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COVID-19ANDTELEMEDICINEToolforassessingthematuritylevelofhealthinstitutionstoimplementtelemedicineservicesVersion3.0,July2020

COVID-19ANDTELEMEDICINE‒Toolforassessingthematuritylevelofhealthinstitutionstoimplementtelemedicineservices

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COVID-19ANDTELEMEDICINEToolforassessingthematuritylevelofhealthinstitutionstoimplementtelemedicineservices

Introduction..............................................................................................................................................3

I.Organizationalreadiness.....................................................................................................................4

II.Processes...............................................................................................................................................6

III.Digitalenvironment...........................................................................................................................7

IV.Humanresources...............................................................................................................................9

V.Regulatoryissues..............................................................................................................................10

VI.Expertise...........................................................................................................................................11

Guidelinesforanalyzingtheresults...................................................................................................11

Referencesandothertoolsforfurtherself-assessment................................................................12

Projectteam..........................................................................................................................................13

Appendix.Contributorstothedevelopmentofthistool...............................................................13


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COVID-19ANDTELEMEDICINEToolforassessingthematuritylevelofhealthinstitutionstoimplementtelemedicineservicesIntroductionThis tool has been designed to help health institutions assess their level of maturity to offertelemedicineservices.Furthermore, it facilitatesthe identificationofpossiblegapsorareasthatcouldrequiremoreattentionandexperttechnicalsupport.Thelevelofmaturityisscoredfrom1(lowest)to4(highest).

Levelofmaturity

None(1) Beginner(2) Advancing(3) Ready(4) Requeststechnicalsupport

Noinitiativeisinplace.

Somestepshavebeentaken,buttheinstitutionisstillfarfrombeingabletoimplementservices.

Goodprogress,andsometelemedicineservicescouldbegintobeimplemented.

Everythingisreadyfortelemedicineservicestooperateatfullcapacity.

Requiresexperttechnicalsupporttomakefurtherimprovements.

Thistoolformspartofthesupportforpandemicresponseoperations.Itsdesignisbasedonthemodelsthat have been implemented by different health institutions with different levels of complexity inseveral countries. The tool was developed collaboratively with institutions and experts specialized intelemedicine and in the use of information technology (IT) in public health, from the Region of theAmericasandSpain(seeAppendix).The tool has been developed with the understanding that there is an institutional commitment toimmediatelyimplementtelemedicineservices.However,itwillalsobeusefultoinstitutionsthatalreadyhavetelemedicineprogramsupandrunning,whichwanttoperformaself-assessmenttoredefinetheirpriorities in light of the pandemic. The tool comprises a series of questions, organized into the sixcategoriesindicatedbelow.


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I.Organizationalreadiness

QuestionLevelofmaturity

1 2 3 4Requeststechnical

support

1 Isseniormanagementcommittedtoofferingtelemedicineservices?

2 Isitclearlyunderstoodwhichservicescanbeofferedviatelemedicine?

3 Havetheservicestobeofferedviatelemedicinebeenidentified?

4 Isthereabudgetavailableforofferingtelemedicineservices?

5 IstheITstafftrainedtoprovidesupportservicesfortelemedicine?

6 Dothenationalorlocalregulationsallowtheimplementationoftelemedicineservices?

7 Doestheinstitutionhavereliableinternetaccess?

8 Doestheinstitutionalreadyhavesomekindoftelemedicineprograminoperation?

9 Doestheinstitutionhaveanyexperienceinusinginstantmessagingortextingforhealthpromotion?

10 Doestheinstitutionhaveanyexperienceinhealthservicedeliverythroughvirtualconsultations?

11 Doestheinstitutionhaveanyexperienceinremotemonitoringofpatients?

12 Couldthefundingoftelemedicineservicesbeextendedbeyondtheinitialplanningandpilotstages,tobecomeasustainablemodel?

13 Ismedicalstafftrainedinprovidingtelemedicineservices?SeesectionIV(onhumanresources)belowformoreinformation.

14 Ifthescoregivenonthepreviousquestionis1or2,havetelemedicinetrainingoptionsbeendetermined?

15 Doestheinstitutionhavetheinfrastructurenecessaryforprovidingtelemedicineservices?


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15.a ● Sufficientspace

15.b ● Reliableelectricitysupply

15.c ● Acceptableilluminationlevels

15.d ● Supportteams

16 Hasanyonebeendesignatedtoberesponsiblefortelemedicineservices?1

17 Ismedicalstaffinagreementwithofferingtelemedicineservices?

18 Hasanythingbeendonetoaddressresistancetochangesinroutineswithwhichphysiciansfeelsafeandcomfortable,andtoanewandunknownsysteminvolvingacertaindegreeofinitialuncertainty?

19 Ifthescoregivenonthepreviousquestionis1or2,canthisproblembesolvedthroughparticipatorydialogue?

20 Haveanyincentivesbeenputinplacetopromotetheuseoftelemedicine?

21 Ismedicalstafffamiliarwithprivacyandsecuritypracticesbasedoncurrentethicalandlegalprinciples?

22 Hastheworkloadinvolvedinlaunchingthistypeofprograminthecurrentenvironmentbeendefined?

23 Doestheprogramhavethesupportofaninstitutionspecializedintelemedicineservices?

24 Hastheinstitution’sstaffbeeninformedoftheintentiontoimplementorexpandtelemedicineservices?

25 Havethepotentialbeneficiariesofthesetelemedicineservicesbeeninformedoftheirlaunchorexpansion?

26 Havepatientcareagendasbeenchangedduetotheneedforremoteconsultations?

27 Whatistheexpectedlevelofacceptancefortelemedicineservicesfromtheirpotentialbeneficiaries?

28 Arethereculturalorlinguisticbarriersthatcouldcausedifficulties

1. This individual isresponsibleforoverseeingtheservice,offeringsupportforreferrals,secondopinions,clinicaldecisions,operationofthe

program,andevolutionofthesystemingeneral.


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duringthedeliveryoftelemedicineservices?

29 Isthelevelofconnectivityofpotentialpatientsknown?

30 Isthelevelofdigitalliteracyofpotentialpatientsknown?

31 Havegovernancemechanismsbeenestablished?

32 Havecontinuousassessmentmechanismsbeenestablished?

II.Processes

Question

Levelofmaturity

1 2 3 4 Requeststechnicalsupport

33 Havetheduties,roles,andresponsibilitiesassociatedwiththetelemedicineservicesbeendefinedforallstaffwhowillbeinvolved?

34 Havetheduties,roles,andresponsibilitiesrelatedtothetelemedicineservicesbeendefinedforalladministrativestaff?

35 Haveproceduresbeendefinedtoaddressthesecurityconsiderationsregardingpatientsandinstitutionallegalresponsibility?

36 Haveproceduresbeendefinedtosafeguardthesecurity,confidentiality,andbackupofthedataandinformationgeneratedbytelemedicineservices?

37 Areproceduresinplacetorecordthelevelofpatientsatisfactionwithtelemedicineservices?

38 Arenotificationproceduresinplaceintheeventofincidentsoradverseeventsduringtelemedicineconsultations?

39 Aretherestandardizedprocedurestonotifyanddocumentpossibletechnicalfailuresduringaconsultationthatcouldaffecttheclinicaloutcome?

40 Arethereformalprocedurestoremotelyobtaininformedconsentfrompatients?

41 Arethereproceduresortoolsforstaffandpatientstosharetheir


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concerns,suggestions,orcommentsregardinghowthetelemedicineprogramisworking?

42 Isthereastrategyandoperationplantoorienthealthcareproviderstowardsoptingforoutpatientteleconsultationsandremotemonitoringoftheirpatients?

43 Aretherecommunicationmechanismsforinformingandeducatingthepublicabouttherecommendeduseoftelemedicine?

44 Isthereaprocedureoremergencyplanforphysicianspracticingtelemedicineiftheyconsiderthatapatientshouldbereferredtoanintensivecarecenter?

III.Digitalenvironment

Question

Levelofmaturity


INTERNETCONNECTIONANDCONNECTIVITY

45 Isaregular,reliableinternetconnectionavailable?

46 Doestheavailablebandwidthmakeitpossibletooffertelemedicineserviceswithoutaffectingotherservices?

47 Istheinstitutionabletocalculatethebandwidthnecessaryforprovidingtelemedicineservices?

48 Isthenecessaryminimumhardwareavailable?

49 Ifthescoregivenonthepreviousquestionis1or2,isthereabudgetavailabletoprocurethenecessaryequipment?

50 Istheretechnicalsupportavailabletosolveproblemsrelatedtoconnectivity?

51 Isthereacybersecurityplan?

52 Aretechnicalsupportmanualsavailabletoaddressconnectivityissues?

53 Isthereacontingencyplanintheeventofequipmentorconnectivityfailures?


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54 Hasthepossibleimpactofthenewtelemedicineservicesonthecurrenttechnologicalinfrastructurebeenconsidered?

APPLICATIONS(SOFTWAREFORMANAGINGMEDICALRECORDS,PATIENTPORTALS,ETC.)

55 Isthereanelectronicpatientrecordsystem?

56 Isthereapatientportal?

57 DoestheinstitutionknowwhatsoftwareorITsolutionsarenecessarytooffertelemedicineservices?

58 Aretherestandardoperatingproceduresformanagingthedataandprocessesinvolvedintelemedicinedelivery?

59 Arethereguidelineson:

59.a ● Patientsafety?

59.b ● Privacyanddataconfidentiality?

60 What is the level of interoperability among the telemedicineservices’differentsystemsanddatabases?

61 AretheretermsofreferencefortheprocurementofITsolutions?

62 HasitbeendecidedwhethertelemedicineITsolutionswillbeintegratedintootherexistingsystemsandprocesses,suchasthoseformedicalrecords,patientportals,andmessaging?

63 Aretherestandardoperatingproceduresformanagingdataandprocessesrelatedtoprovidingcaretopatients?

64 Dothemedicalrecordsplatformsusedinthetelemedicineserviceshavethecapacitytoincludecopiesofalltheelectroniccommunicationsrelatedtothepatient?

APPLICATIONS(ADMINISTRATIVESOFTWAREFORBILLING,PAYMENTS,MONITORINGHOURS,ETC.)

65 Aretheadministrativemanagementplatformsreadytoworkwiththeimplementationoftelemedicineservices?

TECHNICALEQUIPMENT(HARDWAREANDOTHEREQUIPMENT)

66 Isthereaninventoryofallthetechnicalequipment,includingthebrand,model,timeinoperation,andserialnumber?

67 Isthereasecurelocationtostoretheequipmentwhenisitnotin


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use?

68 Isthereamaintenanceprogramforthetechnicalequipment?

69 Hasconsiderationbeengiventothetechnologicalcapacityforstorageandsecuritythatwillbenecessarytodocumentandrecordface-to-facemeetings?

70 IstechnicalsupportavailablefromITspecialists?

71 Arethereplansforupdatingtechnicalequipment?

IV.Humanresources

Question

Levelofmaturity


HEALTHWORKERS

72 Istherestaffavailabletoparticipateinthetelemedicineprogram?

73 Hasitbeenclearlydefinedwhichstaffmemberswillworkontelemedicineservicesorspecialties?

74 Havetheminimumskillsetsnecessaryforthedifferenttelemedicineservicesbeendefinedforthosewhowillbeworkingintelemedicine?

75 HasthepossibilityofimplementinganexpeditedtrainingplanbeenconsideredforstaffwiththelowestlevelofITskills?

76 Isthereaccesstoexpeditedtrainingprogramsatotherinstitutions,ifnecessary?

77 Arethereplanstoprovidetelemedicineservicesoutsidetheusualface-to-facehours?

78 Whatisthelevelofstafftrainingnecessarytoprovidetelemedicineservices?

ITSTAFF

79 Istherein-houseITstafftosupporttelemedicineservices?

80 Iffewerthan3ITstaffareavailable,isitclearwhatqualifications


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shouldberequiredforthosewhowillbeprovidingtelemedicineservices?

81 Istheretrainedstaffabletocriticallyassessanyequipment,andtheITthatshouldbeprocured?

82 IstherestaffwiththenecessaryexperiencetonegotiatewithprovidersforpurchasingorcontractingITorsupportservices?

83 Howqualifiedistheinstitution’sITstafftoprovidetelemedicineservices?

V.Regulatoryissues

Question

Levelofmaturity


84 Areallthelegalissuesassociatedwiththedeliveryoftelemedicineservicesperfectlyclear?

85 Isthereaprocedureinplacetokeepstaffwhoprovidetelemedicineservicesuptodateonpossiblechangesinregulations,statutes,federalandsubnationalpolicies,andlegislationrelatedtotelemedicineservices?

86 Doestheinstitutionhavein-houselegaladvisoryservices?Doesithaveaccesstoaspecializedconsultancytoreceiveexpertadviceonlegal,ethical,privacy,andsecurityissues?

87 Isitknownforcertainthatthepatientsarelocatedwithinthesamecatchmentarea(e.g.state,province,ormunicipality)astheinstitutionprovidingthetelemedicineservices?

88 Arethemalpracticeissuesrelatedtothetelemedicineserviceswellunderstood?

89 Hasaprocessbeenputinplaceforobtaininganddocumentingtheconsentofpatientsbeforetheyparticipateinatelemedicinevisit?

90 Istherearegulatoryframeworkforauthorizing,integrating,andreimbursingtelemedicineinthedeliveryofcaretoallpatients,particularlyduringemergenciesandoutbreaks?

91 Arenewregulationsorlegaltechnicalframeworksnecessarytoimplementtelemedicineservices?


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VI.Expertise

Subject

Levelofmaturity


92 Indicatorsfortelemedicineprojectsastoolstoreduceinequitiesinhealth.

93 Treatmentprotocolsfortelemedicine.

94 ITstandardsinhealthandinteroperability.

95 Managementofchange.

96 Architectureofpublichealthinformation.

97 Technologicalreadinessinpublichealth.

98 Datagovernanceinpublichealth.

99 Implementationframeworkfortelemedicineservices.

GuidelinesforanalyzingtheresultsTheresultsshouldbediscussedininterdisciplinaryteamscomprisingspecialistsfromthedifferentareasinvolved.Ifthereisenoughtime,theyshouldalsobevalidatedbyexpertsinhealthservicesandITwhohavetelemedicineexperience.

Questions that are answered “requests technical support” will serve as the basis for developing acollaborationagreementwithspecializedpartners.Thefollowingguidelinesshouldbeusedtointerprettheresults,sectionbysection.

Levelofmaturity

None(1) Beginner(2) Advancing(3) Ready(4) Requeststechnicalsupport

Noinitiativeisinplace.

Somestepshavebeentaken,buttheinstitutionisstillfarfrombeingabletoimplementservices.

Goodprogress,andsometelemedicineservicescouldbegintobeimplemented.

Everythingisreadyfortelemedicineservicestooperateatfullcapacity.

Requiresexperttechnicalsupporttomakefurtherimprovements.


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● Ifamaturityscoreof1or2isgivenforanyofthequestionsbetween1and7,therecommendation

istodelay implementationoftelemedicineservicesuntil levelofmaturity3 isachieved,bytakingthefollowingactions:○ Formulate an action plan and an evidence-based budget for discussion at the decision-

makinglevels.○ Setupataskforce.○ Ensurereliableinternetaccess.○ Definewhichhealthcareserviceswillbeofferedviatelemedicine.○ IdentifyITstaffspecializedintelemedicineorinmorecomplexinformationtechnologies.○ Carryoutaspecificlegalconsultation,takingasanadditionalreferencethequestionsin

sectionV(onregulatoryissues)ofthistool.

● Any questions for which amaturity score of 1 or 2 is given should serve as the main basis forplanning the necessary actions and investments to be incorporated into the final telemedicineprogram.

● Thosequestionsforwhichamaturityscoreof3or4isgivenshouldbeanalyzedinamacro,rather

thananindividual,contexttodeterminewhetheritispossibletobeginofferingsometelemedicineservicespartially and securely. In this situation, it is suggested that theprocessbe validatedwithexpertsinhealthservicesandITwhohaveexperienceintelemedicine.

● If someof thequestions fromnumbers8 to11aregivenamaturityscoreof3or4, thenaquick

analysis should be conducted on lessons learned that could lead to recommendations for thecurrentsituation.Thiswouldmeancarryingoutanassessmentontheinitiativesthatareorwereinoperation.

● Workingwithoutsideexperts isrecommendedtodesignaroadmapbasedonanalysisoftheendresults.

● Aframeworkformonitoringandevaluatingtheprocessisstronglyrecommended.Referencesandothertoolsforfurtherself-assessment• PanAmericanHealthOrganization.FrameworkfortheImplementationofaTelemedicineService.

Washington,D.C.:PAHO;2016.Availableat:https://iris.paho.org/bitstream/handle/10665.2/28414/9789275119037_eng.pdf?sequence=6&isAllowed=y

• NationalFrontierandRuralTelehealthEducationCenter.TelehealthCapacityAssessmentTool(TCAT).NFARtec;2013.Availableat:https://www.nfartec.org/wp-content/uploads/2018/08/nfar_tcat_508.pdf


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• U.S.DepartmentofJustice,OfficeofJuvenileJusticeandDelinquencyandWesternRegionalChildren'sAdvocacyCenter.TelemedicineReadinessAssessmentTool.Availableat:http://www.westernregionalcac.org/tmhresourcecenter/getting-started-introduction/getting-started-assessing-readiness/

• UniversityofMarylandSchoolofMedicine.TelehealthReadinessAssessmentTool.2019.Availableat:https://mhcc.maryland.gov/mhcc/pages/hit/hit_telemedicine/documents/TLHT_TRA_Tool.pdf

Projectteam

PanAmericanHealthOrganization/WorldHealthOrganization• SebastianGarciaSaisó,Director,DepartmentofEvidenceandIntelligenceforActioninHealth,PAHO/WHO• MarceloDAgostino,DepartmentofEvidenceandIntelligenceforActioninHealth,PAHO/WHO• MyrnaMarti,DepartmentofEvidenceandIntelligenceforActioninHealth,PAHO/WHO

Inter-AmericanDevelopmentBank• FerdinandoRegalia,DivisionChief,SocialProtectionandHealth,IDB• LuisTejerina,SocialProtectionandHealth,IDB• JenniferNelson,SocialProtectionandHealth,IDB• AlexandreBagolle,SocialProtectionandHealth,IDB

Appendix.ContributorstothedevelopmentofthistoolThefollowinginstitutionsandexpertsintelemedicineandtheuseofITinpublichealthfromtheRegionoftheAmericasandSpainhavecontributedtodevelopingthistool:

● SocialProtectionandHealthDivision,Inter-AmericanDevelopmentBank.● Departmentof IT inHealth, ItalianHospitalofBuenosAires (PAHO/WHOCollaboratingCenter for

InformationSystemsandDigitalHealth)● OpenUniversityofCatalonia(UOC)(PAHO/WHOCollaboratingCenterforeHealth)● Center for Health Informatics, University of Illinois (PAHO/WHO Collaborating Center on Information

SystemsforHealth).● Salud.uy,AgencyforeGovernmentandtheInformationSociety(AGESIC)ofUruguay● TelemedicineNetworkfromBrazil(RedeRUTE)● TheCentralAmericanHealthInformaticsNetwork,RECAINSA

PAHOInformationSystemsforHealth(IS4H)networkofexperts

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