A VIRTUOUS IMPLEMENTATION of TELEMEDICINE SERVICES in RHEUMATOLOGY: DESCRIPTION of CHANGE MANAGEMENT PRACTICES ADOPTED by the NIGUARDA HOSPITAL

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.