Cresswell and Sheikh (2013) and Herepath (2014) all reported on this type of context. Examples of intensive case studies of phased change can be found in the work of Williams and Karahanna (2013) and in a paper by Shaw et al. (2018) who undertook a comparative study across three organisations using realist methodologies in the context of an integrated care project. Shaw et al. contended that an event such as the passing of legislation can act “as both a mechanism and a context depending on the specific perspective from which the case is being analysed” (p. 9). In this extensive, longitudinal analysis spanning multiple organisations, I argue that critical events represent the outcomes of historical interactions between contexts and mechanisms that accumulated in importance over time, conditioning the context to potentially accommodate change. Critical events are distinguishable from other outcomes because they mark the triggering of widespread contextual changes. Critical events may have only short-term consequences or implications that may last for many years. Markers of a critical event can be a health reform proposal, commencement of a telehealth program, changes in government priorities, creation of new infrastructure or changes in resource allocation. Figures 5.3 and 5.5 in Chap. 5 illustrated some of the critical events and related processes in the development of telehealth services in Australia and Brazil. The most important critical events in the history of Australian telehealth prior to the COVID-19 pandemic are shown in Table 12.1. One event can be related to a period of rapid technological change, three events can be linked to political changes resulting in a new government taking office and one event represented a response to a “natural” disaster arising from processes not directly related to healthcare. Similarly, the most important critical events in the history of Brazilian telehealth prior to the pandemic are shown in Table 12.2. Two can be linked to political changes resulting in a new government taking office, and one represented a response to a political and economic crisis.

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Table 12.1  Critical events in the history of Australian telehealth prior to 2020 Critical events

Implication for telehealth services

Advice and lobbying to government (conditioning) for telehealth initiatives to be subsumed under eHealth projects which have a better business case With the election of a new government in 2007, improved access to broadband became a key initiative, resulting from years of lobbying (conditioning) which has improved the reliability of telehealth services Health and hospitals reform In some states, the responsibility for (2010) telehealth services was devolved from states to smaller local health organisations Government re-elected in 2010; improved Creation of nine Telehealth telehealth services were part of the election Pilot projects and funding platform through the MBS for a limited range of consultations (2011–ongoing) Australian bushfires in late 2019 impacted Increased range of telehealth the health of many regional communities, services available under the particularly mental health which could be MBS to support recovery from provided using telehealth service bushfires (2019)

Prioritisation of health information systems over telehealth service development (2002–ongoing) Initiation of the NBN and national telehealth pilot projects using the NBN (2011–2015)

Table 12.2  Critical events in the history of Brazilian telehealth prior to 2020 Critical events

Implication for telehealth services

With the re-election of a new government in Initiation of the Brazilian Telehealth Networks program 2006, there was a movement (conditioning) to improve the quality of primary healthcare by the Brazilian Ministry of using ICTs Health (2005–2007) With the election of a new government in Expansion of the Brazilian Telehealth Networks program 2011, the Ministry of Health decided the outcomes of the initial telehealth program to the majority of states (conditioning) justified further expansion (2012) and integration Complex political and economic issues Budgetary restrictions placed conditioned government policy from 2015 on health and telehealth onwards and reduced funding to telehealth services as part of national centres austerity measures (2015–ongoing)

Decisions, plans, projects and regulatory changes in both countries

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have influenced telehealth provision. The major critical events in the history of telehealth prior to 2020 in both countries can be linked to political changes, responses to development of ICTs or adverse environmental, political or economic circumstances. In 2020 the COVID-19 virus emerged as the result of biological and social processes that are yet to be fully understood, but the beginning of the COVID-19 pandemic was clearly a critical event that impacted most human activities. The role that telehealth services played in the response to the pandemic will be discussed in the final chapter of this book.

12.6 The Mechanisms of Telehealth Services Pawson and Tilley (1997) referred to the role of contexts in conditioning as “the potential interactions between social or cultural structures and individual or collective agency” (p. 216). The corollary processes, where individual or collective agency expressed through social interactions conditions contexts, are the mechanisms influencing social and cultural structures. These social interactions form the major underlying mechanisms operating in professional and organisational contexts. Danermark et al. (2019) described this duality between structure and agency as “a dynamic in which social structures and agency form and reform each other over time” (p. 93). Clearly, the relationships between mechanisms and contexts are complex, and it is sometimes difficult to identify which explanations relate to contexts and which relate to mechanisms. Shaw et al. (2018), in a comparative cross-organisational study, discussed the interrelationship of mechanisms and contexts at the policy, organisational and healthcare provider level, concluding that “mechanisms may also act as contexts in any individual intervention” (p. 11). The relationships between organisational contexts, professional contexts and four macro-mechanisms operating to influence contexts and thereby enable telehealth services are illustrated in my meta-theoretical model of telehealth service development in Fig.  12.1. This meta-­ theoretical model suggests that the development of telehealth services is not one of technology acceptance, normalisation or the attainment of sustainability, but is better explained as a process of contextual

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Fig. 12.1  How contexts and mechanisms influence telehealth services

adaptation, resolution of differing sociotechnical codes and the influence of social mechanisms. The model has two major components: organisational contexts (discussed in Chap. 6) and professional contexts (discussed in Chap. 7). In each of these contexts, historical processes and their components have shaped, and continue to shape, contexts. I have chosen not to describe these processes, although important, as contemporary mechanisms, because my analysis showed that they were historically connected to contexts. For instance, how care is organised, structured and automated is historically part of the social structures of

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organisational contexts. Similarly, conflicts in professional contexts over separation of care, medical practice and control of technology are historically linked to the cultural structures of professional contexts. Within organisational and professional contexts, an ongoing process of mutual adaptation to telehealth services is influenced by macro-­ mechanisms operating at the group or societal level. This ongoing interaction among telehealth services, contexts and mechanisms can be represented as an interlocking set of processes. The outcome arising from these complex interactions is not normalisation or sustainability, but a new contextual state, a “new normal’, marking the beginning of a new adaptation cycle. Figure 12.1 provides a graphical representation of these interactions. According to my meta-model, contextual change is driven not by technology or organisations or individuals, but by component processes and mechanisms given causal power through interactions within the underlying relationships among actors, especially health professionals, managers and technologists working in healthcare organisations within their professional contexts. Table  12.3 outlines how social and cultural component processes have influenced the structures within which telehealth services operate.

Table 12.3  Social and cultural processes influencing telehealth services Structures

Component processes

Organisation of care and Social structures: Determine the influence of organisational contexts on telehealth services priorities for care shape telehealth services (Chap. 6) Organisational structures circumscribe telehealth services Healthcare automation has contradictory consequences for telehealth services Separation of care challenges Cultural structures: Influenced by conflicting sociotechnical codes about telehealth services usual practice Medical practice is influenced within professional contexts (Chap. 7) by competing norms Control of technology is disputed

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Organisational contexts represent the social structures of healthcare. Three component processes in organisational contexts, described in Chap. 6, have been found to influence telehealth services: firstly, how care is organised and prioritised to shape telehealth services; secondly, how organisations are structured to shape telehealth services; and thirdly, the drive to automate healthcare, which has had positive benefits for telehealth services but has also diverted resources from telehealth services. Professional contexts, discussed in Chap. 7, represent the cultural structure of healthcare. Professional contexts have been the site of conflict over the adaptation of professional cultures containing conflicting sociotechnical codes relevant to telehealth service operation. Firstly, when healthcare activities are supported at a distance, customary place-based care practices require modification. Secondly, medical practice has, over time, been subject to competing codes (patient-centred care, evidence-­ based care, integrated care, automated care) and telehealth services that seek to modify customary place-based practices. Thirdly, there is ongoing conflict for control of technologies used in care which is clearly evident in telehealth services. Social interactions over norms, processes and practices mediate these conflicts, legitimise telehealth service provision and build confidence in modified professional practices supporting healthcare activities at a distance. Interacting with the organisational and professional structures of telehealth services, there are four key macro-mechanisms which explain how: • • • •

norms, processes and practices legitimise services; building confidence in practices determines service use; relationship-building supports the development of services; and application of resources enables the development of services.

The role of sociotechnical codes is prominent in each of the four macro-mechanisms. Within professional contexts, practices, particularly medical practices, manifest the sociotechnical codes which are central sites of contest in the development of norms, processes and practices which legitimise services (Chap. 8). Sociotechnical codes are reconfigured in the building of confidence in services (Chap. 9), and through the social relationships supporting services (Chap. 10) sociotechnical codes

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Table 12.4 Macro and contributory mechanisms operating across telehealth services Four macro-mechanisms operating across telehealth services Norms, processes and practices legitimise modified professional practices (Chap. 8)

Building confidence in practices cements professional practices (Chap. 9) Social relationships mediate conflicts over professional practices (Chap. 10)

Distribution of resources supports the social structures needed by telehealth services (Chap. 11)

Contributing mechanisms Organisational strategies shape norms Guidelines and regulations define healthcare processes Social interactions influence practice Accepting technology in practice Managing risks of practice Creating trust in practice Collaboration establishes relationships Relationships provide a means of resolving conflicts Leadership develops relationships across boundaries Availability of infrastructure Availability of staff Availability of funding

are provided with causal power. Distribution of resources (Chap. 11) is conditioned by sociotechnical to support or inhibit the social structures needed by telehealth services. Associated with these macro-mechanisms, a number of contributory mechanisms operating at the micro-social level (individual) and the meso-social level (group) level have been described in each of these previous chapters. Table  12.4 lists these macro-­ mechanisms and contributory mechanisms. Summarising Table 12.4, four mechanisms have been found to operate across the contexts of Australian and Brazilian telehealth services. Each macro-mechanism consists of several contributory mechanisms. Firstly, norms, processes and practices legitimised telehealth services in Australia and Brazil. For instance, my findings show that organisational strategies and guidelines shape organisational and professional norms. Regulations play a strong role in defining healthcare processes (i.e., what can and should be done in practice), and social interactions, particularly between healthcare professionals, influence practice.

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Secondly, building confidence in practices comes through the acceptance of new techniques and technologies which support healthcare activities at a distance in both Australia and Brazil. Confidence in new or modified practices is built by conscious management of perceived clinical and technological risks by health professionals. Trust is thereby created in practices employing new techniques and technologies. Thirdly, participants in my research emphasised that social relationships, often supported by leadership from “boundary spanning” roles, support the development of services through the establishment of collaborations; that relationships provide a means of resolving conflicts over technology use; and that changes to practice enable health professionals to create trust in practice. In both Australia and Brazil, social relationships were considered important. However, Brazilians valued collaboration more than Australians did, and Australians looked to the role of champions to support telehealth services more than Brazilians did. Finally, but no less importantly, all telehealth services in Australia and Brazil reported that the distribution of resources to their organisations or services profoundly influenced the scope and scale of services they could provide. In Brazil, the allocation of financial resources for telehealth services by government was a significant concern, whereas in Australia, participants were more concerned about the availability of technology. Although my research is based on critical realist ontology, I did not intentionally set out to operationalise Archer’s (1995) morphogenetic, cyclic frameworks of social change. However, my analysis supports Archer’s conceptualisation of social change and my meta-theoretical model of how contexts and mechanisms influence telehealth services allow for the deployment of many mid-range theories for more detailed explanation of the contributory, lower-level (micro or meso) mechanisms. For instance, the legitimisation of telehealth services can be understood through normalisation process theory constructs; or the building of confidence in the practices of telehealth services can be the subject of diffusion of innovations theory or technology acceptance modelling—or it can be seen as resulting from the triggering of social mechanisms by critical events such as the separation of care brought on by the COVID-19 pandemic. How mechanisms responded to the contextual changes for healthcare that we have experienced since the beginning of the COVID-19

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pandemic in 2020, and what a new normal for telehealth services could look like, will be discussed in the final chapter of this book.

References Archer, M. (1995). Realist social theory: The morphogenetic approach. Cambridge University Press. Australian Government Department of Health. (2020, November 27). Doorstop Interview on 27 November, 2020 [Text]. Australian Government Department of Health; Australian Government Department of Health. https://www. health.gov.au/ministers/the-­hon-­greg-­hunt-­mp/media/doorstop-­interview-­ on-­27-­november-­2020 Bashshur, R. L., Shannon, G., Krupinski, E. A., & Grigsby, J. (2013). Sustaining and realizing the promise of telemedicine. Telemedicine and E-Health, 19(5), 339. Blom, B., & Morén, S. (2011). Analysis of generative mechanisms. Journal of Critical Realism, 10(1), 60–79. https://doi.org/10.1558/jcr.v10i1.60 Clark, A.  M. (2013). What are the components of complex interventions in healthcare? Theorizing approaches to parts, powers and the whole intervention. Social Science & Medicine, 93(Supplement C), 185–193. https://doi. org/10.1016/j.socscimed.2012.03.035 Collier, A., Morgan, D. D., Swetenham, K., To, T. H., Currow, D. C., & Tieman, J.  J. (2016). Implementation of a pilot telehealth programme in community palliative care: A qualitative study of clinicians’ perspectives. Palliative Medicine, 30(4), 409–417. https://doi.org/10.1177/0269216315600113 Cresswell, K., & Sheikh, A. (2013). Organizational issues in the implementation and adoption of health information technology innovations: An interpretative review. International Journal of Medical Informatics, 82(5), e73–e86. https://doi.org/10.1016/j.ijmedinf.2012.10.007 Danermark, B. (2002). Explaining society: Critical realism in the social sciences (1st ed.). Routledge. Danermark, B., Ekstrom, M., & Karlsson, J.  C. (2019). Explaining society: Critical realism in the social sciences (2nd ed.). Routledge. Dobson, P. J., Jackson, P., & Gengatharen, D. (2013). Explaining broadband adoption in rural Australia: Modes of reflexivity and the morphogenetic approach. MISQ Archivist. https://pdfs.semanticscholar.org/305c/27ddf86 4b851d975ef31185221b49d0845a5.pdf?_ga=1.191743082.174851839 5.1482243206

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Elder-Vass, D. (2010). The causal power of social structures. Cambridge University Press. Fleuren, M., Wiefferink, K., & Paulussen, T. (2004). Determinants of innovation within health care organizations – Literature review and Delphi study. International Journal for Quality in Health Care, 16(2), 107–123. https://doi. org/10.1093/intqhc/mzh030 Gartner. (2016). Gartner’s 2016 hype cycle for emerging technologies. http://www. gartner.com/newsroom/id/3412017 Greenhalgh, T., Wherton, J., Papoutsi, C., Lynch, J., Hughes, G., A’Court, C., Hinder, S., Fahy, N., Procter, R., & Shaw, S. (2017). Beyond adoption: A new framework for theorizing and evaluating nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability of health and care technologies. Journal of Medical Internet Research, 19(11), e367. https://doi. org/10.2196/jmir.8775 Gundim, R. S. (2018). Telemedicine and telehealth services and their sustainability. Latin American Journal of Telehealth, 5(3) http://cetes.medicina.ufmg. br/revista/index.php/rlat/article/view/260 Herepath, A. (2014). In the loop: A realist approach to structure and agency in the practice of strategy. Organization Studies, 35(6), 857–879. https://doi. org/10.1177/0170840613509918 Horrocks, I. (2009). Applying the morphogenetic approach. Journal of Critical Realism, 8(1), 35–62. https://doi.org/10.1558/jocr.v8i1.35 May, C. (2006). A rational model for assessing and evaluating complex interventions in health care. BMC Health Services Research, 6, 86. https://doi. org/10.1186/1472-­6963-­6-­86 May, C. (2013). Towards a general theory of implementation. Implementation Science, 8, 18. National Broadband Network. (2020). How we’re tracking: November 2020. NBN Co. https://www.nbnco.com.au/corporate-­information/about-­nbn-­co/ updates/dashboard-­november-­2020 New Zealand Ministry of Health. (2020, November). Digital enablement oversight group – Gap analysis (p. 27). https://www.health.govt.nz/system/files/ documents/media/digital-­enablement-­gap-­analysis-­final.pdf Pawson, R. (2003). Nothing as practical as a good theory. Evaluation, 9(4), 471–490. Pawson, R. (2013). The science of evaluation: A realist manifesto. SAGE Publications. Pawson, R., & Tilley, N. (1997). Realistic evaluation. Sage. Rogers, E. M. (1971). Diffusion of innovations (2nd ed.). Free Press.

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Shaw, J., Shaw, S., Wherton, J., Hughes, G., & Greenhalgh, T. (2017). Studying scale-up and spread as social practice: Theoretical introduction and empirical case study. Journal of Medical Internet Research, 19(7), e244. https://doi. org/10.2196/jmir.7482 Shaw, J., Gray, C.  S., Baker, G.  R., Denis, J.-L., Breton, M., Gutberg, J., Embuldeniya, G., Carswell, P., Dunham, A., McKillop, A., Kenealy, T., Sheridan, N., & Wodchis, W. (2018). Mechanisms, contexts and points of contention: Operationalizing realist-informed research for complex health interventions. BMC Medical Research Methodology, 18(1), 178. https://doi. org/10.1186/s12874-­018-­0641-­4 Snoswell, C.  L, Caffery, L.  J., Hobson, G., Taylor, M.  L., Haydon, H.  M., Thomas, E., & Smith, A.  C. (2021). Telehealth and Coronavirus: Medicare Benefits Schedule (MBS) activity in Australia (Taylor). Centre for Online Health, The University of Queensland. https://coh.centre.uq.edu.au/ telehealth-­and-­coronavirus-­medicare-­benefits-­schedule-­mbs-­activity-­australia Wade, V., Eliott, J., Karnon, J., & Elshaug, A. G. (2010). A qualitative study of sustainability and vulnerability in Australian telehealth services. Studies in Health Technology and Informatics, 161, 190–201. Westhorp, G. (2018). Understanding mechanisms in realist evaluation and research. In N.  Emmel, J.  Greenhalgh, A.  Manzano, M.  Monaghn, & S. Dalkin (Eds.), Doing realist research. SAGE Publications. Williams, C. K., & Karahanna, E. (2013). Causal explanation in the coordinating process: A critical realist case study of federated IT governance structures. MIS Quarterly, 37(3), 933.

13 Telehealth Services in the Age of the COVID-19 Pandemic

Abstract  The COVID-19 pandemic responses in many nations enforced the physical separation of healthcare activities. This major contextual change triggered some of the key mechanisms of social change previously identified in this book, namely, the need to legitimise and resource telehealth services and to build confidence and relationships to support separated care. These mechanisms worked to extend and reorientate existing services. Looking into the future for telehealth services, as contexts continue to change under the influence of mechanisms, new contextual states will be created, which in turn will evolve under the influence of continuing, modified or new mechanisms. Whether universal healthcare then becomes a reality for everyone as part of an evolving new normal will depend on all of us—healthcare clients, patients, healthcare professionals, managers and technologists. The discovery of the highly infectious COVID-19 virus at the start of 2020 triggered a complex series of cascading interventions to counter the global threat to public health. Although the origins and causal history of © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 A. Taylor, Healthcare Technology in Context, https://doi.org/10.1007/978-981-16-4075-9_13

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the virus remain unexplained, it seems that the  COVID-19 pandemic stemmed from a set of interactions between humans and biological contexts. The declaration of a pandemic and the serious consequences of being infected had multiple repercussions: This one critical event triggered a series of cascading public health interventions. The principal intervention mechanism was the call to maintain social distancing between the human hosts the virus infects. The entire response to the pandemic is described by Pawson (2021) as: a massive array of public policies and social interventions that reach into every institution and every sphere of public and private life. It is an unprecedented attempt to manage social change on a grand scale. It is, in short, a complex, adaptive, self-transforming system. (p. 7)

Increased social distancing had direct implications for telehealth services across the world because of the need for greater physical separation of healthcare. This final chapter will examine the contextual changes arising from the pandemic, and the concomitant triggering of mechanisms which enabled telehealth services to become part of the overall response to the pandemic. In identifying these mechanisms, I draw on the conclusions of my research across Australia and Brazil on the development of telehealth services, contemporary publications on telehealth, which are outlined in Chap. 12, as well as my own research on the impact of the pandemic on telehealth services. Other research I will refer to includes a follow-up survey that I undertook with the 42 health professionals I originally interviewed for my research, at the start of the pandemic. This follow-up survey provided useful insights into the changes beginning in telehealth services early in the pandemic and confirmed the conclusions of my research presented in Chap. 12. I also refer to a survey of subscribers to the Australian Telehealth Society (ATHS) newsletter which elicited 91 responses between 5 July 2020 and 10 September2020 from GPs, medical specialists, nurses, allied health providers, health service managers, researchers and telehealth coordinators (Australian Telehealth Society, 2021). This survey focused on the contextual changes and the mechanisms involved in enabling telehealth services to respond to the pandemic.

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In this chapter, I hope to provide the reader with an overview of the changes to telehealth services and their organisational and professional contexts during the pandemic; discuss which mechanisms were activated in bringing about those changes; and reflect on the challenges for separated care that can be anticipated in the future.

13.1 Reorganising Healthcare The extent to which many countries reorganised their health systems to make greater use of telehealth services during the COVID-19 pandemic seemed to be dependent on the pre-existing contexts for healthcare before the pandemic. In Italy, telehealth services were not widely deployed during the pandemic. Reasons given for this include a lack of interoperability between health information systems, limited pathways between primary and acute care services and a failure to make telehealth services freely available as part of the national health system (Garattini et  al., 2020, p.  3). South Korea was another example of a country that lacked the contextual preconditions for the use of telehealth services during the pandemic. South Korea has a very dominant private healthcare sector; consequently, despite government advocacy of telemedicine, primary care providers resisted its use because they feared competition from larger, hospital-based organisations (Kim & Choi, 2020, p. 4). In Europe, according to the OECD and European Union (2020), 14 of 31 OECD countries expanded their use of telehealth services when the pandemic began. Chittim et  al. (2020) claimed that France, Portugal, Sweden and the UK were the European countries which increased their adoption of telehealth services most, because their previous levels of adoption were relatively high compared with other countries. In supporting this proposition, Nascimento et al. (2020) emphasised the value of being able to reorientate established services in a Brazilian hospital group during the pandemic because: a complex technology information system had already been developed for multiple purposes, including online scheduling of medical appointments, authorisation of procedures and patient/staff education. Furthermore, the

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majority of interactions with clients are already made through a patient-­ friendly mobile app, which was then adapted for the COVID-19 systems. Second, there was a pre-established programme of home care and monitoring for vulnerable patients. (Nascimento et al., 2020, p. 6)

In Australia and Brazil, which both had extensive telehealth services prior to the pandemic, health organisations reorganised services to support remote consultations and advice for a range of conditions. In these country contexts, the priorities for care were set by new political necessities which influenced organisational priorities, as I discussed in Chap. 6. The new priority was to provide remote consultations supporting the triaging of patients with possible COVID-19 infections or other conditions according to the seriousness of their condition. Depending on the triaging decision, patients were then managed either remotely or within a health facility. We saw large increases in the volume of remote consultations in the Australian public hospital sector: Queensland Health and South Australian Health reported increases of more than 150% in video consultations in the first three months of the pandemic (Queensland Health, 2020; South Australian Health, 2020). The Australian private hospital sector responded to the pandemic by extending existing telehealth services or setting up new ones. For instance, Austin Health in Victoria set up a telehealth “hub” that is reported to service approximately 26,000 appointments each month (McDonald, 2020b). The private appointment booking service, HealthEngine, claimed to have facilitated 220,000 telehealth bookings between April and June 2020 with GPs and specialists who subscribe to the service (HealthEngine Insights, 2020). In the Australian primary and specialist health sector where consultations are subsidised by Australian Government via the MBS, key regulatory changes to the payment regulations legitimised and resourced the use of telehealth across a much greater range of healthcare activities than was previously permissible. Subsequently, there were huge increases in the volume of telephone and video-based consultations between doctors and patients for services funded by the MBS. As of November 2020, remote consultations comprised 25% of 11.8 million general practice consultations, 15% of 2.5 million specialist consultations, 27% of 1.0

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13  Telehealth Services in the Age of the COVID-19 Pandemic  12.000

5.000

In-person consultations (million)

4.000 3.500

8.000

3.000

2.500

6.000

2.000 4.000

1.500 1.000

2.000

Telephone or video consultations (million)

4.500 10.000

0.500 0.000

Videoconference consultations

0.000

Telephone consultations

In-person consultations

Fig. 13.1  GP consultations in Australia during the pandemic (the left-hand vertical axis refers to the number of in-person consultations, and the right-hand vertical axis refers to the number of video conference consultations and telephone consultations). (Adapted from Snoswell et al., 2021)

million mental health consultations, 20% of 56,500 nurse practitioner consultations and 4% of 1.0 million allied health consultations (Snoswell et al., 2021). Figure 13.1 illustrates that consultations provided by GPs since the start of the pandemic using telephone or video modalities increased, while in-person consultations declined. However, between September and November 2020, when the pandemic was suppressed in Australia, the number of in-person consultations began to rise proportionately, while telehealth consultations fell. Only time will tell where the new normal level for telephone and video (conference) consultations will stabilise, or if more than short-term stability will eventuate. In March 2020, legislation passed in Brazil allowed telehealth services to provide remote consultations between health professionals and public or private patients. The organisations in Brazil’s large private care sector that took advantage of this legislation were a mix of private health

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insurance companies, philanthropic hospital organisations and technology service companies, as I outlined in Chap. 1. In Australia and Brazil, established services were repurposed. In some health services, organisational processes began to support separated care by including telehealth consultations in patient appointment systems. The Australian national call centre coronavirus helpline (Healthdirect Australia, 2020) provided advice services for the general population about the symptoms and management of COVID-19 conditions. Building on existing services for primary healthcare, Brazilian telehealth continued to provide education, second-opinion telephone and online services orientated towards management of COVID-19 conditions in primary healthcare settings. For instance, in the state of Sergipe, online seminars discussed the management of COVID-19 conditions (Gois-­ Santos et al., 2020). Similarly, in Minas Gerais, the state-based telehealth centre developed infographics and webinars for “health professionals and general population about key themes, such as respiratory syndromes, personal care and ventilator support” (Silva et al., 2020, p. 2) for countrywide viewing. The Brazilian University Telemedicine Network (RUTE), which is a key component of publicly funded telehealth services in Brazil, had for some time supported a large number of virtual SIGs to exchange experiences in a wide range of health specialities. RUTE formed a COVID-19 professional network providing “presentations through web conferencing and streaming with invited guest speakers from Israel, Italy, Spain, Portugal, and USA sharing their expertise and difficulties on diagnostic tests and exams” (Eisenstein et al., 2020, p. 96). During the pandemic, information technology played an important role. System capacities were rapidly increased in Australia (National Broadband Network, 2020) to cater for increased use of internet and video conferencing applications. The Brazilian Academic Network commenced a project to provide internet connectivity to a wider group of primary health facilities. By November 2020, a total of 1210 facilities had been connected, with an additional 9796 connections planned (COSEMS / SP, 2020). New services were slower to emerge. A COVID-19 symptom monitoring platform in Bendigo, Victoria (Croxon, 2020) and South Western Sydney Local Health District service (McDonald, 2020a) provided

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monitoring and management of the health of people who were isolating at home or in a quarantine location. The Brazilian public health system launched a range of services including mobile apps, online chat, voice messaging and WhatsApp services to provide advice on COVID-19 conditions (Ministério de Saúde, 2020). The increased provision of separated care, in many cases, required changes to the organisational pathways for managing patients. The impact on workflow organisation within health services stemming from this was not immediately apparent to those outside an organisation. A nurse gave an insider view of the difficulties that were encountered: We have had some regular telehealth clinics for years and others that are ad hoc, however, the amount of telehealth has tripled, funding was made available for the central sites in our district however not for someone to assist with the telehealth clinic or for administration. So our facility has been working hard to find the money to pay for a telehealth nurse and we have rearranged the administration so one position is the central go-to person who coordinates the clinic between the two facilities and the patients. We are still scrambling for space to hold the enormous inflow of telehealth. We are expecting post COVID-19 that there will be more of a trend to do telehealth and it will be more culturally accepted as the norm. (Olive, Nurse)

13.2 Changing the Culture of Healthcare Cultural structures are influenced by conflicting sociotechnical codes about telehealth services. In Chap. 7, I showed that separation of care challenges usual practice, medical practice is influenced by competing codes and the control of technology is disputed in professional contexts for telehealth services. Notably, during the COVID-19 pandemic there was a significant cultural shift in the willingness of health professionals to adjust their practices. Professional practices were undoubtedly challenged by the need to separate care during the pandemic. Practice, particularly the willingness of actors to change, is articulated through perceptions of culture (Greenhalgh et al., 2017). This was highlighted by a health professional

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Table 13.2 Changes to professional culture during the pandemic (Taylor et al., 2021) Professional group Managerial culture

Medical culture

Technical culture

Assisted in the use of telehealth

Most frequent response

Below median, n (%)

Above median, n (%)

McNemar’s Chi-square p-value

Before the outbreak of COVID-19 After the outbreak of COVID-19 Before the outbreak of COVID-19 After the outbreak of COVID-19 Before the outbreak of COVID-19 After the outbreak of COVID-19

A moderate amount

17 (51.5)

16 (48.5)

0.001

A lot

5 (10.9)

41 (89.1)

A moderate amount

17 (65.4)

9 (34.6)

A lot

5 (12.5)

35 (87.5)

A lot

14 (50)

14 (50)

A lot

7 (20)

28 (80)

0.001

0.125

who felt that “rapid change has highlighted how little the available technologies, management practices and practice structures were geared to cope with non-face-to face care” (David, GP). Changing these practices was associated with the willingness of health professionals to change long-standing practices, behaviour and beliefs expressed through culture. A Brazilian professional stated that: The managerial culture has changed based on evidence of the effectiveness and efficiency of telehealth, but there is still a lot of difficulty in investing professionals’ time and financial resources in this activity. The medical and technical culture changed because of the compulsory use of services, which demonstrated the ease and usefulness of telehealth. (Pedrina, Telehealth coordinator)

Respondents to the ATHS survey (Taylor et al., 2021) were also asked to compare the extent to which professional managerial, medical or technical cultures assisted the use of telehealth services before and after the

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outbreak of COVID-19. Table 13.2, which records the results of applying McNemar’s Chi-square test to the survey responses, shows that managerial and medical cultures, but not technical cultures, significantly changed their support for the use of telehealth services. Parmelli et al. (2011) made the point that “culture is … a lens through which an organisation can be understood and interpreted” (p. 1). Survey respondents in Australia interpreted the changes that they had experienced in organisational cultures in many different ways. An allied health professional in Victoria felt that medical and managerial cultures had become more cooperative, and technical culture more adaptive: Technical cultures are required to deliver solutions that can work and so COVID has eased their ability to innovate or adopt as needed. Medical culture has stopped being so obstructive, and managerial has now got more ability to operate with cooperation from partners or other previous barriers. (ATHS Survey respondent)

Many respondents to the ATHS survey (Taylor et  al., 2021) commented on shifts in Australian healthcare organisational culture in order to legitimise separated care. Managers were felt to be much more cooperative and supportive. Medical professionals appeared much less opposed to the use of telehealth services, and technologists were recognised as providing essential support in the face of significant demands arising from the increased use of online services by the entire workforce.

13.3 Legitimising Telehealth Services The substitution of in-person care with separated care using telehealth services was seen as a means of maintaining healthcare services during the COVID-19 pandemic. Thus, for the first time, the wide-scale use of telehealth services at scale was legitimised. In Australia and Brazil, the mechanisms used to legitimise greater use of telehealth services were changes to legislation and regulations. On 13 March 2020, at a time when in-person consultations were already decreasing, the Australian government introduced legislative and

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regulatory changes to make temporary MBS COVID-19 telehealth items available. These new items enabled GPs, specialists, nurse practitioners and allied health professionals to claim subsidies for telephone and video consultations. The new items in the MBS mirrored the pre-existing, in-­ person consultation items by adding rebates for telehealth and telephone consultations. In all, 279 COVID-19 items were introduced (Australian Department of Health, 2020). This was not the first time that these regulations had been changed in response to a critical event—the bushfires in the Australian summer of 2019–2020 had triggered the introduction of MBS items for mental health and well-being in January 2020. On 20 March 2020, the Ministry of Health in Brazil introduced regulations governing the use of telemedicine for pre-admissions, remote support, consultations, monitoring and diagnosis using ICT in the public and private healthcare sectors (Imprensa Nacional, 2020). These regulations anticipated the passage of a law ratified by the president of Brazil on 15 April 2020. Notably, a clause in the draft legislation that envisaged the regulation of telemedicine being returned to the CFM after the pandemic had passed was vetoed by the president. The CFM had previously opposed extension of telehealth services. The effect of these regulatory measures was to legitimise the use of technology-supported healthcare across a much greater range of healthcare activities than had been the case and to extend the ways in which technology could be used by telehealth services. In Australia, providers were allowed to claim for telephone as well as video consultations. In Brazil, the possibility of consultations between doctors and patients, using a range of video, telephone and messaging technologies, opened up. Previously, only doctor-to-doctor consultation in the form of second opinions and advice had been permitted by the CFM, although other professions such as mental health professionals had been providing patient consultations in this way for some time. The denial of the authority of the CFM to regulate telemedicine in Brazil was an important step for Brazilian telehealth services because, as I discussed in Chap. 8, the CFM had in the past been concerned to protect the face-to-face business models of a powerful, private small business health sector, which could be challenged by online healthcare offerings from large technology-based services.

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However, in Australia and Brazil, none of these regulatory measures was accompanied by any coherent strategy or significant national program to support telehealth services. It was left to each health organisation to devise ways to deliver separated care at scale. Garattini et al. (2020), in discussing the future for telemedicine in Europe, argued that “the real priority for European health systems is to truly implement comprehensive strategies aimed at boosting telemedicine” (p. 3). Australian health professionals echoed the importance of strategies for telehealth services when responding to surveys, with one health administrator stating, “there is still little broad support for telemodels by management”. While Brazilian professionals felt limited by legal and financial constraints, there was a “‘boom’ in the perception of the importance and potential of telehealth services, and professionals feel quite unprepared for this use” (Catarina, Orthodontist). Australian professionals involved in telehealth services welcomed the changes to government regulations, although one commented that the “COVID19 pandemic has created real change at a rapid pace, however it has not been supported by quality, safety, or standards oversight” (David, GP). In an effort to fill this need, in Australia, there was a proliferation of new guidelines on how to do telehealth (ACRRM, 2020) and profession-­ specific guides for digital mental health (Australian Commission on Safety and Quality in Health Care, 2020), exercises and sports science (Exercise and Sports Science Australia, 2020) and diabetes. In Brazil, there were calls for “the Councils and Professional Societies in Medicine and other Health professions [to] establish regulations for specific good practices for Telemedicine and Telehealth” (Associação Brasileira de Telemedicina e Telessaúde, 2020). Thus, in the absence of coordinated national programs to support telehealth services, professional organisations stepped in to provide the guidelines supporting the operations of telehealth services. I next consider what other resources were mobilised for telehealth services during the pandemic.

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13.4 Resourcing Telehealth Services In Chap. 11, we saw that telehealth services depend on infrastructure, staff and funding. In Australia, changes to funding regulations allowed the wider application of telehealth services by private GPs and specialists, whereas in Brazil this was not the case. Some additional funding was transferred to the public health system, but this was not telehealth-­specific (Souza et al., 2020). Private health insurance funds and hospitals began to offer plans to clients that included telehealth services, and some hospital groups have been able to obtain tax concessions for providing telehealth services to the public. In both countries, national governments effectively subsidised the private sector to offer telehealth services, and the public sector care had to rely on state governments to support the additional demands on hospital-based telehealth services. In Brazil, where austerity measures were already impacting healthcare before the COVID-19  pandemic struck, many telehealth centres that had previously received federal funding for primary healthcare service were forced to close for lack of funding or offer reduced services (Telessaúde-UFSC, 2021). Unfortunately, this situation did not change during the pandemic, as one of the people I interviewed for my research summarised: (Brazilian) public health institutions and their managers, the main organisations I work with, have not planned to include telehealth services in their own routine organisational services. They do not have a budget for this purpose, they did not enable teleworking for their employees, they did not invest in the technological structure required. (Pedrina, Telehealth coordinator)

Initially, Australian MBS rebates for telehealth services covered the full costs to patients for consultations, until lobbying by doctors’ organisations (RACGP, 2020) forced the reintroduction of additional patient payments. For some providers this meant that “clients benefited from 4 months of telehealth rebates (courtesy of COVID 19), only to have them wrenched away again” (GP in New South Wales), which raises the question of whether maintenance of equitable access to healthcare as advocated by the Australian Healthcare and Hospital Association (Australian

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Hospitals and Healthcare Association, 2020) was maintained during the pandemic. Additionally, an initial loosening of restrictions to enable all patients to be seen by telehealth was followed by a stipulation that only patients who had attended a practice within the last 12 months could be seen remotely. This meant that not all patients could access telehealth services within a reasonable time frame. One specialist gave this account: [T]he pull-back of GP telehealth rebates, restricting eligible consultations to a patient’s “usual” GP, caused my client base to dwindle overnight. A large proportion of my clients are in vulnerable rural and remote areas, and can’t afford health services with no rebates. (Australian specialist)

These changes to the MBS adversely affected some services such as sexual health, which service clients directly rather than through referral from a GP, because they could no longer claim rebates from first-time clients (“Medicare Rollback Will Limit Sexual & Reproductive Health Access” 2020). Such difficulties demonstrated that established mechanisms operating in the interests of the private, for-profit health sector meant that the expansion of telehealth services did not necessarily improve access to care, previously considered a core aim of these services. Inequities in the access to telehealth services remained in Australia, Brazil and other countries. In the USA during the pandemic, inequities in the delivery of telehealth services were acutely felt. Ortega et  al. (2020) spelled out these policy issues for telemedicine in the USA as being: (1) disparities in access to broad-band internet and related technology, (2) financial barriers to the reimbursement of telemedicine, and (3) lack of institutional commitment to equity in telemedicine. We believe disparities in access to broadband connectivity and mobile technologies represent a social determinant of health now to an even greater extent than before the COVID-19 pandemic. (p. 2)

Apart from financial support, other types of resources were consistently rated by health professionals who deliver telehealth services as very important, including staff training, access to reliable technology, appointment systems designed to schedule remote consultations and appropriate

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physical space to conduct telehealth consultations (Taylor et al., 2021). Some Australian organisations had allocated more resources, including “more personnel available to assist setting up telehealth, more equipment, changes to protocols to make telehealth easier” (Health service manager). The allocation of additional resources was not universal, and there were complaints about lack of equipment and insufficient support for users, indicating that not all organisations had been able to fully resource an expansion in services. However, an administrator in Western Australia felt that the process of resourcing equipment had become easier: “COVID provided significant enabler of telehealth use and process development. Usual bureaucratic processes around new telehealth processes and equipment procurement were rapidly short-cut due to executive imperative to continue service delivery made during COVID”. Training was singled out as a significant need in responses to the ATHS survey: “we found an extremely significant shift in the telehealth training requests during COVID. Clinicians (generally) wanted to be taught how to use the equipment and get access immediately” (South Australian administrator). As Fisk et al. (2020) argue, “telehealth, regardless of the impact of COVID-19, must also become integrated within the training curricula for both health and social care professionals and practitioners” (p. 9). In Chap. 12, I concluded that the distribution of resources to organisations or services is key to supporting the social structures needed to operate telehealth services. It is clear that provision of many of these resources was not triggered by simple changes to regulations and that a more comprehensive intervention is still required. The existing Australian MBS activity-based funding scheme remains unable to support multidisciplinary practice models, because: Australia still has a very doctor-centric primary care system, reinforced by our Medicare system, based as it is on fee-for-service remuneration principally of medical practitioners. This puts barriers in the way of practices using staff from other professions as part of the treatment team. (Duckett, 2020, p. 57)

To improve support for multidisciplinary practice, the Australian Hospitals and Healthcare Association (2020) called for a redistribution

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of resources for virtual care which “requires blended payments including Telehealth MBS items across the health care team; and incentive payments for adoption of virtual health care within local integrated care pathways” (p. 3). Apart from improvements to broadband connectivity during the pandemic in Australia and Brazil, other infrastructure changes have not yet been observed, perhaps because infrastructure takes time to build. In Australia, for video consultations, many existing services were pressed into use, including “HealthDirect Video and Zoom (dedicated platforms); through to Apple Facetime and GoogleMeet; despite some of these services not meeting current data security policies for health” (Pearce et al., 2020, p. 28). My conclusion is that without an appropriate distribution of resources, long-term confidence on the part of health professionals in virtual care or telehealth services will be difficult to achieve.

13.5 Building Confidence Building confidence in the use of technology-supported care is essential to cementing professional practices. In Chap. 9, we saw that confidence was built through the acceptance of technology, management of the risks of practising separated care and creation of trust in daily practice. In the view of many health professionals, acceptance of telehealth services during the pandemic was “enforced” as a result of a risk analysis that compared the risks of infection control during place-based, in-person care with the risks of physically separated care using telehealth services. However, for the first time, clinicians looked beyond the risks usually nominated as barriers for telehealth services, such as the diagnostic limitations of separated care. As a consequence, the external huge risk of COVID made in-roads into the status quo – where change was necessary/mandated in order to offer continued care to clients. That is/was the opportunity in a nutshell – the nature of normal risk aversion and standard fear of change got beaten to death by the much larger imposed risk profile. (Queensland telehealth coordinator)

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The forced acceptance of telehealth services during the COVID-19 pandemic removed some of the previous behavioural barriers to uptake and encouraged clinicians to persevere until they were able to confidently use telehealth platforms. One telehealth service manager observed that: after years of trying to implement telerehabilitation as “routine” the COVID-19 pandemic changed the use / acceptance of … (then) overnight – partly due to government encouragement, funding mechanism changes, risk to personal health of clinicians and reduced access for patients due to lock down. (Sasha, Physiotherapist)

0.90

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Responses to the ATHS survey (Taylor et  al., 2021) included comments that “confidence has grown hugely. Most clinicians are now savvy and adaptable on any platform”, but that confidence had been building for some time because “I have worked in reviewing patients via telehealth for

In-person consultations

Fig. 13.2  Mental health consultations in Australia during the pandemic (the left-­ hand vertical axis shows the number of in-person consultations, the right-hand vertical axis shows the number of telephone and video conference consultations). (Adapted from Snoswell et al., 2021)

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over the last 4 years and have slowly watched an increase in acceptability and confidence in the ability to provide healthcare in this manner”. As a result of increased confidence and cultural changes arising from the enforced use of telehealth services by medical staff, during the pandemic, the concerns of health professionals no longer focused on the clinical limitations of separated care. Responses to surveys emphasised the importance of having easy-to-use systems, having the assurance that systems are private and secure, obtaining technical or administrative support quickly, triaging the most suitable patients and being able to trust colleagues. While increased acceptance and confidence in telehealth services resulted from their enforced use of separated care, interesting differences between the adoption of some technologies remain. As Snoswell et  al. (2020) reported, in Australia there was a much lower adoption of video consultations compared with telephone consultations, except in the case of mental health services. Figure 13.2 shows video (conference) and telephone consultation volumes as almost equal. My own GP used the telephone for consultations during the pandemic, but found the experience a “bit weird”. According to another GP, barriers to the use of videoconferencing included: negative attitudes to video; unfamiliarity with video; the perception that the time taken to set up a video consultation will encroach on the time available to attend to the patient; interruption and/or disruption to workflows in the clinic; low competence and/or low confidence with the technology, equipment, and software; and “it’s easier to pick up the phone”. (Baird, 2020)

The lower use of videoconferencing may be explained by variations in need, availability of the technology or confidence in the medium. For instance, a video consultation may not be needed when renewing a prescription, while mental health consultations may benefit from visual cues (Sansom-Daly & Bradford, 2020). Variations in the availability of cameras in consulting rooms or poor interoperability between videoconferencing solutions may also be a factor (Taylor et  al., 2016). It is also possible that there was not yet confidence in video conferencing as a

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medium through which relationships between clinicians and patients could be built.

13.6 Building Relationships As established in Chap. 10, I found that there were three major contributory mechanisms to relationship-building in support of telehealth services: collaboration between health professionals, the role of relationships in conflict resolution and the ability of leaders to develop relationships across organisational boundaries. Collaboration, teamwork, networking and leadership amongst health professionals were identified as being very important, in responses to the ATHS survey (Taylor et al., 2021). This comment from a manager illustrates that during the COVID-19  pandemic, collaborative activities increased: our unit runs many meetings each week which have now been transformed to use telehealth platforms. This has been extremely beneficial to keep things going on a service, education, and patient review level. It has also allowed our regional colleagues to feel more like part of the service. (ATHS Survey respondent)

Increased networking among clinicians caring for patients and within teams was supported by virtual meeting spaces using videoconferencing. One participant commented that the “team ethos has been reinforced with a much more equal attitude between team members, i.e. a service philosophy rather than ‘clinical is king’” (ATHS Survey respondent). It is too early to judge whether clinicians have become more accepting and cooperative in their attitudes to telehealth services, although there is no doubt that increasing numbers of providers were using these services. This increase was undoubtedly underpinned by organisational leadership. Responses to the ATHS survey (Taylor et al., 2021) included comments that there was “corporate involvement in provision of telehealth services” and “very strong management support”, tempered by more cautious comments such as “management have commenced a governance/working group to support up take and embedding telehealth. A slow process commenced a bit late” (Allied health professional, Victoria) or “it has been difficult to get the ear of

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management as they are occupied with dealing with COVID!” (Health service manager, Tasmania), illustrating that organisational norms and strategies took time to evolve. Relationships are at the heart of a wide range of norms, strategies, processes and practices which, taken together, form the complex sociotechnical codes of telehealth services. As I argued in Chap. 7, tensions over sociotechnical codes have to be resolved through the social interactions that create trust and build confidence in new practices. Relationships take time to build because they are formed through social interactions. For instance, in Brazil, it took many months in 2020 to construct the relationships supporting the launching of a parliamentary front to argue for telehealth service to have a permanent role in Brazilian healthcare (Câmara dos Deputados, 2020). Each of the mechanisms discussed so far—legitimising and resourcing telehealth services, building confidence and relationships—contributed, to a different degree and at different times, to the changes made to the provision of separated care during the pandemic.

13.7 Adjusting to Separated Care Changes in organisational and professional contexts undoubtedly occurred during the pandemic, particularly to service volumes, service types, use of ICTs, workflow organisation and cultures. The snapshots I have depicted of these changes show the adaptations each country, state and health organisation made to established professional services and cultures in response to the needs of separated care. Pawson and Tilley (1997) referred to the role of contexts in conditioning “the potential interactions between social or cultural structures and individual or collective agency” (p. 216). My research found that significant changes to organisational and professional contexts conditioned interactions over the separation of care between providers and patients during the pandemic. Professional cultures, especially managerial and clinical attitudes, shifted from hesitant support for remote consultations to a determined encouragement of this modality. In this instance,

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professional cultures provided a supportive context for change and a mechanism to stimulate the development of telehealth services. When contexts are adjusted, individual or collective agency expressed through social interactions or mechanisms is free to operate in different ways. While acknowledging that the demarcation of mechanisms and context is not always clear, I have no doubt that mechanisms operating in the social world “do” work: they can be seen as constructs, processes or theories explaining “what it is about a program, in this case telehealth services, which makes it work”. This adjustment process during the COVID-19 pandemic can be broken down into a series of phased changes. The four key mechanisms I identified in Chap. 12 were able, to differing degrees, to “do work” to influence the changes to healthcare contexts, resulting in a greatly increased volume and type of telehealth services. In Australia and Brazil, one of the first mechanisms to be triggered by the new public health context was the increased legitimisation of telehealth services through the passing of specific regulations and legislation intended to encourage the increased use of telehealth services. Other activities supporting the legitimisation of telehealth services emerged during the pandemic, notably the definition by various professional bodies functioning as “norm circles” (discussed in Chaps. 3 and 8) of an increasing number of guidelines or sociotechnical codes for the operation of telehealth services. The second mechanism triggered, particularly in Australia, was the application of additional resources for telehealth services. Resources such as funding, availability of infrastructure and staff with suitable competencies can be seen as contributory or micro-mechanisms. Infrastructure takes time to build, and staff take time to train. While there is as yet no hard evidence that these micro-mechanisms have had a significant influence, many people who contributed to my research for this book advocated for increased attention to these aspects. Availability of resources for telehealth services, particularly infrastructure and funding, appears to be more limited in Brazil than in Australia. The key contextual difference between Australia and Brazil is that Brazilian health professionals felt that the national austerity measures in place since 2016 had put the whole Brazilian universal healthcare system at risk, and that this threat continued to affect the stability of telehealth services.

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The course of the COVID-19 pandemic revealed that a third mechanism, the building of confidence in the practice of separated care, gathered force. Confidence building requires acceptance of the tools or technology used in separated care, processes to manage the risks of separated care and the creation of trust in modified practices. The responses to the two surveys of health professionals referred to in this chapter indicate that clinicians’ confidence in telehealth services increased significantly. This was mainly because the enforced acceptance of telehealth services during the pandemic removed previous behavioural barriers to uptake, which encouraged clinicians to persevere until they had gained confidence in using telehealth platforms. This enforced acceptance resulted from a risk assessment: clinicians accepted telehealth services when they fitted into their own risk envelope and the risk envelope imposed on them during the pandemic. However, sections of the Brazilian workforce retained the fear that telemedicine would influence face-to-­face relationships with patients and, indirectly, their employment options. Last but not least, relationships between health professionals were crucial to the development of telehealth services. Many people reported increased collaboration during the pandemic, especially teamwork. There was similar cooperation in the fight against the spread of the COVID-19 virus outside of the health sector. In my research I found that collaboration of professionals across geographic, organisational, disciplinary and political boundaries was a key mechanism in developing safe practices for separated care. Certain professional roles developed relationships across organisations and disciplines. Individuals working in these roles became boundary spanners and developed strong communities of practice or “norm circles”. Although this mechanism was important in both countries, Brazilian professionals relied more on collaborative networks than did their Australian counterparts. The process of contextual adjustment to separated care occurs over time and within social and cultural structures, represented by organisational and professional contexts respectively. Consequently, as contexts changed during the pandemic under the influence of mechanisms which had been triggered, new contextual states were created. These contexts will, in turn, evolve under the influence of the same continuing, modified

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or new mechanisms. In other words, a “new normal” contextual state will become a fresh context for telehealth services.

13.8 Changing the New Normal! At the beginning of this book, I echoed Zuboff’s (2019) concern that technology is perceived as “an autonomous force with unavoidable actions and consequences” (p. 225). I also posed the question of whether the technologies used in telehealth services shape our healthcare, or whether we, collectively, change and shape the technology and services used in healthcare. My findings show that once technology is understood as the assembly of decontextualised technical elements combined in unique configurations for specific social purposes—in this case, telehealth services—technology can be seen to be shaped by social mechanisms. These mechanisms have causal power derived from interactions within the underlying relationships among actors in organisational and professional contexts. These interactions occur over time and determine which norms, processes and practices the sociotechnical codes of telehealth services form part of and simultaneously shape how technologies are adopted. In both Australia and Brazil, providing separated care using telehealth services involved similar challenges related to medical culture and adapting practices to work across places with the aid of technology. In both countries, response to the COVID-19 pandemic and reforms at a political, organisational, economic or regulatory level significantly influenced the contexts for the operation of telehealth services. Given the important differences between the way health services are structured in Australia and Brazil and the different modalities of telehealth services in the two countries, it was surprising to discover that the underlying mechanisms influencing telehealth services and their contexts were similar. The pandemic is not the only critical event that has led to significant changes in telehealth services. Political decisions, organisational strategies or bushfires (in Australia), which themselves originated in wider contextual processes, have also precipitated important changes. The central conclusion of my research across both Australia and Brazil is that the adaptation of organisational and professional contexts to provide

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separated care has not been driven by technologies, organisations or individuals. Instead, it has been driven by the interaction of four macromechanisms within organisational and professional contexts which: • legitimise practice based on explicit and implicit sociotechnical codes including strategies, guidelines and clinical routines; • build confidence in practices through accepting technology into practice, management of the risks of practice and creation of trust in practice; • build relationships between actors (health professional, managers, technologists); and • acquire resources including technology, human resources and funding. Because contexts differ over space and in time and never reach a “normal” stable state, any expectation that the application of technology can in itself alleviate deficiencies in healthcare either during or beyond this pandemic is misplaced. I have to agree with Fagherazzi et al. (2020) who, when discussing the potential of technologies to fight the pandemic, concluded that the “COVID-19 crisis is a typical example of the impossibility of establishing a single global technological solution to a given problem” (p. 5). This picture of ever-changing contexts has implications for finding possible explanations for the sustainability or non-­sustainability of telehealth services. My meta-theoretical model, outlined in Chap. 12, suggests that the processes shaping the development of telehealth services are not those of innovation, normalisation or the attainment of sustainability. Instead, we need to understand the pre-existing social and cultural contexts circumscribing the development of telehealth services. Interactions between professional groups and individuals can change organisational and professional contexts. They can also alter the contexts in which telehealth services operate. The fact that some services expanded during the pandemic, while others did not, should not imply success or failure or “sustainability” or a lack of it in telehealth services. Importantly, we need to recognise that the operation of telehealth services is never guaranteed; it is contingent on and sustained by multiple mechanisms embedded within social and cultural structures.

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This book has shown that telehealth services are a viable means of extending care to underserved populations and that providing access to universal healthcare has underpinned the motivating vision for telehealth services. Looking into the future for telehealth services, as contexts change under the influence of mechanisms, new contextual states will be created. These, in turn, will evolve under the influence of the same continuing, modified or new mechanisms. Whether the contemporary inequities in healthcare will be reduced and telehealth services will assist in reducing health inequalities as part of an evolving “new normal” will depend on all of us—healthcare clients, patients, healthcare professionals, managers and technologists. We all have the power to influence the mechanisms which will support access to universal healthcare using telehealth services. Zuboff (2019) concluded that “we too … can reclaim the digital future” (p. 525). In support of this call, it should now be clear, at least in the context of my research on telehealth services, that the answer to the question of whether technology or humans are responsible for determining how technology is used in healthcare is, simply: “We are, and we can do it!”.

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Silva, L. B., Sousa, L. A. P., Resende, R. E., Fortini, A. A., Pessoa, C. G., Alkmim, M. B. M., Ribeiro, A. L. P., Tupinambás, U., Oliveira, C. R. A., & Marcolino, M. S. (2020). Actions of a Brazilian public telehealth service to help coping with the new coronavirus. European Journal of Public Health, 30(Supplement_5). https://doi.org/10.1093/eurpub/ckaa165.068 Snoswell, C.  L., Caffery, L.  J., Haydon, H.  M., Thomas, E.  E., & Smith, A. C. (2020). Telehealth uptake in general practice as a result of the coronavirus (COVID-19) pandemic. Australian Health Review. https://doi. org/10.1071/AH20183 Snoswell, C.  L., Caffery, L.  J., Hobson, G., Taylor, M.  L., Haydon, H.  M., Thomas, E., & Smith, A.  C. (2021). Telehealth and coronavirus: Medicare Benefits Schedule (MBS) activity in Australia. Centre for Online Health, The University of Queensland. https://coh.centre.uq.edu.au/ telehealth-­and-­coronavirus-­medicare-­benefits-­schedule-­mbs-­activity-­australia South Australian Health. (2020, May 2). Embracing technology to provide better health services during COVID (South Australia) [Text]. Latest News. https://www.covid-­1 9.sa.gov.au/latest-­n ews/embracing-­t echnology-­t o-­ provide-­better-­health-­services-­during-­covid Souza, C. D. F. de, Gois-Santos, V. T. de, Correia, D. S., Martins-Filho, P. R., Santos, V. S. (2020). The need to strengthen primary health care in Brazil in the context of the COVID-19 pandemic. Brazilian Oral Research, 34. https:// doi.org/10.1590/1807-­3107bor-­2020.vol34.0047 Taylor, A., Morris, G., Tieman, J., Currow, D., Kidd, M., & Carati, C. (2016). Can video conferencing be as easy as telephoning? – A home healthcare case study. E-Health Telecommunication Systems and Networks, 05(01), 8–18. https://doi.org/10.4236/etsn.2016.51002 Taylor, A., Caffery, L., Gesesew, H. A., King, A., Bassal, A., Ford, K., Kealey, J., Maeder, A., McGuirk, M., Parkes, D., & Ward, P. R. (2021). How Australian health care services adapted to telehealth during the COVID-19 pandemic: A survey of telehealth professionals. Frontiers in Public Health, 9. https://doi. org/10.3389/fpubh.2021.648009 Telessaúde-UFSC. (2021). Telessaúde UFSC retomará a oferta de serviços em 2021. Sistema Catarinense de Telemedicina e Telessaúde. https://telessaude. ufsc.br/telessaude-­ufsc-­2021/ Zuboff, S. (2019). The age of surveillance capitalism: The fight for a human future at the new frontier of power. Public Affairs.

Glossary

CFM 

The Brazilian Federal Medical Council is a professional association of medically qualified professionals DTN  The broadband health network used by South Australia Health  FSMB  Federation of State Medical Boards in the USA GPs  General practitioners are doctors working in Australian primary healthcare MBS  The Australian Medicare Benefits Schedule subsides the costs to patients of consultations and procedures performed by private providers Medicare  Medicare is Australia’s universal health insurance scheme. It guarantees all Australians (and some overseas visitors) access to a wide range of health and hospital services at low or no cost. RegulaSUS  A triaging service provided by some Brazilian states which aims to reduce the waiting time for patients referred from a primary healthcare for specialist treatment RUTE  The Brazilian University Telemedicine Network SDN  The broadband health network used by Queensland Health SIGs  Brazilian Special Interest Groups for healthcare SUS  The Brazilian publically funded universal healthcare system) Teleconsultas  Doctor to patient consultations provided at a distance using technology. Also loosely used to refer to diagnostic procedures where a report is provided to the requesting doctor. © The Author(s), under exclusive licence to Springer Nature Singapore Pte Ltd. 2021 A. Taylor, Healthcare Technology in Context, https://doi.org/10.1007/978-981-16-4075-9

285

286 Glossary Teleconsultorias 

Second opinions provided from one doctor to another In Brazil, an adviser in family health who responds to the problems of primary care doctors TelessaúdeRS-UFRGS  The telehealth centre for the Brazilian state of Rio Grande do Sul Telessaúde-UFSC  The telehealth centre for the Brazilian state of Santa Catarina UNA-SUS  The Open University of the Brazilian Universal Health System Teleregulator 

Bibliography

Archer, M. (1995). Realist Social Theory: The Morphogenetic Approach. Cambridge University Press. Bashshur, R. L., & Shannon, G. W. (2009). History of Telemedicine: Evolution, Context, and Transformation (1st ed.). Mary Ann Liebert. Bijker, W. E., Hughes, T. P., & Pinch, T. J. (1987). The Social Construction of Technological Systems: New Directions in the Sociology and History of Technology. MIT Press. Danermark, B., Ekstrom, M., & Karlsson, J.  C. (2019). Explaining Society: Critical Realism in the Social Sciences (2nd ed.). Routledge. Elder-Vass, D. (2010). The Causal Power of Social Structures. Cambridge University Press. Emmel, N., Greenhalgh, J., Manzano, A., Monaghan, M. P., & Dalkin, S. (Eds.). (2018). Doing Realist Research. SAGE Publications. Feenberg, A. (2002). Transforming Technology a Critical Theory Revisited (2nd ed.). Oxford University Press. Fleury, S. (2014). Democracia e Inovação na Gestão Local da Saúde. Cebes/ Editora Fiocruz. Flichy, P. (2007). Understanding Technological Innovation: A Socio-Technical Approach. Edward Elgar Publishing.

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International Organisation for Standardization. (2021). ISO 13131:2021 Health informatics—Telehealth services—Quality planning guidelines. Latour, B. (2007). Reassembling the Social an Introduction to Actor Network Theory. Oxford University Press. Liamputtong, P. (2019). Handbook of Research Methods in Health Social Sciences. Springer Singapore. Maxwell, J. (2012). A Realist Approach for Qualitative Research. Sage. Pawson, R. (2013). The Science of Evaluation: A Realist Manifesto. SAGE Publications. Pawson, R., & Tilley, N. (1997). Realistic Evaluation. Sage. Rogers, E. M. (1971). Diffusion of Innovations (2nd ed.). Free Press. Zuboff, S. (2019). The Age of Surveillance Capitalism: The Fight for a Human Future at the New Frontier of Power. Public Affairs.

Index1

A

Acceptance of technology, 7, 18, 23, 49, 53–55, 174, 177, 240, 248, 253, 271 Acceptance of telehealth, 21, 54–57, 173, 174, 240, 271, 272, 277 Acceptance theories, 54 Access, equitable, 5, 35, 66, 126, 212, 268 Access to healthcare, 1, 4, 20, 35, 36, 43, 52, 66–69, 73, 81, 82, 87, 96, 123, 126, 157, 159, 209, 213, 218, 221, 224, 268 Acute care, 16, 67, 106, 109, 128, 131, 151, 153, 259 Adaptation cycle, 23, 250

Adoption, 7, 8, 30, 37, 51, 54–57, 109, 158, 178, 183, 198, 235, 240, 245, 259, 271, 273 cumulative, 235 Align, 178 Allied health, 16, 93, 164, 168, 193, 214, 258, 261, 265, 266, 274 Amazon, 68, 100 Amazonas, 97 American Telemedicine Association (ATA), 34, 40, 41, 43 ANZ Telehealth Committee (ANZTC), 87–89, 133 Austerity, 97, 105, 211, 268, 276 Australian College of Rural and Remote Medicine (ACRRM), 34, 163, 176, 267

 Note: Page numbers followed by ‘n’ refer to notes.

1

© The Author(s), under exclusive licence to Springer Nature Singapore Pte Ltd. 2021 A. Taylor, Healthcare Technology in Context, https://doi.org/10.1007/978-981-16-4075-9

289

290 Index

Australian Digital Health Agency (ADHA), 37, 38, 73, 88 Australian Medical Association (AMA), 69, 199, 200, 224, 225 Automation, 20, 53, 73, 122, 133–137, 240, 241, 251 B

Barriers, 30, 31, 37, 41, 108, 130, 160, 198, 205, 265, 269–273, 277 Border/s, 43, 52, 66, 127, 165, 202, 214 Boundary/ies, 13, 19, 22, 41, 57, 66, 82, 123, 125–132, 134, 135, 192, 193, 198, 199, 202–205, 214, 227, 240, 241, 274, 277 Brazilian Telehealth Networks Program, 96, 97, 99, 100, 123, 124, 160, 195, 211, 221 Brazilian University Telemedicine Network (RUTE), 97, 98, 100, 101, 110, 193, 196, 219, 262 Bricolage, 53 Brisbane, 106, 107, 128 Broadband, 74, 88, 90, 92, 102, 107, 127, 200, 216, 221, 225, 245, 269, 271 Bushfires, 88, 225, 266, 278 C

Centre for Online Health, 34, 223 Clinical processes, 21, 34, 131, 158, 179, 184 Co-design, 52, 53, 177

Collaboration, 21, 22, 103, 110, 191–198, 201, 203, 205, 253, 274, 277 Competencies, 210, 276 Confidence, 8, 17, 21, 23, 41, 105, 143, 169, 173–187, 219, 251, 253, 271–275, 277, 279 Confidentiality, 18, 33, 34, 37–39, 42, 162, 181 Conflict/s, 9, 20–22, 36, 37, 41, 42, 142, 149, 152, 158, 163, 174, 177, 182, 191, 192, 197–202, 212, 220, 242, 243, 250, 251, 253, 274 Consent, 33, 37–39, 58, 162, 164 Contexts, 2, 29, 31–34, 50, 65, 81–87, 121, 142, 161, 180, 196, 211, 234–254, 258 definition of, 32–34, 59, 237 Control, 9, 20, 21, 35, 38, 89, 126, 127, 142, 147, 151–153, 174, 179, 192, 198, 201, 205, 212, 242, 243, 271 Control of healthcare, 9, 20, 192, 242 Control of technology, 20, 137, 142, 154, 250, 251, 263 Cooperation, 60, 90, 153, 193, 194, 265, 277 Coordination, 128, 179, 204 COVID-19 virus, 9–11, 23, 34, 91, 222, 248, 257, 258, 260, 262, 263, 265, 266, 270, 277, 279 COVID-19 pandemic, 2, 14, 16, 17, 32, 73, 82, 84, 87, 90, 93–95, 128, 147, 149, 165, 166, 175, 224, 225, 236, 241, 245, 246, 248, 253, 254, 257–280 Critical event, 23, 245–248, 253, 258, 266, 278

 Index 

Critical realism, 12, 237 Culture, 22, 30, 53, 57, 129, 148, 149, 158, 160, 192, 203, 204, 220, 239, 251, 263–265, 275, 276, 278 D Decentralisation, 126–129, 131, 133, 198, 241 Decentralised, 19, 66, 67, 89, 127, 128, 198 Democratic, 1, 123, 126, 240, 241 Design, 52, 53, 124, 132, 135, 152, 153, 162, 163, 176, 177, 212 Diffusion, 18, 33, 55, 56, 59, 235, 240 Diffusion of innovations, 7, 55, 56, 253 Digital literacy, 21, 174–176 Digital Telehealth Network (DTN), 74, 92, 136, 159 Disputes, 20, 142, 152, 154 Distribution, 8, 22, 69, 70, 82, 126, 209–215, 217–220, 241, 252, 253, 270, 271 E

Education, 5, 11, 22, 36, 50, 60, 70, 84, 91–93, 98–100, 102, 104, 107, 109, 124, 149, 160, 161, 175, 176, 179, 192, 194, 210, 215, 217–221, 245, 259, 262, 274 Embedded, 2, 14, 42, 52, 56, 58, 94, 108, 125, 153, 177, 186, 214, 235, 236, 242, 279 Emergency, 71, 92–94, 99, 108, 109, 124, 134, 144, 150, 159, 176, 181, 183, 222

291

Empirical, 13, 16, 19, 111, 122, 212, 240, 244 Epistemology, 12, 13 F

Facilities, 4, 31–33, 40, 66–68, 70, 74, 75, 82, 92–94, 100, 101, 103, 106, 107, 109, 110, 124, 127–129, 133–135, 145, 146, 160, 168, 179, 193, 210, 215–218, 260, 262, 263 Family health, 19, 66, 70, 84, 98, 100, 104, 124, 160, 193, 195 Federal Medical Council in Brazil (CFM), 11, 96, 99, 100, 147, 148, 165, 166, 200, 266 Financing, 22, 71–72, 101, 210 Florianópolis, 109, 218 Funding, 5, 9, 19, 22, 71, 72, 84, 87–89, 92, 93, 95, 97, 101, 104, 106, 107, 110, 124, 126, 127, 130, 159, 165, 210–212, 214, 215, 217, 220–228, 241, 263, 268, 270, 272, 276, 279 activity, 93, 101, 103, 214, 226, 270 block, 72, 99, 222, 223 incentive, 72, 222, 224 G

General practitioners (GP), 10, 16, 38, 40, 69, 70, 74, 90, 92, 93, 128, 130, 143, 151, 168, 182, 185, 196, 200, 201, 216, 222, 224, 225, 258, 260, 261, 264, 266–269, 273

292 Index

Geographical, 19, 41, 52, 66, 68, 69, 123, 125, 127, 128, 134, 165, 202, 213, 240, 241 Gold Coast, 106, 128 Guidelines, 4, 6n2, 8, 17, 20, 21, 30–35, 37–43, 52, 58, 102, 131, 136, 157, 158, 162–167, 169, 174, 176, 179, 184, 186, 194, 252, 267, 276, 279

Internet, 4, 36, 74, 75, 97, 135, 210, 216, 217, 220, 262, 269 Interventions, 3, 13, 23, 53, 58, 59, 92, 136, 180, 181, 197, 210, 225, 238, 238n1, 242, 248, 257, 258, 270 J

Joinville, 109

H

L

Human agency, 22, 192, 239, 245 Human resources, 19, 66, 69–70, 75, 133, 215, 241, 279

Legal, 4, 8, 30, 32, 42, 43, 125–127, 134, 159, 162, 181, 241, 267 Legislation, 38, 56, 87, 95, 98, 99, 159, 165, 166, 246, 261, 265, 266, 276 Legitimise, 23, 162, 251, 265, 266, 279 Legitimising, 30, 157–169, 265–267, 275 Liability, 18, 21, 37, 42–44, 158, 162, 163, 204, 238, 243 Luiz Inácio Lula da Silva (Lula), 211n1

I

Inequities, 123–126, 240, 269, 280 Information and communications technology (ICT), 6, 7, 9, 11, 19, 30, 38, 39, 41, 50, 66, 72–75, 100, 106, 127, 161, 175, 204, 210, 217, 240, 241, 248, 266, 275 Infrastructure, 8, 22, 31, 67, 72, 74, 75, 84, 88, 89, 102, 106, 107, 129, 135, 136, 159, 199, 210, 213, 215–217, 227, 241, 246, 268, 271, 276 Innovation, 3, 7, 35, 55–57, 109, 129, 193, 235, 239, 240, 253, 279 Integrated care, 162, 202, 213, 214, 246, 251, 271 International Organization for Standardization, 6, 6n2, 32, 33, 102, 178

M

Macro-mechanisms, 23, 234, 248, 250–252, 279 Mato Grosso do Sul, 97, 101 Mechanism/s, 3, 13–17, 20, 23, 58–60, 122, 175, 199, 201, 212, 215, 228, 234–254, 258, 259, 265, 269, 272, 274–280 causal, 13, 167, 238 definition of, 13, 59, 244 generative, 13, 238

 Index 

macro (see Macro-mechanisms) micro (see Micro-mechanisms) social, 2, 3, 23, 59, 235, 238, 245, 249, 253, 278 Medicare Benefits Schedule (MBS), 70, 84, 88–91, 128, 165, 214, 224, 225, 260, 266, 268–271 Metropolitan, 19, 22, 39, 66, 68, 82, 128, 165, 200, 210, 213, 216, 224, 240 Micro-mechanisms, 276 Minas Gerais, 97, 101, 262 Mobile apps, 11, 260, 263 Mobile devices, 5, 10, 98, 175, 210 Mobile phone, 6, 11, 60, 102, 176, 182, 210 Model of care, 20, 91, 109, 131, 132, 137, 158, 167, 168, 186, 214, 227 Models, mental, 21, 30, 174, 176, 186 Morphogenetic analysis, 238, 239 Morphogenetic change, 239 Morphogenetic cycle, 239, 246 Mutual adaptation, 23, 234, 237, 250 N

National Broadband Network (NBN), 88, 90, 92, 196, 245, 262 New normal, 23, 250, 254, 261, 278–280 New South Wales, 90, 91, 101, 268 Normalisation, 7, 9, 23, 56, 58, 59, 235, 236, 240, 248, 250, 253, 279

293

Normalisation process theory (NPT), 7, 58, 253 Norm circles, 60n1, 169, 201, 202, 277 Norms, 18, 20–22, 30, 39, 42, 43, 53, 59, 60, 60n1, 123, 137, 142, 146–150, 157–162, 168, 169, 179, 187, 192, 201, 202, 237, 242, 251, 252, 263, 275–278 Northern Territory, 91 O

Ontology, 12, 13, 253 Organisational change, 58, 122, 159, 161, 238, 239 Organisational context, 16, 19, 20, 23, 30–32, 59, 81, 121, 122, 134, 137, 214, 234, 237, 241, 248–251 Organisational culture, 149, 158, 265 P

Pandemic, 2, 3, 9–12, 14, 16, 17, 19, 23, 32, 73, 82–85, 87, 90, 91, 93–95, 99, 111, 121, 128, 147, 149, 165, 166, 175, 224, 225, 236, 241, 245, 246, 248, 253, 254, 257–280 Pathways, 20, 130–133, 142, 169, 199, 242, 259, 263, 271 Pernambuco, 102 Place-based, 18, 33, 37, 39, 40, 42, 44, 52, 53, 125, 136, 143, 145, 146, 167, 168, 181, 184, 197, 212, 236, 242, 251, 271

294 Index

Power, 2, 22, 43, 54, 59, 71, 136, 142, 148, 151–153, 160, 185, 187, 192, 198, 201, 205, 210, 238, 243–245, 250, 252, 278, 280 Practice clinical, 3, 8, 18, 22, 30, 33, 39, 43, 44, 49, 50, 53, 57–59, 135, 142, 149, 150, 154, 158, 159, 162, 165, 167, 186, 192, 198, 199, 202, 205, 219, 243 communities of, 91, 193, 198, 277 general (GPs), 67, 130, 200, 260 medical, 17, 18, 34, 42, 53, 137, 142, 143, 146, 149, 150, 165, 166, 168, 200, 242, 250, 251, 263 professional, 23, 29–44, 112, 137, 142–154, 214, 251, 263, 271 telehealth, 43, 127, 147, 162, 164, 169, 173–187, 191–205, 236 Primary healthcare, 5, 16, 19, 66, 67, 71, 75, 81, 84, 89, 93, 102, 103, 109, 110, 123, 124, 130, 132, 147, 149, 160, 179, 180, 212, 224, 262, 268 Primary health facility, 67, 70, 75, 100, 101, 218, 262 Priorities, 67, 72, 99, 122–126, 135, 161, 162, 181, 211, 212, 215, 240, 241, 246, 260, 267 Privacy, 8, 18, 29, 33, 34, 37–40, 42, 44, 162, 181, 182 Procedure, 20, 21, 30, 33, 39, 58, 69, 84, 97, 131, 142, 162–165, 174, 224, 236, 242, 259

Professional context, 8, 20, 23, 30–34, 54, 59, 142, 151, 154, 187, 234, 236–238, 242, 248–251, 259, 263, 275, 277–279 Professional culture, 251, 264, 275, 276 Protocol/s, 15, 20, 33, 98, 99, 103, 132, 158, 163, 166, 167, 179–181, 198, 270 Q

Quality and safety, 17, 37, 39–41, 136, 162 Quality of care, 33, 34, 36, 39, 44, 217 Queensland, 3, 16, 19, 37, 38, 68, 68n2, 72, 82, 85, 86, 90, 92, 94, 106–109, 125–127, 130, 132, 135, 144–146, 153, 159, 163, 168, 177, 178, 184, 199, 203, 211–213, 221, 222, 236 Queensland Health, 106–108, 127, 159, 160, 222, 260 R

Realism, 12, 237 Realist, 7, 12, 13, 60n1, 234, 238, 238n1, 239, 243, 246, 253 Realist evaluation, 239 Referral, 6, 70, 86, 97, 99, 102–104, 107, 111, 112, 124, 126, 131, 132, 166–168, 179, 180, 198, 199, 269 Regional, 3, 9, 10, 19, 22, 36, 66–70, 82, 83, 87, 88, 92–94, 96, 99, 102, 103, 106, 107, 123–125, 128, 129, 159, 160,

 Index 

165, 196, 200, 210, 213, 218, 221, 226, 240, 245, 274 Regulation/s, 9–11, 15, 17, 20, 21, 40, 96, 97, 99, 100, 104, 110, 111, 148, 157–159, 162–167, 169, 180, 195, 252, 260, 265–268, 270, 276 Relationships, 2, 8, 9, 17, 18, 21, 22, 23, 30, 37, 41–42, 50, 51, 54, 55, 57, 60, 125, 132, 150, 167, 169, 182–185, 187, 191–205, 212, 238, 241, 243–245, 248, 250, 251, 253, 274, 275, 277–279 Resources, 13, 14, 17, 19, 22, 23, 30, 55, 59, 66, 69–72, 75, 98, 122, 128, 133, 151, 153, 162, 195, 198, 203, 205, 209–228, 237, 241, 243, 246, 251–253, 264, 267, 269–271, 276, 279 Responsibility, 2, 17, 29, 32, 37, 40–42, 44, 125, 130, 131, 162, 181, 227 Rio Grande do Sul, 3, 5, 16, 19, 57, 75, 82, 84, 86, 97, 99, 100, 102–105, 124, 132, 161, 163, 180, 213, 221, 223, 236 Risk/s, 8, 18, 20, 21, 32, 37, 40, 42–44, 103, 143, 153, 158, 159, 162, 163, 169, 173–175, 178–184, 186, 187, 236, 253, 271, 276, 279 assessment, 43, 178, 179, 277 management, 21, 174, 179, 180 Routine/s, 5, 19, 21, 33, 35, 52, 58, 94, 95, 104–106, 111, 149, 154, 158, 162, 167, 168, 174, 184, 186, 235, 236, 242, 268, 272, 279

295

Royal Australian College of General Practitioners (RACGP), 34, 38, 40, 74, 225, 268 Rudd, Kevin, 90 Rural, 5, 22, 39, 43, 70, 82, 88, 90, 92, 94, 107, 109, 128, 159, 176, 200, 210, 213, 217, 219, 224, 227, 228, 269 Rural Doctors Association of Australia (RDAA), 34, 38, 39, 200 S

Safety, 2, 8, 17, 21, 29, 32, 33, 37, 39–43, 73, 136, 158, 162, 180, 267 Santa Catarina, 3, 11, 16, 19, 57, 75, 82, 84, 97, 100, 105, 109–112, 161, 166, 194, 196, 198, 213, 215, 219, 221, 223, 228 São Paulo, 11, 16, 19, 75, 84, 97, 100, 103, 104, 161, 215, 221, 228 Scheduling, 31, 33, 60, 145, 146, 168, 259, 269 Second-opinion, 5, 6, 11, 96–98, 100–101, 166, 200, 223, 262, 266 Separated care, 17, 18, 20–23, 38, 40, 42, 44, 75, 121, 137, 142–144, 146, 151–154, 157, 158, 168, 169, 173, 174, 181, 184, 187, 192, 212, 214, 219, 239, 242, 259, 262, 263, 265, 267, 271, 273, 275–279 Separation of care, 33, 39, 143–146, 152, 181, 224, 250, 253, 263, 275

296 Index

Sistema Único de Saúde (SUS), 66, 160, 161, 219, 224 Skills, 21, 52, 54, 150, 167, 174–176, 183, 218 Social forces, 239, 243–244 Social interaction/s, 13, 59, 167–169, 237, 239, 248, 251, 252, 275, 276 Sociotechnical codes, 7, 8, 18, 18n5, 20–23, 50, 59–61, 60n1, 131, 137, 142, 146, 148–150, 154, 158, 169, 174, 176, 177, 187, 192, 234, 241, 242, 249, 251, 263, 275, 276, 278, 279 definition of, 18n5, 59–61 Sociotechnical frames, 60 South Australian Health, 260 South Australia (SA), 3, 16, 19, 55, 82, 85, 92, 94, 95, 106, 125, 129, 136, 153, 159, 180, 193, 199, 204, 221, 236 Spatial, 59, 125, 214, 237, 241 Special Interest Groups (SIGs), 84, 98, 107, 193, 194, 219, 262 Specialist, 4–6, 10, 15, 16, 19, 35, 37, 50, 66, 68–70, 82–84, 90–95, 97, 98, 100, 102–104, 111, 124, 127, 128, 130–132, 135, 136, 144, 145, 149–153, 163, 164, 167, 168, 176, 178–182, 185, 186, 193, 194, 196, 198–201, 203, 204, 210, 211, 216–218, 224, 225, 227, 239, 245, 258, 260, 266, 268, 269 Specialist consultation, 10, 224, 245, 260 Specialist opinion, 4, 70, 130

Specialist services, 5, 19, 35, 66, 69, 93, 100 Staff, 22, 31, 58, 70, 73, 98, 110, 147, 167, 168, 183, 184, 205, 210, 211, 217–219, 237, 259, 268–270, 273, 276 Standards, 17, 39, 40, 43, 60, 89, 99, 148, 163, 224, 267, 271 Strategy/ies, 20, 21, 37, 72, 73, 99, 124, 157–162, 164, 167, 169, 174, 196, 214, 252, 267, 275, 278, 279 Structural conditions, 30, 59, 122, 237 Structure, 2, 19, 21, 30, 52, 57, 59, 67, 121–137, 187, 191, 196, 198, 202, 212, 224, 236–239, 243, 245, 248–252, 263, 264, 268, 270, 275, 277, 279 Sustainability, 23, 225–228, 234, 235, 237, 248, 250, 279 Sustainable, 22, 40, 204, 228, 234–237 T

Tasmania, 83, 90, 93, 275 Teamwork, 192, 193, 274, 277 Technical element, 18, 50, 51, 53, 142, 242, 278 Technologist, 9, 15, 20, 23, 35, 53, 122, 127, 134, 142, 151–153, 161, 162, 177, 178, 182, 184, 197, 198, 201, 220, 242, 243, 250, 265, 279, 280 Technology acceptance model (TAM), 7, 54, 55, 174 Teleadvice, 6, 57, 97–105, 110, 166, 223

 Index 

Telecardiology, 4, 33, 101, 102, 110, 180 Telecare, 6, 32, 53, 161 Teleconsultas, 6 Teleconsultation, 4, 10, 11, 58, 97, 99, 100, 147, 148 Teleconsultorias, 6, 86, 106, 166, 167 Teledentistry, 101 Teledermatology, 4, 57, 59, 100, 112, 219 Telediagnostic/s, 5, 96, 98, 100–103, 109–111 Teleeducation, 4, 97, 102, 219 Telehealth pilot projects, 88, 123, 124 Telehealth services, 1–23, 29–44, 49–61, 65, 66, 69, 70, 72–75, 81–112, 121–137, 142, 143, 145–149, 152–154, 157–169, 174–176, 178–181, 183–187, 192–205, 209–228, 234–254, 257–280 defintion of, 6n2, 7–9, 50, 99, 166, 195 Telemedicine, 6–8, 10, 31, 32, 37, 50, 55–57, 60, 61, 89, 93, 94, 99, 107, 125, 130, 147, 148, 151, 165–167, 183, 185, 187, 196, 217, 220, 259, 266, 267, 269, 277 Telementoring, 4 Telemonitoring, 5, 10 Teleoncology, 4, 132 Teleorthopaedics, 4 Telepathology, 4 Telephone, 4, 5, 9–12, 36, 56, 57, 90, 93, 97, 102, 104, 144, 147, 166, 182, 199, 225, 227, 228, 260–262, 266, 273 Teleradiology, 33, 92, 97, 224 Teleregulator, 195

297

Telerehabilitation, 4, 40, 93, 144, 152, 272 Telessaúde, 5, 6n1, 102 Theory of planned behaviour (TPB), 7, 54, 174 Townsville, 5, 106, 107 Training, 8, 21, 22, 70, 92, 95, 97, 98, 161, 174–176, 200, 210, 217–220, 225, 269, 270 Transport, 37, 68, 71, 92, 100, 135, 179, 210, 217, 227 Triage, 103, 174, 179–181 Triaging, 21, 99, 100, 104, 162, 163, 174, 179–181, 198, 260, 273 Trust, 21, 41, 174, 182–187, 253, 271, 273, 275, 277, 279 U

Unified theory of acceptance and use of technology (UTAUT), 7, 55 Universal healthcare, 1, 17, 19, 22, 23, 66, 82, 123, 161, 209, 212, 217, 219, 240, 280123–126, see universal care Universidade Aberta do Sistema Único de Saúde (UNA-SUS), 84, 98, 195 University, 11, 84, 97, 98, 101, 110, 161, 176, 193, 196, 203, 223 V

Victoria, 83, 93, 101, 260, 262, 265, 274 Video conferencing, 6, 10, 12, 15, 74, 84, 91, 92, 97, 98, 100, 102, 104, 106, 107, 145, 163, 168, 181, 220, 225, 262, 273, 274

298 Index

Vision/s, 9, 17, 30, 34–37, 82, 159, 161, 196 W

Waiting list/s, 37, 69, 100, 101, 103, 104, 110, 124, 131, 132, 177, 180, 181, 198

Waiting times, 59, 103, 110 Workflow, 31, 33, 145, 146, 194, 263, 273, 275 Workforce, 22, 32, 55, 69, 70, 82, 84, 89, 102, 124, 126, 146, 150, 160, 175, 192, 210, 215, 217–220, 265, 277