ABSTRACT
Background: Over the past few decades there have been an increasing debate around the use of telemedicine. Despite this, there is still a slow rate of adoption of telemedicine services. According to a recent scoping review this may be due to a piecemeal approach to the change process, and a lack of understanding of how to plan, manage and reinforce change when implementing telemedicine service1. A virtuous example of implementation of telemedicine services can be found within the rheumatology unit of Niguarda Hospital in Milan (Italy), where the whole staff has been involved in experimenting with new multichannel interactions to communicate with patients for more than a decade. Developed in 2011 with the introduction of the iAr Plus app for the collection of Patient Reported Outcomes (PROs), the project was first targeted to patients with Rheumatoid arthritis, Pso-riatic arthritis and Spondylarthritis. In 2019 the project consolidated and added the home delivery of biological drugs for the stable patients. During spring 2020, this experience was further enhanced and extended to all patients treated with biological drugs to facilitate patient interaction during Covid-19 and was characterized by three elements: remote monitoring, triage through phone calls and home delivery of medication. What contextual factors and mechanisms adopted to plan, manage, and reinforce change where more successful? Objectives: This study aimed to highlight what were the distinctive and successful elements of this implementation experience, what we could learn from it, and which managerial implications we could derive for future implementations. Methods: We adopted a realist evaluation approach2 to identify the underlying generative mechanisms that explain 'how' the outcomes were caused and the influence of context. Thus, we deepened how the change management process has been managed by conducting semi-structured interviews with the unit director, and the staff members involved in the phases of the project (i.e., clinicians, nurses, and administrative staff). The interviews were recorded and analyzed through an ad-hoc framework1 for the analysis of change management practices. This framework identifes 10 change steps divided into 13 strategic practices and 6 operational practices that are important during the preparatory phase of the change process, for managing the change, and to sustain and reinforce longterm change. Results: Our study identifed the most relevant actions put in place by the rheumatology unit during the three major steps of preparing for change (e.g., developed telemedicine App, assigned coordinating role, identifed champions), managing change (e.g., developed and articulated a clear vision, provided training, developed ownership), and reinforcing change (e.g., continued to engage partners). The analysis highlighted four main lessons learned: frst the characteristics of the context and a strong managerial structure were a prerequisite for success. The generative mechanisms that explain how these successful outcomes were caused are: a leadership role able to defne a clear vision and a clear specialization of tasks and roles;the involvement of all team members;regular meetings and interactions. Second, patients should be involved as central actors in the defnition of the care pathway. The fnal decision on the kind of services to be used was made by the patient. Third, the relevant stakeholders should be involved since the co-design of the app. Finally, change should be incremental. The Rheumatic unit introduced one change at a time, and this brought to constant improvements. Conclusion: The framework adopted can be used either to retrospectively analyze the experiences developed but may also act as a tool to guide future tele-medicine service implementation and research. As well as the lessons learned can guide the implementation of future telemedicine experiences.
ABSTRACT
Background: With the beginning of the Covid-19 pandemic, many hospital departments worldwide, including rheumatology ones, were forced to implement telemedicine strategies. Telemedicine revealed to be an umbrella term, with various practical implementations and different degrees of pre-paredness1. Some practitioners were already familiar with telemedicine, as in the case of the Rheumatology Unit of ASST Niguarda Hospital in Milan (Italy), where telemedicine projects have been implemented for more than a decade with structured design and organized processes. Moreover, patients in Niguarda have experimented telemedicine with personalized mixes of channels, including e-mails and phone calls, Patient Reported Outcomes questionnaires, and home delivery of drugs. This represents a paradigmatic case study that enables us to deepen essential questions on the success of telemedicine. Objectives: Given that the last decision on joining telemedicine rests with patients2, we decided to adopt their perspective. We deepened three main aspects: i) the benefits perceived, ii) the willingness to enrol in future projects, iii) the preference on the service-mix, i.e., on-distance contacts rather than in-person visits. Most importantly, we investigated differences in the three areas among all patients based on the type of personalized experience had. Methods: We conducted a survey from November 2021 to January 2022, enrolling randomly outpatients who attended the rheumatology unit for any reason. The survey originated from well-known surveys, such as the Tele-Health Usability Questionnaire3 and the Intention to use telehealth services4. However, we decided to overcome the usual separation that makes surveys addressed either to users or no users of telemedicine. Our survey comprised an introductory set of questions related to personal, social, clinical and ICT skills information, followed by the central part on telemedicine, which explored the three areas mentioned: benefits, adherence, preferences on service-mix. For this part, questions were the same for all patients apart from the tense used, being conditional tense for no-users and past tense for users. All the answers were analysed with descriptive statistics and regression models. Results: A complete response was given by 400 patients: 71% were female, 59% were 40-64 years old, 53% of them declared to work, and the diseases most represented were Rheumatoid Arthritis (36%) and Osteoporosis/arthrosis (21%). The descriptive statistics revealed interesting differences between users and no users, e.g., the desire to participate in future projects was stated by 95% of users, 81% of no users. These results were confrmed by multivariate logistic regression models that controlled for the influencing patients' characteristics (such as being old or a frequent hospital attender). It emerged that no-users imagined wide-ranging benefits. As for the willingness to participate to future telehealth projects, even if personal characteristics showed an impact (e.g., being a worker increased the probability to adhere), other things being equal, having had a more intense experience of telemedicine increased the odds of accepting by 3.1 times (95% C.I. 1.04-9.25), compared to no users. Furthermore, the more telemedicine was experienced, the higher the willingness to substitute in-person with online contacts. Conclusion: Our study contributes to enlighten the crucial role played by the telemedicine experience in determining patients' preferences. On one side, users appeared more aware of the realistic benefts to be expected from telemedicine. On the other side, it seemed that the more telemedicine was experienced, the higher the willingness to adhere to future projects and to increase on-distance contacts.
ABSTRACT
Background: The COVID-19 public health emergency has amplifed both the potential value and the challenges with healthcare providers deploying telehealth solutions. Furthermore, outpatients may wait up to several months for their frst appointment with specialists including rheumatologists for diseases other than COVID-19. In Italy it is now possible to get access to telemedicine services within the national healthcare systems, yet only follow-up visits are allowed for reimbursement purposes. Instead, it is not clear the role of telemedicine as a tool for improving frst access and patient acceptance of this innovation. Objectives: To investigate the feasibility of a 'teletriagerheum' service before the frst visit and to identify potential benefts and disadvantages of it by comparing frst face-to-face visit preceded by 'teletriagerheum' service to regular frst visit without it. Methods: A pilot prospective monocentric study was conducted. Consecutive patients were contacted by phone 30 days before the scheduled rheu-matological frst visit by administrative staff to investigate their willingness to receive 20 days before the frst visit a phone call ('teletriagerheum' service) by a physician of the Rheumatology Unit. The 'teletriagerheum' service aimed at investigating the reason for the visit and at prescribing additional exams or specialistic consultations before the face-to-face frst visit to facilitate the diagnosis process or anticipate the appointment in case of urgency. Socio-demographic characteristics, reason for referral, face-to-face visit duration, number of additional exams prescribed, number of defnite diagnosis at frst visit in the 'teletriagerheum' group were compared to the ones receiving regular frst visit without 'teletriagerheum' service. Results: In October 2021 a total of 102 patients were phone called by administrative staff: 18 (17.6%) did not answer for a maximum of three times, 9 (8.8%) responded but refused the 'teletriagerheum' service (6 cancelled the visit, 1 postponed, 2 for unknown reason) and 75 (73.5%) accepted the service, but 21 were not real first visits and 8 patients did not answer the call of physician. Among the remaining 46 (45.1%) pts (the 'teletriagerheum' group) the median call time was 11.5 minutes (IQR 5-15 min), blood exams were prescribed to 34 (74%) and instrumental exams to 8 (17.4%). Further consultation was prescribed only to 1 patient and the visit was not anticipated in any case. A preliminary diagnosis was possible in 36 (78.2%). In most of the cases (33, 76%) no difficulties were reported by the physician, in 7 (16.3%) there were difficulties in communication, in 1 (2.3%) difficulty to get the history from a patient suffering from a psychiatric disorder. Socio-de-mographic characteristics, Information and communication technologies skills, face-to-face visit duration were not statistically different between the 'teletriagerheum' group (46 pts) and the group receiving regular first visit without 'teletriagerheum' service (52 pts). In the 'teletriagerheum' group, a lower number of blood exams (14% vs 46%, p<0.005) and a lower number of instrumental exams (25% vs 45%, p=0.04) were prescribed during the face-to-face frst visit;a higher percentage of defnitive diagnosis (79% vs 67%, whilst not statistically signifcant p=0.2) and a lower number of patients requiring a visit before 6 months (26% vs 54%, p<0.05) were observed compared to the group without teletriagerheum service. Conclusion: These preliminary data showed that telemedicine for the frst rheu-matological visit was well-accepted by patients searching for rheumatology consultations and had the potential to be a tool for improving clinical diagnosis and rheumatological follow up in everyday clinical practice. A larger cohort will let us to further explore the potential benefts of telemedicine to improve accessibility to rheumatological services.