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COVID-19ANDTELEMEDICINEToolforassessingthematuritylevelofhealthinstitutionstoimplementtelemedicineservicesVersion3.0,July2020
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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
1 2 3 4 Requeststechnicalsupport
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
1 2 3 4 Requeststechnicalsupport
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
1 2 3 4 Requeststechnicalsupport
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
1 2 3 4 Requeststechnicalsupport
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